A draft operational guide released by Health PEI last month states that every family doctor should be responsible for seeing 24 patients daily.byryo/iStockPhoto / Getty Images
Should family doctors be obliged to see a minimum number of patients daily? Should they also have a minimum panel of patients for whom they are responsible?
Those loaded questions are at the heart of a spat between the Medical Society of PEI (representing doctors in Prince Edward Island) and Health PEI (the provincial health care authority).
The debate also has repercussions for Canada’s 48,000 family doctors and the broader health system, as it touches on sensitive issues like physician accountability and autonomy.
Last August, the leaders of MSPEI and Health PEI were all smiles when they signed a new contract together. The new deal recognized family medicine as a specialty (a first in Canada) and promised family docs a 35-per-cent pay hike over five years.
The deal was an integral part of a government promise that every Islander would have a primary care provider by 2027 (currently, about 36,000 of PEI’s 180,000 residents are unattached).
On May 30, Health PEI released a draft operational guide, a document that sets out how the contract terms will play out practically.
Fairly standard stuff, except for one section stating that every family doctor should be responsible for a panel of 1,600 patients minimum and should be seeing 24 patients daily, for 15-minute visits each.
The MSPEI was not amused. The group threatened to sue Health PEI for breach of contract, saying these metrics were not included in the physician services agreement and that docs were not consulted.
This led to some furious backpedalling, with Health PEI CEO Melanie Fraser saying the targets were “maximums,” not minimums, despite the operational guide explicitly saying “minimum.”
Health Minister Mark McLane also weighed in, stressing that the operation guide was a draft, and there would be a six-week consultation period during which problems could be ironed out.
The minister insisted, however, that there must be some targets in place, and that the government has a “responsibility to measure” its spending, to ensure it’s getting value for its health care dollars.
That’s refreshing, because we don’t hear this type of call for accountability nearly enough from elected leaders.
Some 6.5 million Canadians don’t have a primary care provider.eggeeggjiew/iStockPhoto / Getty Images
Canada spends nearly $50-billion a year on physician services – 13.3 per cent of the country’s total spending of $372-billion on health care last year. About 70 per cent of that total is comprised of fee-for-service payments: doctors bill for services they provide, with the fees paid for each procedure set out in provincially negotiated contracts. The balance is paid in salaries or capitation (a set fee for overseeing a patient’s care).
A lot of that money is paid out without any clear expectations in return. Canadian doctors have a tremendous amount of autonomy. But autonomy doesn’t mean freedom from responsibility.
About 6.5 million Canadians don’t have a primary care provider. This has become a political hot-button issue.
For the most part, the response of governments has been to jack up the money paid to family docs – in PEI, it was a 35-per-cent hike. Other provinces, like B.C., have changed the payment model more fundamentally, paying not only fee-for-service, but an hourly wage to account for paperwork, and extra fees based on the complexity of patients.
PEI docs have argued that a panel of 1,600 patients is way too large, and that 24 patients a day is unrealistic.
But the real problem with these benchmarks is that they are too crude. The number of patients a doctor can see daily, and still deliver appropriate care, depends on their complexity. Proper panel size, for its part, depends on how care is delivered.
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Across the Western world, panel sizes for family docs range anywhere from 1,200 to 2,500.
Canada is decidedly at the lower end of the scale. In 2021 (the latest year for which data are available), the average panel size for a family doc was 1,353 patients. That is down markedly from the average of 1,746 patients in 2013.
In other words, doctors are now caring for far fewer patients. There are reasons for this, including the growing complexity of patients (driven by an aging population), and more attention being paid to work-life balance.
But these same issues exist in other countries. The problem in Canada is that doctors spend far too much time doing things that other practitioners could do more efficiently and effectively. In short, we don’t have enough teamwork.
There is also a decided lack of accountability in Canadian health care. We make very poor use of metrics and key performance indicators.
There is no question that every Canadian should have a primary care practitioner. But that’s not going to happen without more accountability and new ways of practising medicine.