The staff of Midtown Kingston Health Home are now a go-to resource for Kingstonians who, in some cases, have waited years for family physicians on Ontario's Health Care Connect service.
By the time Dorothyanne Brown got the call from a new primary-care clinic in Kingston, she was getting desperate. The 65-year-old former nurse, who has multiple sclerosis, diabetes and osteoarthritis, had been without a family doctor for more than four years after moving to the eastern Ontario city from the east coast. Managing her own medical care with occasional walk-in clinic visits and virtual nursing services had become, she says, “an absolute nightmare.”
That’s why there was “much happy dancing going on – as much as I can dance around my apartment” when she learned last month that the Midtown Kingston Health Home would take her as a patient because of where she lived.
Ms. Brown is one of thousands of lucky people living in postal codes that start with K7M, the catchment area for the new clinic, which began inviting patients to join in mid-September. She is also something of a guinea pig in a primary-care reorganization experiment championed by Jane Philpott, the former federal health minister who on Dec. 1 begins the daunting job of fixing primary care in Ontario, where 2.5 million people don’t have a family doctor.
Dr. Philpott’s vision, laid out in a best-selling book published in April, is of a primary-care system that works like the public school system, with residents’ access decided according to catchments. Premier Doug Ford named her the head of a new primary-care action committee on Oct. 21. She has asked him to give her 100 days to sketch out a plan for what she and her team could accomplish in their first three years of work.
In Dr. Philpott’s ideal scenario, every Canadian would be entitled to a spot at a local “health home,” where teams of family doctors, nurse practitioners and other professionals work together to keep people healthy. Nobody would go without care because a doctor retires, just as students don’t go without an education when a teacher quits. If every local health home was full, a new one would be built, the same way new schools are erected in growing neighbourhoods.
Dr. Philpott’s approach would be a departure from how most patients access primary care today. Canada’s universal public health system does not guarantee anyone a family doctor or nurse practitioner. People who want a regular primary-care provider often call clinic after clinic to beg for a spot, or use social connections to squeeze on to a physician’s roster. Many jurisdictions have central waiting lists, but those lists tend to move slowly – a reflection of demand for primary care outstripping supply.
Jane Philpott, a former minister in the Trudeau government, has now been tasked by Ontario to overhaul primary care.Adrian Wyld/The Canadian Press
Dr. Philpott knows there will be pushback against her vision, including its cost. She estimates the province would have to spend between $1-billion and $2-billion more a year to ensure every Ontarian has a place in a health home. To put that in perspective, Ontario’s 2024-2025 health budget is $85-billion.
But assigning patients to primary-care teams by geography “is what has worked in countries that do a lot better than us,” Dr. Philpott told The Globe and Mail in an interview. “It makes sense. People understand it when we talk about the example of the public school system. The fact that this is the way it’s been designed in Scandinavian countries, in the Netherlands, in the U.K., gives us really good evidence that it’s doable.”
The question remains, is it doable or desirable in Canada, a country where the primary-care system is less a unified system than a scattered collection of doctors-cum-small businesspeople who have jealously guarded their independence in the past? Is it doable in a country that has historically spent far less on primary care than it spends on hospitals, where people are treated for illnesses they might have avoided if only they had a family doctor?
In Kingston, where Dr. Philpott served as dean of the Faculty of Health Sciences at Queen’s University until her new appointment, health leaders are trying to answer those questions by putting the school zone concept into practice. They’ve recruited new family doctors and nurse practitioners, carved the region into catchment areas, and started calling people who’ve languished for years on Health Care Connect, the province’s waiting list for family physicians, to offer them spots in newly created health homes.
Kingston paramedics rush to the long-term care facility that, once renovated, will be the permanent seat of Midtown Kingston Health Home. Since the COVID-19 pandemic, Kingston and nearby communities have lost many family doctors to retirement.
It’s early days, and not everything has gone well, particularly for patients living in areas excluded from the first wave of action. But Meghan O’Leary, director of clinical services for Kingston Community Health Centres, said that overall the new approach, “is giving people a sense of hope.”
