Public Health Primary Care Ideas from the Ontario College of Family Physicians Walter W Rosser MD, CCFP, FCFP, MRCGP(UK)

ONTARIO COLLEGE OF FAMILY HYSICIANS  The OCFP is a voluntary organization with over 6,000 members.  Over a period of 1.5 years the OCFP produced a document titled Family Medicine in the 21 st Century.  The document was developed by the board with input from all members.  Since the document was published in the Fall of 1999 three forums involving all stakeholders have resulted in continual modification of the overall plan.

Problems Related to the Four Principles The family physician is a skilled physician  Educated in comprehensive skills (i.e., obstetrics, emergency medicine, in-hospital care, long term care of the elderly).  Financial incentives in the fee-for-service schedule rewarded a very narrow scope of practice.

Some System Problems: The family physician is a skilled physician  The lack of a single medical record for each patient leads to duplication and fragmentation.  The isolation of physicians leads to difficulty in keeping up with rapid change and what other agencies in the community are doing.  Patients are not informed of the services provided by their family physician.

The physician-patient relationship is central to practice  A narrowing scope of practice increased fragmentation and resulted in a decline in continuity and deterioration in the physician- patient relationship.  Physicians found low satisfaction and emigration to the USA increased dramatically.  Fragmentation, caused by an increased use of walk-in clinics and emergency rooms, increased health care costs threatening the sustainability of the health care system.

The family physician is a resource to the community  Lack of integration and support, including information technology, nurse practitioners and the ability to communicate with community agencies led to fragmentation.  The fee schedule does not support appropriate preventive and chronic care programs (i.e., diabetes, asthma and care of the elderly with multiple complex problems).

The family physician is community based  Government policy reduced family physician supply reducing the number of practicing family physicians.  Mal-distribution of practicing family physicians has increased problems of access in over 100 communities with a narrowing of the scope of practice. This has reduced the capacity to work with Public Health.

A Plan to Enhance Family Medicine  Patient choice: Every patient would choose a family physician. Physicians would provide patients with the basket of 15 services.  Family physicians would work in groups: Ideal size 6-8 physicians but flexible. Groups could be physically together or virtual.

Enhanced Family Practice  Family practice groups provide the basket of services 24 hours/7 days a week. Infrastructure to include telephone triage system.  Information technology: Each physician would require a computer system, comprising electronic medical record, linked to other physicians in the group, hospitals, long term care facilities, community health care providers and consultants.  The patient’s complete medical record would be maintained by the family physician.

 Support services would include nurse practitioners, public health nurses, social workers to support mental health care, home care and midwives to support obstetrical care. The family physician would accept responsibility for patient care. A nurse in each group would be responsible for community Liason.

Physician payment via blended funding model Capitation for each patient according to age, sex, acuity index and rurality index. Fee-for-service (obstetrics, emergency services, specific services). Programmatic funding (special preventive or health promotion incentives). Salary/benefit package reflecting training, seniority and location of practice.

 Accountability. Within each region a family physician would be appointed community chief family physician who would be responsible for family practice groups in the region and the needs of patients being met.  Part of this mandate would be to consult with Public Health over appropriate community needs to develop physician’s incentive programs.

 Questions arise as to how Public Health Nurses, Nurse practitioners and Midwives would be employed in group practices.  One suggestion is that they all be employed by the Public Health Department and be attached to group practices in the community

 This model would strengthen the link between clinical practice and Public Health  The Public Health capacity for epidemiology could be used to identify community needs and then measure the impact of integrated health promotion and preventive programs

Conclusion  Adoption of the enhancement of family practice as proposed by the OCFP. Would promote integration of Public Health with health care delivery.  Would provide a health care delivery system responsive to community needs.  Would integrate all prevention and health promotion programs.

 The enhanced model of family practice would make the health care system more responsive  Integration of programs should make current resources more efficient and effective.  The OCFP has developed 15 detailed papers on various issues arising out of this model. The web site is