Patients and providers design primary care in Vancouver

What would happen if we asked 500 family doctors, 1000 citizens and 50 health system experts to redesign primary care?

In 2013 and 2014, I was privileged to lead a team that did just that in Canada’s third-largest city, where almost 20% of residents do not have a family doctor.  Over 8 months, we brought 350 GPs and health authority staff together to answer a simple question:  “what can be done to improve primary care relationships, so that more people can have a family doctor?”   What started with a simple question is leading us to a new era in health care.

Using this question as our focus, we held several dialogue sessions that included over 300 family physicians and health authority staff.  Through these, we generated 250 pages of data, from which we extracted 22 ideas for making the family doctor’s office more efficient and better connected to the wider health care system in BC.  Then we circled back to all 800 local GPs to see which of these interventions were most practical, to create a shorter list of ideas with great promise.   

Once we knew what doctors thought would be possible, we asked patients – citizens – what they thought of those ideas.  Again using the theme of relationships, over 1000 citizens filled out an online survey to assess the physician-generated ideas.  We created a separate process for vulnerable groups (urban Aboriginal families, newcomers, seniors and others) to participate through a dozen in-person kitchen table events.  

It would be unfair to promise patients the moon, so we asked them to assess the extent to which the ideas generated by health system experts – including family doctors – would address their needs, and what trade-offs people would make so that everyone could have a family doctor.  We found that people were easily able to make actionable recommendations for system change when we used the lens of therapeutic relationships.  For example, we found that patients place a high value on everyone having a family doctor, that they want both continuity and convenience, and would much prefer to see or talk with their own doctor’s office instead of going to a walk-in or emergency department.   These are all ideas that support health system sustainability.

Through the process, we uncovered clues that will form the foundation for the next era of primary care: 

·       how seniors and millenials share many preferences in the design of family practice,

·       how to best engage citizens and clinicians in co-designing primary care,

·       how a culture shift among primary care providers will form the foundation of a primary care system that can enable everyone to have a family doctor

From this work, a few of us have created a new organization to implement the vision of hundreds of family doctors and thousands of patients.   The Vancouver Citizens Health Initiative brings patients and providers together to co-create primary care settings through the lens of relationships, and an eye on convenience for citizens and work-life balance for clinicians. 

Our sights are set on developing a model of whole-person, collaborative care that is sustainable within fee for service, while doing everything we need primary care to do for patient, provider and community health.  Our preliminary business case shows that our primary care clinics can achieve twice the capacity, offer more convenient and timely access, and work upstream, supporting patients to address their social determinants of health.  You can check our progress at www.vanchi.ca, or follow us at @VancouverCHI. 

It turns out that it’s easier to reimagine primary care than we thought:  all we have to do is listen to what’s important to the people at the centre of the system!

Thank You Nurses…Now, Can You Do More?

National Nursing Week is in full swing in Canada, and it’s crucial to recognize the tremendous contribution nurses make in all areas of health care.   I’m happy to see so many people singing their praises…and rightly so!  But, despite their great commitment and healing impact, I think nurses can play a stronger role in health care.   

I have never met a health care professional who thinks that the system can’t be improved, and nurses know that the system would be better if they could do more for patients, alongside their clinical colleagues.  In fact, if we want to provide quality health care to our children and their children, we will need nurses to play a stronger role, particularly in primary care settings like the family doctor’s office. 

A new study from the Canadian Academy of Health Sciences explores the clinical division of labour that will support a health care system that serves all Canadians.  The report is called “Optimizing Scopes of Practice:  New Models of Care for a New Health Care System.”  The upshot of their analysis is that the current, limited range of activities for nurses and other regulated health care professionals is more a result of past practices and politics than evidence or even legal rulings of clinical responsibility.   

The limits exist despite the broad training that we offer nurses.  As one of the report authors, Ivy Lynn Bourgeault says, when it comes to nurses and other professionals, “we train and then constrain.”   This means that nurses are capable of taking on a wide range of roles, but are then limited when they enter the workforce –by the expectations that have developed through decades of habit and politics. 

The report calls for us to approach the issue of “scope of practice” from the dual perspective of flexibility and accountability.   Its authors argue that we need to develop roles that are based on patient and community need, rather than habit and historical pattern.  They also suggest we see the issue through the lens of “optimal scope of practice,” so that team-based clinics can evolve the best division of labour based on clinicians’ relative competencies, and aimed at meeting the health needs of their panel and the community.