Hope was hard to find a few years ago when Ms. O’Leary and other health leaders in Kingston began drafting a proposal for a single health home based loosely on the premise Dr. Philpott describes in her book, Health for All: A Doctor’s Prescription for a Healthier Canada.
Like many places in Canada, Kingston and the nearby town of Greater Napanee lost a slew of family doctors as the pandemic receded.
Some MDs who had been trying for years without success to convince young doctors to take over their practices hung on through the worst of COVID-19, then packed it in. “Many of them that I know personally tried for so long that the only way they ended up retiring was due to illness and age,” said Hugh Langley, a Kingston family doctor who is intimately familiar with the toll of the primary-care shortage.
Dr. Langley has a contract with Cancer Care Ontario to co-ordinate follow-up care for patients with abnormal cancer screening results who don’t have a doctor. He used to see one or two women a month in that boat, but recently their numbers have ballooned to the point that he estimates one in five women undergoing screening mammograms in southeastern Ontario don’t have a family physician.
Dr. Langley’s impressions jibe with the figures that Kim Morrison, a family doctor in Greater Napanee, uses in her work as executive lead of the Frontenac, Lennox & Addington Ontario Health Team, one of dozens of organizations the Ontario Progressive Conservative government created in 2018 to co-ordinate health-care delivery at the local level. Kingston is the largest city in the FLA OHT.
Kingston's water tower is just a short walk north of the health home's current location on Princess Street.
Dr. Morrison said somewhere between 20,000 and 30,000 people in the region of 220,000 don’t have a family doctor or nurse practitioner.
The reason for the shortage is relatively straightforward, Dr. Morrison added. Up-and-coming doctors simply do not want to practise family medicine the way their forebears did, not even in a beautiful city on Lake Ontario with good hospitals and a prestigious medical school.
Most don’t want to work 80 hours a week or be solely responsible for a roster of 3,000 patients or shoulder the administrative burden of a family practice, where doctors say they spend 19 hours a week on charting and paperwork.
They crave work-life balance, said Craig Desjardins, who courts doctors as director of the office of strategy, innovation and partnerships at the City of Kingston. So they choose to work in hospitals or in focused practices such as sports or cosmetic medicine instead.
“That’s not to say that all [medical] residents don’t want the sort of entrepreneurial life where they have employees and have a business and own the building. That’s certainly still a model that’s out there,” Mr. Desjardins said. “But we’ve seen a transformation, and the turning point seems to be the pandemic.”
In the last few years, 15 doctors in the FLA OHT left or retired without finding replacements, Dr. Morrison said. Six were from a single practice: Frontenac Medical Associates at 791 Princess Street. They all hung up their stethoscopes on the same day, May 26, 2023, leaving more than 8,000 patients without primary care.
Frontenac Medical lost six physicians in 2023, leaving a significant gap in primary care in Kingston.
Fortunately, the FLA OHT and other health leaders in Kingston, including Dr. Philpott, saw these and other departures coming.
Six months earlier, in November of 2022, they sent a business proposal to Ontario Health, the superagency that oversees the province’s health-care delivery, requesting funding for a new interdisciplinary primary-care clinic rooted in what the group called the “periwinkle model.”
The five-petaled flower referred to a “quintuple aim,” health-policy jargon for a system that prioritizes better care, a healthy population, equity, good value and happy providers.
To meet those aims, the group proposed a clinic where doctors would be employees paid a salary instead of independent businesspeople billing the government for every patient they enrolled (a model called capitation) or episode of care they delivered (known as fee for service.) They asked for public money to hire a team of allied health professionals, and promised to provide primary care to thousands of people who didn’t have family doctors living in a defined geographic area.
Kingston Community Health Centres led the proposal, but the plan also had the backing of city hall, the FLA OHT, the public health unit, all the local hospitals and the Queen’s faculty of health sciences.
The Ontario government greenlit the proposal earlier this year, granting the group $4.1-million for one fiscal year as part of a $110-million investment in expanding primary-care teams across the province. The money was earmarked for five doctors, three nurse practitioners, two social workers, a diabetes educator, a practical assistance worker (to help patients overcome barriers such as transportation to the clinic) and a health educator for families with complex needs.
