Innovative thinking required in health care
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The public in Manitoba has little exposure to the “business” of medicine. Recent coverage of the financial challenges of the Manitoba Clinic highlights a problem: the lack of high-earning specialists willing to pay rent to their colleague-owners of the new state-of-the-art building.
While this is an indication of a shortage of specialists in Manitoba (we have the third-lowest ratio of physicians to population in Canada), it is not the underlying problem our health-care system faces.
Our health-care system is once again overwhelmed — not just by the pandemic, but by the fundamental flaws the pandemic has exposed. Manitoba, like other Canadian provinces, has seen an exodus of nurses and physicians based on their pandemic experience. This has been imposed on a system that had no reserve capacity, as a result of the long-overdue health-care transformation which unfortunately resulted in, among other consequences, staff dissatisfaction.
The opportunity to transform an outdated, poorly functioning system was sidetracked by the government’s focus on cost-saving. Instead of building an integrated, primary-care-focused system that can meet most of the needs of the population through community-based services, the process of transformation was started in the hospital system.
We saw the results of this when Manitoba was forced to transfer patients out of the province during the height of the pandemic. The province cancelled thousands of necessary surgeries, and widespread staff burnout occurred.
Winston Churchill once said, “Never let a good crisis go to waste.” We should take advantage of our current health-care crisis to fix community-based care in Manitoba.
The recently announced Virtual Emergency Care and Transfer Service is an example of innovative thinking. The service is, however, focused on rural care only, and does not address community-based (primary) care. The Manitoba Clinic’s financial crisis may present an opportunity to convert a specialist-focused clinic into an integrated, primary care-focused hub for patient-centered care.
There is plenty of international research that confirms the importance of primary care in high-functioning health-care systems. These are systems that provide cost-effective care to benefit the population. The same research ranks our Canadian system relatively poorly in terms of being primary-care focused.
This is the opportunity, then: we can do more with less by enhancing primary-care services, which are less costly than acute hospital-based care.
A strong primary-care system will increase our capacity to prevent illness within a strong relationship-based care environment. We are more likely to seek and take advice from family doctors and nurse practitioners whom we know and respect. The advice we receive is more likely to be relevant and practical if it comes from somebody who knows us and understands our values.
This may lead to lifestyle changes such as smoking cessation, increased physical activity and other stress-reduction techniques that have all been shown to be beneficial. A thoughtful discussion about the harms and benefits of vaccination with a trusted health-care provider is likely to lead to increased uptake of the influenza vaccine, preventing many emergency-room visits.
There are many advantages to strong, primary care-based systems. Sustained relationships with primary-care providers improves diabetes outcomes and care for other chronic conditions. Interdisciplinary team-based primary care has also become essential to making careers in primary care attractive to providers.
The current fee-for-service model of payment for family doctors does not support interdisciplinary teams, as there is no funding for other team members. Fewer medical students are choosing family medicine as a career, because fee-for-service does not support this crucial model of care.
The government of British Columbia recognized this, and in October proposed a new method of remuneration for family doctors that will encourage team-based care. These teams allow a wide range of health-care providers to contribute to the care of the patient in an integrated way.
An integrated system requires patient information to be shared to ensure a consistent approach to patient care. Manitobans assume that their health records are shared across multiple providers, but this is still not the case.
We cannot provide team-based care without the seamless sharing of information, nor can we provide continuity of care between the community and hospital (when hospitalization is necessary) without real-time, two-way information sharing.
These are not new problems, but it is time to address them.
The shortage of health-care providers that is causing our current crisis is directly related to our inefficient and dysfunctional system. The solutions may involve increased costs in the short term, but failing to address the challenges will only perpetuate the problems.
Alan Katz is a professor in the departments of community health sciences and family medicine at the University of Manitoba.