I witnessed this dynamic several years ago when BC was developing its initiative to increase the availability of Nurse Practitioners.  A group of physicians and nurse practitioners spent over an hour demystifying their clinical roles, revenue sources and range of activities to each other so that we could lose our assumptions and approach the integration of nurse practitioners from a new perspective.  My fear is that as the cost of health care systems rise, we may not have the luxury of limiting this dialogue to small group discussions.  We need a critical mass of innovation to introduce interdisciplinary team-based care if we want to bend the cost curve in a meaningful way. 

In my recent blogs, I describe how doctors doing less of what we have come to expect, can result in better and more convenient access to quality primary care treatment and prevention.  This is only possible if we reimagine clinical culture and workflow from a fresh perspective that defines “scope of practice” through the lens of patient health and safety, provider wellness and system sustainability.   I think that enabling the full range of activities that nurses can do to keep us healthy should be a priority for all of us who appreciate what nurses already do! 

In my next blog, I’ll describe governance and collaboration models that will help move these changes forward.  In the meantime and if you’re interested, you can find the Executive Summary of Optimizing Scopes of Practice here:   http://www.cahs-acss.ca/wp-content/uploads/2014/05/Optimizing-Scopes-of-Practice_-Executive-Summary_E.pdf

 

Why Doctors Working Less Means Healthcare Can Deliver More Part 2

In my previous blog, I described one perspective on how health care can do more with less…or more precisely, how inter-professional collaboration will improve access to family doctors, improve quality of care and create work places where many young doctors (and other clinicians) want to practice.

Dr. Kristy Williams is another BC-based family physician resident who sees a future in team-based care for a different reason:  she envisions new models that enable her to provide the kind of care that prevents people from having to visit their doctor in the first place!

Kristy realizes that there are limits to what a doctor can do – especially if we look at our health care system as means to balance both patient health and clinician self-care.  By working as part of a team with nurses, pharmacists and patient advocates, she feels well have a better system for everyone:  “We should be looking at models where patients feel better supported and have the tools to follow through on treatment plans. Research shows that up to 50% of patients dont fill their prescription.  Do we know why this is the case? We need get more patient involvement and feedback to help identify how care can be more appropriately delivered and I think that means breaking down the idea that working solo is best.  ”

Kristy feels that if we are able to do this, well be better able to assist patients to achieve health, and more importantly, to maintain health:  “If we address discrimination between types of clinicians with different training we will be able to focus on what we all bring to the care of the patient.  I’m personally inspired how we could mobilize upstream interventions, like using community gardens, art and social programs to prevent illness.”

Like many younger doctors, Kristy sees the fee for service payment model as a barrier to providing this kind of care: “Fee for service takes away from the focus on the patient, and its not sustainable because its not fulfilling for many physicians entering the profession.”  By encouraging limits like “1 problem per visit” it moves us away from providing truly comprehensive care and solutions that fit the life circumstances of people outside of the clinical setting.

From my conversation with Kristy and other younger doctors, we have an opportunity to shift our primary care system towards more and better care, with doctors working as part of a team and sharing responsibilities.  This reduces the burden of care solely on physicians…in other words enabling more to be done with less. In my next article, Ill be speaking with a young pharmacist who sees his future as part of a team with doctors and nurses.   I will also describe a new initiative that will develop models of care to increase physician and practice capacity by involving citizens in their design and operation. 

What do you think about a future where health care delivers more with less?

Why Doctors Working Less Will Mean Healthcare Delivers More, Part 1

It sounds like a contradiction to say that someone working “less” will do more, but in primary care that may be the case.   Currently there is a culture shift happening among family doctors – many younger doctors don’t want what the previous generation had: responsibility for opening and operating their own family practice clinics where the doctors are supported by a receptionist, but otherwise do everything from soup to nuts.

I sat down with Dr. Daniel Heffner, a pharmacist and now family practice resident in Vancouver.   Dr. Heffner is currently working in one of VCH’s Community Health Clinics, and looking forward to his career as a family doctor. Beyond his talents as a clinician, Daniel is also a virtuoso flamenco-fusion guitarist.

Daniel identifies himself as part of a new breed of family physician who loves being a generalist but doesn’t feel like it’s possible to do everything perfectly for every patient on his own.   Daniel says: “providing care is so complex now.  For example, prescribing used to include detailed knowledge of only a few categories of drugs, but now the number of new medications, complex indications and the circumstances of every patient make it challenging even for specialists to make the best decision within their area of expertise.” 