In July, the periwinkle clinic, renamed the Midtown Kingston Health Home for simplicity, opened in a temporary location at 791 Princess Street – the very space that was left empty when six doctors retired from Frontenac Medical on the same day.
Eileen Nicolle says she was 'looking for something different' when she joined Midtown in Kingston.
The Frontenac doctors couldn’t persuade new doctors to take over under the old model. But the new approach succeeded in attracting doctors like Eileen Nicolle, who moved from Toronto to Kingston with her husband and three young children to take a salaried, three-day-a-week job at Midtown.
“After working in all the different models,” Dr. Nicolle said, “I was really looking for something different. I wanted something that would provide high-quality, comprehensive care, but also where, if you needed it, you could take a vacation or be home sick with your kids.”
Dr. Nicolle appreciated that Midtown built administrative time into her schedule and paired her with a nurse practitioner, Edward Cho. They work as a team. One of their new patients is Ms. Brown, the former nurse who hadn’t had a family doctor for four years.
She had her first appointment as a rostered patient on Oct. 25. “Just back from my appointment with the excellent NP Edward Cho,” Ms. Brown wrote in an e-mail to The Globe. “He explained the dyad model to me (NP/MD) and saw to my concerns (med renewal/ assessment) and sprained foot! And then caught me up on preventive details, flu shot, tetanus, planned testing that had been forgotten for years. I came away feeling very well looked after.”
Mr. Cho also sent Ms. Brown for an X-ray on her foot, which turned out to be broken. He referred her directly to a fracture clinic, allowing her to bypass the ER.
Nurse practitioner Edward Cho works in a team with Dr. Nicolle.
As of Nov. 8, Midtown had rostered 949 patients. Their goal is to enroll as many as 8,000 people, but they’re doing it gradually so that each new patient can get a first appointment shortly after being plucked from Health Care Connect.
In the meantime, Midtown is also offering booked walk-in appointments at its temporary location. City Council voted last month to spend more than $9-million transforming an old nursing home into a permanent home for the clinic.
The challenge with replicating the early success at Midtown is that the special one-time funding it received isn’t available to every group of doctors that might prefer to work for a salary in an interdisciplinary team.
However, that didn’t stop doctors in Greater Napanee, a town of about 17,000 that is also part of the FLA OHT, from creating a workaround after four local doctors left without finding replacements over the last couple of years.
Twelve of the remaining MDs in Napanee banded together with the Napanee site of Kingston Community Health Centres (KCHC) – a long-standing model of interdisciplinary practice in which doctors are paid a salary to care for marginalized populations – to create the Greater Napanee Health Home.
They pooled their earnings as independent practitioners who bill the government via a capitation model to pay KCHC staff to do their back-office work and manage office staffing. Then they paid themselves salaries.
“A year ago, in my old model, I had to hire and fire staff. I had to run payroll. I had to make sure I had my insurance. I had to call the plumber when the toilet broke,” Dr. Morrison said. “And now, by pooling all this together, I go in and I see patients.”
Midtown also offers sexual health services.
The new model has helped the Greater Napanee Health Home sign five doctors in the last six months. Between 4,000 and 5,000 patients were orphaned when the four doctors left. “Our goal is to have them all attached by the end of March,” Dr. Morrison said, along with everyone else in Napanee who doesn’t have a primary-care provider.
Shortly before new doctors and nurse practitioners started joining the Midtown and Greater Napanee Health Homes, CDK, a local walk-in clinic, got the necessary permission from the province for some of its doctors to join a capitation model. It attracted four new doctors and opened a third site.
Meanwhile, one new doctor joined a practice called Greenwood Medical for a six-month placement. Greenwood operates with an eye to rostering patients who don’t have a doctor on the east side of the Cataraqui River, the waterway that bisects Kingston. A new doctor was found to replace Mary Rowland at a KCHC site called the Weller Clinic when Dr. Rowland left in September to become the medical lead at Midtown, which also part of KCHC.
