Ford government reforming primary care amid family doctor 'crisis'

EDITOR’S NOTE: This article originally appeared on The Trillium, a Village Media website devoted exclusively to covering provincial politics at Queen’s Park. 

The Ford government is making significant changes to family medicine in Ontario, but doctors and other health-care experts are warning that primary care is already "in crisis" and the government isn't moving fast or far enough.

Health Minister Sylvia Jones recently announced over $110 million for 78 "new and expanded primary care teams" across the province as part of a bilateral health-care deal with the federal government, green-lighting the first major expansion of the team model in over a decade. The money will go to create 53 new team-based primary care clinics and expand 25 others.

Jones' ministry is also consulting on a proposed regulation that would see 58 regional bodies known as Ontario Health Teams (OHTs) get involved in organizing primary care — whether delivered by family doctors or nurse practitioners — in their area.

The change would mean many doctors who work independently today would be connected with health-care providers in their communities through the OHTs, which will be governed by non-profit boards, should the proposed regulations be implemented. 

But many — doctors, nurses, a former Ford government minister, and even a group of northern Ontario steelworkers — are warning it's not enough to heal what's ailing primary care today.

One of the people calling on the government to do more is Merrilee Fullerton, a former minister of long-term care under the Ford government and a former family doctor.

In a post on Substack, she wrote that the primary care shortage had been "brewing for decades and had begun to boil over when the Ford government took office in 2018." She described a "stunning failure to plan" for the aging of the population, driven by a desire to cut costs.

"Make no mistake… it’s about the money," wrote Fullerton, calling the $110 million "simply insufficient both in the short term and the long term."

"Why did this take so long to come up with and if it is not about the money, as Minister Jones has expressed, then why only enough for 300,000 more people instead of for the 2.3 million Ontarians that the Ontario Medical Association (OMA) says are without a primary care doctor?"

"Let’s strip away the political-speak: it’s about the money. It always was. As long as we have a finite single-payer system, it always will be."

The Registered Nurses' Association of Ontario (RNAO) — a staunch defender of the single-payer system — concurred with Fullerton that the funding doesn't go far enough.

CEO Doris Grinspun said the province is sitting on "100 or more" additional proposals for primary health care teams awaiting funding from the government, including nurse-practitioner clinics and doctor-led family health teams. Funding those teams would bring more nurse practitioners into — or back to — the primary care system and could solve the shortage of care, she said.

Doctors who've spoken publicly and with The Trillium generally called the funding a good start — most prefer a team-based model to being a sole practitioner working on a fee-for-service basis — but also warned it isn't enough when doctors are fleeing family medicine at an alarming rate.

Burden of 'paperwork'

At a media event hosted by the OMA this month, doctors urgently called for the province to reduce the "paperwork" family physicians are burdened with and offer them additional compensation to stay in the field.

"The crisis really needs to be solved by the doctors we already have; that's where the focus needs to be," said Dr. David Barber, chair of the OMA’s Section of General and Family Practice and a family doctor in Kingston, of the $110 million being spent on creating and expanding primary health teams.

That said, the doctors noted that when they can work in a team, their patients can see other health-care workers — nurses, pharmacists, social workers, dietitians, physiotherapists — where appropriate, and doctors can share the administrative burden with staff.

Dr. Kevin Samson, president and board chair of the Association of Family Health Teams of Ontario, said much the same, and that team models allow doctors to see more patients each than a strictly fee-for-service model — so increasing the number of teams in Ontario, should help some of the 2-million-plus unattached Ontarians get primary care.

Family Health Teams "aren't immune" to the burden of administrative work on family doctors, but it's eased, and there remains a pay gap between family medicine and other specialties, said Samson. Still, funding more teams should help the province with its family doctor retention and recruitment problems, he said.

Meanwhile, three doctors who've served in OMA positions took the extraordinary step of advising family medicine residents not to start their own practices in Ontario right now.

"Family medicine is in crisis," they wrote in an op-ed in the Toronto Star. "Family doctors in Ontario are unable to provide the care they could and should. We face unprecedented levels of administrative burden, unsustainable business expenses, lack of health care resources, lack of social and cultural support for our patients and ourselves and finally, a lack of respect. This has led to widespread burnout and exhaustion."

Dr. Sohail Gandhi, a family doctor and past president of the OMA, said the trouble in family medicine has been building for nearly a decade. In his view, technological failure is a big contributor to the administrative burden that is causing doctors to flee primary care.

"The biggest thing that government can do is unify the digital health system and digital health information technology, because the government has failed to do that, and successive governments have failed to do that," he said.

Ontario does not have a single electronic medical record system and the current patchwork of systems has resulted in family doctors being sent a vast number of reports from other parts of the health-care system; they're often incomplete, or the information the doctor needs to know is difficult to find — essentially spamming them with unnecessary information that they need to sort through to find what's important, according to Gandhi.

One of the OMA's top requests of the government is a centralized referral system for specialists. Today, family doctors — or primary care nurse practitioners — refer patients to individual specialists, in some cases by fax, without knowing what their wait time is or if they have the capacity to take on additional patients leading to time-consuming paperwork for doctors and longer wait times for patients. 

While the government has greenlit an e-referral project, it hasn't been universally rolled out across the province. Gandhi said there have been bureaucratic problems and one of the major digital referral providers is currently "frozen out" of the system, said Gandhi.

Asked about the technological problems, Jones said the government is working to expand on several successful pilot projects.

As for the administrative burden, she said it's part of the government's ongoing negotiations with the OMA on a new physician services agreement.

That's true, said Gandhi, who added that months of negotiations have led to the elimination of a single form — it was for hearing aids and used to take him "a couple of seconds to sign" once a month.

Doctors' administrative burden was raised at Queen's Park last week by an unexpected source: the president of United Steelworkers Local 2251, who spoke at a press conference about 10,000 Sault Ste. Marie residents who are losing their family doctors at the Group Health Centre, which was founded by steelworkers.

Mike Da Prat called on the government to bring doctors to smaller and more isolated communities and cast some of the blame for doctors' retirements on paperwork, including referrals and sick notes demanded by the employers, which he called on the government to ban.

Ontario Health Teams

As for connecting primary care doctors through Ontario Health Teams, Gandhi said the success of the plan will depend on the details —  if it means extra resources for physicians while preserving their autonomy in their own offices, it will be a success. If it means additional demands on their time, it will be "dead in the water."

Dr. Nadia Alam, a family physician, former OMA president and a co-author of the op-ed, agreed: a well-designed primary care network would be a success, but one that adds to doctors' administrative burden would backfire.

According to the government's consultation documents, the OHTs would be required to have a Primary Care Network (PCN) that connects primary care within the OHT, provides its voice in the OHT's decision-making, supports primary care providers, facilitates access to clinical and digital supports, and supports health human resources planning within the OHT.

In a statement, a spokesperson for Jones noted that Primary Care Networks already exist in Ontario. 

"Within OHTS, PCNs will have two objectives: to organize the local primary care sector in OHT planning and to serve as a vehicle to support OHTs in the implementation of local priorities," said Hannah Jensen.

The government is planning to move forward initially with just 12 of the province's 58 OHTs. 

"The government is moving at a glacial pace," said Gandhi. "The health care crisis is all around us right now. We can’t just have 12 — if we’re going to do it, we need to get on with it. By the time this gets implemented, it’ll be too late."