The entrance to the emergency department at Peter Lougheed Hospital in Calgary on Aug. 22, 2023.Jeff McIntosh/The Canadian Press
Despite loud concerns that Alberta’s plan to dismantle its health care system into four separate organizations will fracture an already fragile system, there is quiet hope in some quarters that the change will be an impetus to strengthen and modernize primary care.
Hundreds of thousands of Albertans are without a family doctor, which is adding to the crisis in the provincial health system where emergency departments are overflowing and hospitals are on the brink of collapse. Health Minister Adriana LaGrange has stressed that the plan to overhaul the health care system will improve primary care and will help alleviate this strain. But experts say to see real change, the government must address a myriad of challenges unique to this field of medicine.
Family doctors and academics who spoke to The Globe and Mail say the dominant fee-for-service compensation model does not facilitate team-based care and that flawed attraction and retention strategies have resulted in dead zones for health services, primarily in rural areas.
“It really still is, in many ways, the 1970s here,” said Lee Green, a professor of family medicine at the University of Alberta. “But what patients need is not the ‘70s. We have older patients with multiple chronic conditions that need organized, systematic, proactive care, not just acute visits when they’re sick. We haven’t built our system around that.”
In November, Alberta Premier Danielle Smith unveiled her plan to divide the province’s consolidated health system into four sector-specific organizations, focused on primary care, acute care, continuing care and mental health and addictions. Ms. Smith said these new agencies will right the wrongs of Alberta Health Services (AHS), which she claims fumbled its management of the system, leading to family doctor shortages and lengthy emergency room waiting times.
But AHS was never responsible for primary care in Alberta – in fact, no single organization is. Instead, roughly 1,000 clinics are owned and operated by physicians who receive funding through Alberta Health, the government department.
That’s why a new organization dedicated to primary care is being welcomed by some in the field but, they say, the devil will be in the details.
Alberta’s health care system struggling with overflowing hospitals
Cassandra Hoggard, a family physician who practises in Calgary’s bedroom community of Okotoks, said Alberta has “one shot” to take the bold action required to improve primary care. “I’m banking my career on it,” she said. “If it falls flat, I don’t know how much longer I can stay in primary care and I’m the most engaged family doctor I know.”
It’s already too late for some, she said. Many doctors have already left because of poor working conditions and it’s even worse in smaller communities.
“Rural medicine is like a tightly woven tapestry, and you can only pull a few threads before it totally unravels,” said Dr. Hoggard. “The loss of that primary care physician not only threatens your access to a family doctor, but also your ability to keep your hospital open or to provide maternity medicine, or hospice or long-term care.”
A major concern is the dominant fee-for-service payment structure for primary care – in Alberta and across Canada – where physicians are reimbursed for services rendered. This means doctors who see more patients can make more money, often putting quality of care second to quantity. This system creates an incentive for physicians to practise in higher-population areas and a disincentive for using interdisciplinary teams of health professionals, like nurses and pharmacists, to provide care.
For team-based care to work, the role of primary care nurses should be standardized, said Melissa Waddell, president of the Alberta Primary Care Nurses Association. Her organization has put together a preliminary guide but Ms. Waddell said this task should really be taken on by primary care networks, postsecondary institutions and the government – a “very basic thing before you start doing interprofessional collaboration.”
Alberta announced in November that nurse practitioners will be able to open their own primary care clinics under a new funding model. This plan came under swift criticism from some doctors who said their work was being devalued and disrespected.
In late December, Ms. Smith also announced that $200-million in funding from a $1.1-billion bilateral agreement with Ottawa will be used to stabilize struggling clinics in the province until a new compensation model is in place. She provided no further details.
“Regardless of who you bring in, whether it’s nurse practitioners or more family doctors, the system still prohibits the kind of care that is necessary to keep our health system and our communities healthy,” said Dr. Hoggard.
An added layer of complexity is fallout from the COVID-19 pandemic that hammered the health care profession and left workers exhausted and traumatized, which was only exacerbated by work force shortfalls, explained Janet Reynolds, medical director of the Calgary Foothills Primary Care Network. She added that there is also a generational shift in the profession where new doctors are less interested in becoming business owners because of the financial and administrative burden.
That’s why more options for alternative funding models are needed to strengthen the ability to provide team-based care, which is one of 11 recommendations laid out in the Modernizing Alberta’s Primary Health Care System (MAPS) report, co-led by Dr. Reynolds.
Another recommendation is that primary health care funding should be substantially increased and aligned with delivery and accountability. This is also true for Primary Care Networks, which support groups of primary care physicians in a certain area and vary in size.
Braden Manns, a professor of medicine at the University of Calgary and former interim vice-president for AHS, said for real change to take hold, provincial priorities need to be clearly outlined, mandated and measured by the new provincial organization. For example, he said these metrics should address high-volume billers who are, in some cases, providing substandard care while churning out patients.
He pointed to neighbouring British Columbia, which implemented a new payment model to stop family doctors from leaving their jobs. It raised the full-time salary of a family doctor to about $385,000 from $250,000. Dr. Manns said B.C., however, erred in not tying the salary increase to accountability measures.
Someone with a deep understanding of primary care, such as a respected family doctor, is needed to lead Alberta into the future, said Dr. Manns. It must be done by someone who is arm’s length from government, he added, but said the United Conservatives’ tumultuous relationship with doctors over the past five years gives him reason to believe they won’t “give up control.”
Right now, there is optimism, however cautious, that the government could bring primary care in Alberta into the 21st century.
But, Dr. Hoggard said, you can’t bank on hope: “We need action now.”