Another issue we discussed is a culture change among many young doctors.  Younger doctors want to have a healthy work-life balance and time to raise their children, something that is difficult when doctors have responsibility for operating a health care business business and providing comprehensive care for their patients, with little or no support.   

So how will it be possible for family doctors to provide the best care as a generalist in an age of great and increasing complexity?    And how can we have a system that provides more care to more people with more complex conditions, when many in the next generation of GPs wants to do less of what we have come to expect of family doctors?

A new way of providing care can help us achieve more with less, according to Daniel. Working as part of a team that includes physicians, nurses, pharmacists and other care providers will bring a range of expertise to the diagnosis and treatment of illness, so fewer errors will be made.  We discussed primary care settings where nurses will be a core part of continuous care, by being an initial contact and supporting the patient’s treatment plan.  Pharmacists will use their specialized expertise to determine the right medicine for each person’s personal and health circumstances. 

In this situation, doctors can focus on what’s important – the continuous care of the patient, the diagnosis of disease, and the best course of action to treat the patient and their illness.     With a team of providers available, patients can get easier access to the care of their family doctor, avoiding trips to a walk-in clinic or emergency department.

It’s not just about adding more clinicians to the mix – doctors will always be the lead in diagnosing and prescribing treatment.  The change requires working in a different way so that doctors can be freed up to focus what’s important.   Daniel thinks that’s good for him, that it’s the way that many clinicians want to work, and it will ensure quality of care and access for patients.

Daniel points out that “the new generation of doctors are still Type A:  we want to be all things to all people.   But now we realize that better care for patients results from involving the patient and other care providers.”  Working in this way strengthens the doctor-patient relationship because “the doctor is able to focus on what’s most important to the patient.” 

Daniel also wants you to help figure out the solution.  He says: “Society needs to decide what kind of care they want, and then help make it happen.  Do people want access, shared care, community health centres?  Do they want a situation where doctors operate as a business?  There is an opening for citizens to get involved in shaping the health care system.”   

The time is right for new primary care models that will improve access and be functional for the younger generation of clinicians.  In my next article, I’ll discuss how new models can expand the range of preventive services provided by a new generation of team-based clinics to improve wellness.

Incidentally, Daniel is also a virtuoso flamenco guitar player – you can check out his videos at www.danielheffner.com or catch him live in Vancouver or Calgary.

 

 

Why Social Enterprise will Help Save Healthcare in BC

A woman in my neighbourhood was diagnosed with late stage colon cancer by a doctor a walk-in clinic.   She was given two years to live, and recently passed away after three years.  The reason she was diagnosed too late for medical intervention?  She couldn’t find a family doctor. 

In Vancouver where I live, over 120,000 people don’t have a family doctor, and another 25,000 arrivals are expected each year.  That means the problem will get compounded, as new arrivals to Vancouver are the least likely to have a doctor – even after being here for 10 years.  

Who will solve the problem?  Getting family doctors to take up the slack is unrealistic for two reasons.  First, they are already working at or over capacity.  Second, even if each doctor in Vancouver took on another 150 people as patients, their patients would have to wait longer for an appointment.   We could recruit and retain more doctors, but those efforts would only solve the problem for a short time.

What we need is innovation in the way that primary care is provided, to multiply the impact of the doctors we have now.  Most system experts believe that involving nurses and pharmacists as part of a team of care, is the best way to increase access to family doctors without increasing costs to the system.  After all, it is comparatively expensive and time-consuming to train doctors, so increasing their efficiency through team-based care is a good long-term investment.

However, consider that changing to team-based care requires a different business model, and we can’t expect family doctors – who are at the same time business owners – to absorb the risk of changing their model of care in BC…If a family doctor hires a nurse to help provide care, they have to pay their salary and risk reducing their main source of income.  Some are ready to take on this challenge, but many are not.

Enter the social enterprise: non-profits that embody a hybrid of business and community values that have the ability to change the game.  Social enterprises can absorb the risk of exploring new models of care.  Good ones can imagine, build and operate family practice clinics in new ways, so that doctors can focus on doctoring and more people can have a family doctor.  If done well, we could find a model that ensures that our children will have a strong health care system as well.  

Examples are already out there.  REACH and Mid-Main are non-profits that have operated interdisciplinary care models for decades.  There are community dental clinics that have found a way to remove the barrier of cost for low-income individuals and families using a business model that reinvests any profits into free treatment.   In White Rock / South Surrey, a non-profit clinic operated by a group of family doctors and Fraser Health, has helped to make a primary care provider available for everyone…without family doctors having to shoulder the entire burden themselves.

