Access, Equality, Quality, Economy: Good quality primary care for all without bankrupting the province?

The Guardian ran an article on access to family physicians in PEI.

This is part of a wider debate about the rising costs of health care, particularly as the population ages and their medical care becomes ever more complex (and costly).

There are four features of an ideal primary health care system: access, quality, equality, and economy.

In other words, we need a system that patient have easy access to, that provides good quality care, that is available equally to all, and that is affordable.

Lets look at those four topics in more detail.

Access

Unless a primary care service is accessible, it will not meet the needs of patients.

There are three parts to access:

1.  how long patients wait to get on a family physician's list of patients
2.  how long patients have to wait for an appointment with their family physician.
3.  how long patients wait to be seen on the day of their appointment.

These three barriers to access are like a pyramid (see Figure 1 below).  

You have to get past each barrier in turn.

If you don't have a family physician, then short waiting times for patients that do have one are no use to you.

Once you have a family physician, then unless you can get an appointment with your family physician, short waiting times on the day are of no use to you.

We'll look at ways to improve access in a moment, but first we need to look at our other aims to make sure these are met too.




Equality

Access to quality health care is a basic right of citizens in a civilized society.  For society to be fair, access to basic rights must be equal.

It is not acceptable for people to be denied access to quality health care because of where they live, or the level of their income, or the type of job they have, or the colour of their skin, or because they don't know the right people.

Everyone should have equal, fair access to quality health care provision.

So whatever we do to improve our health care system, must met the equality test: Does this make provision of health care more or less fair?


Quality

Health care provision needs to be of high quality to be effective.

It is easy to improve access to health care cheaply by simply providing poor health care.  In fact, this is exactly what New Labour in Britain did to the National Health Service over the last 15 years: they brought waiting times for specialist treatment down dramatically, but the quality of hospital care suffered as a result.  This technique was referred to in the UK press as 'never mind the quality, feel the width'.

It is vital as we look at how to improve provision of health care that we look at ways that also improve - or, at the very least, maintain - quality of care.


Economy

As you might expect, over the years in my discussions with health service managers and politicians, the topic of money causes the biggest disagreements.

There are few problems with the current health care system that could not be solved with an unlimited amount of money.    But sadly, there is not enough money in the world to make this a viable solution.  No-one - not even the richest countries - have access to unlimited amounts of money.  Canada is a rich country, but even Canada could literally spend all of it's GDP (money) on health and still not meet all possible health needs of its citizens.

Secondly, even if we had the money we don't have the doctors.  The shortage of family doctors in rural areas is a world-wide problem that is getting worse.  This is partly due to changes in society - the reduction in the hours doctors are willing to work, the increase in family/work balance, the increase in patient expectations - and partly due to changes in the job - medicine is much more complex and stressful than it used to be.

This is only going to get worse as the population ages.

It is important to make sure that everything we do is cost effective.  The more cost effective we are, the more quality care we can provide with the money that we have.

Thankfully, this is not as difficult as it sounds, because there are lots of things we do currently that are not of any benefit to patients or may even be harmful.   There are lots of cost savings to be made from better prescribing of cheaper medicines that are just as effective.  There are lots of efficiency savings that can be made by making sure we have the right mix of team members doing the right jobs.

Table 1.  Comparison of various models of care.

Model of care	Number of patients	Appointments per week	Ratio appts/wk/patient	Cost per patient/year
Fee for Service	1,500 to 2,000	100 to 150	5% to 10%	$140
Salaried	1,200	100	8%	$180
Multi-disciplinary Team	3,000 to 5,000	300 to 450	8% to 10%	$130

Back to Access

Which brings us back to the main point of this post: improving access.

We must solve the first access barrier - lack of access to a family physician.  Until that is solved, our system will always be unfair and unequal.

We can solve that by simply increasing the number of patients that each doctor has.  That is the most equitable solution as it means everyone will have access to a family physician.  It is also cost effective.  This has been tried in other places, but without other changes this will lead to longer waits to see a family doctor for all patients and/or a decline in quality of care.  It will likely also lead to more doctor burnout, which will reduce access further in the future.

One change we can make is to differentiate more between acute illness and chronic illness.  Acute (short term) illness ranges from simple coughs and colds to medical emergencies like heart attacks.  Chronic (long term) illnesses are things like diabetes, chronic bronchitis, asthma and so on.

Acute illnesses can be dealt with quite effectively without having to see your own family doctor.  The emergency department is the best place for medical emergencies, while the walk-in-clinic system works well for coughs and colds and other minor illness.

It is chronic illnesses (and their prevention) that can only be managed properly by your family practitioner.  Or more correctly, by your family practice team.  Because, the research is that patients do far better when their chronic illnesses are looked after by a good team: usually family practice nurses working with a family physician.  This team is best placed to co-ordinate all the care that is needed for patients with these complex conditions.


The Solution?

So our proposed solution is:

1.  Register a lot more patients so everyone has access to a family doctor.

2.  Set up computerised 'registers' of patients with chronic illnesses.  These patients are the ones that need access to their own family doctor's team.

3.  Use computerised appointment systems to 'time limit' a certain proportion of appointments to improve access (for example, a third of appointments can't be booked until a week in advance).

4.  If waiting times for appointments build up, divert acute illness (coughs and colds) to walk in clinics (emergency departments should be seeing all medical emergencies such as heart attacks and strokes).

5.  Use Practice Nurses to screen for chronic diseases,  look after patients with chronic illness, and educate patients on how to stay well.

6.  Use computer systems to communicate and co-ordinate care better with other health care providers.

7.  Computerised prescribing of medication refills to make medication reviews safer and more efficient.

8.  Focus the doctors' time on what they do best: diagnosing illnesses and advising on medical treatment.


Hopefully this will come as close as is possible to meet our aims: access, equality, quality, economy.