Overall, Kingston recruited 20 new physicians in about two years, many of them fresh out of medical school, said Mr. Desjardins of the City of Kingston. It didn’t hurt that city council offered $100,000 bonuses to new doctors, and innovation grants to ease their administrative loads, although many desperate municipalities now dangle similar incentives.
The FLA OHT’s leaders looked at the influx – a total of 12 “net new” doctors for the Kingston and Napanee areas – and recognized the region had enough new doctors to make a real play for geographic rostering inspired by Dr. Philpott’s concept. People who already had a doctor could stay put, but those without a doctor who had registered with Health Care Connect started getting calls to join a health home based on their postal code.
“We’ve had a few that have cried on the phone,” said Melissa Boivin, a registered practical nurse at KCHC who does intake calls for new patients. She spoke with one who hadn’t had a regular primary-care provider since 1992.
Melissa Boivin makes intake calls to new patients as part of her job as a registered practical nurse at KCHC. She says some have cried tears of joy after waiting years for a doctor.
Small wins started to pile up, said Ms. O’Leary of KCHC. They cleared the Health Care Connect list for Rideau Heights, an economically depressed neighbourhood near the Weller site of KCHC. They cleared everyone who had been on the list for more than three years in the K0H postal codes north of Highway 401. They rostered patients in K7M who were in remission but still attending a local cancer centre for their primary-care needs because they didn’t have doctors.
Still, the shift has had its challenges. The most obvious is that Kingston doesn’t have enough providers to cover every postal code.
Dr. Philpott’s school zone vision only works if every zone has a school, said Dr. Rowland, the medical lead at Midtown. “If you move to K7K and they say, ‘Well, there’s no school in this neighbourhood’ and you can’t go to K7M, that’s not great.”
That’s the complaint that Dr. Morrison, the executive lead of the FLA OHT, hears most often. “People quite reasonably say, ‘Well, I live on the other side of the river. How come I don’t get to be attached?’”
Her response is that doling out spots by geography seemed the only fair option when the need was so great. CDK Family Medicine took a first-come, first-served approach during two rostering days for four new doctors last February, and hundreds of people lined up in the bitter cold. Some lived hours away.
When CDK held another rostering day in April, it limited signups to people who could provide proof they lived in a central Kingston catchment. Ms. Brown, who was there that day as a volunteer, met patients who drove two hours from Ottawa and Perth anyway, desperate for a doctor.
Health officials hope that, with geographic rostering, more people in the Kingston area can get care without a long commute.
There have been other hitches in the rollout, too. In one case, a doctor at Greenwood Medical who couldn’t find a replacement to take over his practice announced he was leaving for family reasons around the same time in August when the FLA OHT issued a news release trumpeting the fact that Greenwood would be rostering 1,000 new patients from a specific geographic zone.
“It was a communications nightmare,” Dr. Morrison said.
Patients were understandably befuddled and furious. Their doctor was leaving. Their clinic had room for new patients. But they would be out of luck if they lived in the wrong postal code.
“I’m angry – very angry – and scared because now I’m without a doctor,” said Karen Cowtan, a 50-year-old mother of two who works in administrative services and lives on the outskirts of Kingston, outside the catchment area for the East End Health Home.
She and her family languished on Health Care Connect for nearly five years after they moved to Kingston from Ottawa in 2015. They only managed to get a doctor in February of 2020 when a friend helped them get in to Greenwood Medical.
Ms. Cowtan has mixed emotions about Dr. Philpott’s vision. “I think everybody is entitled to health care close to their home, but I don’t think it should be at the expense of people being de-rostered to allow others to just take their place because of their postal code.”
If Dr. Philpott’s plan works, even these dropped patients will eventually get a place in a local health home. But all that depends on whether doctors, nurse practitioners and provincial governments embrace the concept.
Dr. Philpott said Ontario government officials have reassured her they’re ready to try.
“This is the kind of investment that, if you don’t pay now, you pay later,” she said. “And you probably pay more later if you don’t get it right.”
Editor’s note: (Nov. 19, 2024): This article has been updated to clarify that Greenwood Medical has not rebranded as East End Health Home, and that the doctor who has joined the practice is there for a six-month placement.
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