BC’s healthcare system is being pressed from all sides.  We need enterprising non-profits to help us find new ways of making a continuous relationship with a primary care provider accessible for everyone.

In my next blog, I’ll describe how the next generation of primary care providers have the right stuff for saving universal healthcare in Canada, partly because they will work shorter hours than previous generations of family doctors.

 

 

 

Playing with our future

Canadians repeatedly and proudly say that our health care system is the most treasured piece of our cultural identity.  Some say it’s our highest expression of how we care for each other.  But what role are we really playing in maintaining the health of the health care system?  Like most aspects of democracy, our role is in transition, and I’d think we can find better ways to put citizens at the centre of health care.

Great efforts are being made to involve people in maintaining their own heath care, improve the planning of health care initiatives and the processes that patients are given so that they can have better health.   But the complexity of the system is a big barrier to getting a wide range of perspectives.  It's complicated, filled with political and professional tension, and very expensive.   Because of this, we often feel that people who have specialized knowledge about how the system works are the only ones who can provide informed input into changing the system.  At the same time, many doctors I work with want to get input from people who have no specialized knowledge of the sector, or the workings “behind the curtain.”   They want to understand how the impact of changes that make the system work better for providers will affect their therapeutic relationship with patients and their patients’ families / caregivers.

Many are looking to expand the range of ways we engage people in improving the health car system.  New apps engage people in playing games that inform them about ways to improve their health, and connect people with others facing the same chronic conditions.   There is evidence now that millions of people use a health app on a regular basis, and while they might not increase diagnostic abilities, they play a role in raising awareness of habits that improve our wellness

Improving the system so that it is sustainable requires that we close the loop on citizen engagement even more profoundly than we do now through surveys, public health announcements and engagement programs.  After all, we’re not just the beneficiaries of and believers in the system.  We’re also ultimately the funders.

I’ve been looking at ways we can involve people in designing a system that works for us and for care providers, without requiring specialized skills.   As much as the health care system is complex, there are patterns in the behaviour of system elements that can be understood and interrupted.   People can understand complexity if it’s presented to them in a way that is meaningful.  Gamification shows us that we need to think outside the box for ways to connect, engage and improve our collective responsibility for a system upon which we all rely.

In the next month, I’ll be offering an opportunity for people who know the system well – patients, professionals and policy-makers – to create a shared pool of knowledge about how we all respond to changes in the system.  Then I’ll be asking game designers and coders to build a tool that helps us to play, explore and discover new potential in our health care system…stay tuned!

Involving the people who matter most to improve health care

November 13, 2014

My interest in health care is personal and generational – I want my kids and their kids (and all Canadians) to have timely access to quality care.   What a great time to reflect on real system change in health care.

Last year, I led the work of the Vancouver’s A GP for Me initiative.  Through that process, which held great promise for increasing the capacity of primary care in Vancouver, we carried out an unprecedented engagement of family doctors and citizens.  Starting with family doctors and staff from Vancouver Coastal Health and Providence Health Care, we framed the issue around the fundamental nature of the therapeutic relationship, which resonated strongly with doctors.   They identified and shortlisted the most feasible and impactful strategies for improving primary care, both in clinical settings and across the sector.  This work involved over 500 family doctors, which means that about half of all family doctors in Vancouver helped to define these.

We distilled those ideas that had relevance or would impact citizens as they made use of health care, and then took those ideas to the people of Vancouver.   Again, we approached citizens through the same lens that we used for doctors:  the importance of the doctor-patient relationship.  Through on-line and in-person engagement of several thousand citizens, we found a few exciting things:

1.    Both doctors and patients / citizens feel strongly that everyone should have a family doctor, and everyone understands the gap it creates when someone doesn't have a primary care provider;

2.    Both would prefer that a patient see their family doctor rather than a walk-in clinic or the Emergency Department

3.    Both would be willing to make trade-offs to improve the strength of their primary care relationship, and make it more convenient to seek care at their family doctor’s office.

Based on these and many other findings, the Vancouver Division developed a plan and has received funding to implement changes and work in partnership with the health authorities.  I have high hopes that the resulting projects will be the seeds of primary care improvement in this great city. 

It’s also led me to reflect on the nature of the health care system itself and how we can involve citizens at a deeper level - in shaping the system of care - without requiring everyone to become fully educated on the nuts and bolts of the health care system.  In my next blog, I’ll start to describe some of the different disciplines that I think we can combine to involve all of us in improving a system that is so vital to our sense of national identity and to our lives.