There are 2.1 million Quebeckers (and 6.5 million Canadians) who don’t have a family doctor.
So what if, in the name of equity, we took away healthy people’s doctors and assigned them to sicker, more vulnerable patients?
Quebec floated that trial balloon this month, and it proved to be Hindenburgesque. The idea was as widely condemned as ridiculous as it was unworkable. Provincial health minister Christian Dubé found himself backpedalling furiously, promising that “Quebeckers who have a family doctor will keep them.”
But before we dismiss this as just another preposterous political blunder, it’s worth pausing and considering what prompted this radical idea to surface.
Quebec already has a serious shortage of family doctors. GPs are burning out and retiring in droves, and recruiting replacements is proving difficult. The province has 70 unfilled positions for family medical residents, compared to five in the rest of the country. Last year alone, 780 Quebec physicians opted out of medicare to open private practices, compared to 14 in the rest of Canada.
Ideally, everyone should have a family doctor from birth until death. Making that a reality should be a priority. Ontario, in contrast with Quebec, has committed to that by appointing former federal health minister Jane Philpott to lead a “primary care action team.”
But in the meantime, what happens when everyone doesn’t have a family doctor? That’s the reality for one in four Quebeckers. Worse yet, those most in need of care – people with serious, multiple chronic illnesses – are least likely to have access to it.
This is not a trivial issue. It challenges the fundamental guiding principle of medicare: that no one should be denied essential care because of an inability to pay. It’s a breach of the social contract.
The policy idea that sparked so much outrage – reassigning doctors to the most needy – came in a report from Quebec’s Institut national d’excellence en santé et services sociaux (INESSS), a respected provincial health research body.
The study itself is a thoughtful academic exercise, and to be fair, INESSS stresses that the theoretical scenario it lays out “cannot be used directly as models for organizing primary care services.”
But the report features a level of detail in data that we rarely see in Canada, giving us a real sense of who uses primary care and how.
The story that emerges from the data is that the allocation of primary care resources is fundamentally unfair. There are 17.6 million visits a year in Quebec, and 40 per cent of them are by healthy people with minor ailments. The report estimates that about 2 million additional visits are required to meet the current needs of patients.
Between the lines, the INESSS study raises some uncomfortable questions about who has a doctor and who doesn’t. The unspoken truth is you need to be connected and privileged to have one.
Much of the response has consisted of people dismissing the notion that equity matters, especially in a publicly funded system. The common refrain is: How dare you take away my family doctor?
Rather, the questions we should be asking are: Why are so many people in need of care unattached to a physician? And how do we fix that inequity?
Quebec currently has a portal called Guichet d’accès à la première ligne (GAP), a central booking service that matches unattached patients with vacant appointments.
The new INESSS report essentially recommends expanding the GAP, but also creating space by reallocating about 1.5 million visits by healthy people to those who are more seriously ill. (For the data geeks, in the report itself there is some dizzyingly complex math on how they got to those numbers.)
There is no doubt that continuity of care is important. So is preventive medicine. But, where there are dire shortages, does it trump caring for those who are seriously ill?
These are not easy debates, ethically or practically.
Quebec is in the midst of high-stakes contract talks with its family physicians. The negotiations are not just about money and payment models (from fee-for-service to capitation), but about a fundamental restructuring of the practice of family medicine.
As a part of broader health reforms, Quebec wants to move toward an interdisciplinary model of care, where minor cases would be handled by pharmacists and nurses, and family physicians would focus on more serious cases.
Among other things, that involves determining how patients access the appropriate practitioner, and fairly. It’s a discussion that’s long overdue, no matter how uncomfortable it makes us.