Opinion piece originally appearing in the Montreal Gazette
_thinkstockphotos-512297766Primary care is at a crossroads in Quebec. Over the past 15 years, there has been a major paradigm shift, with primary care and family medicine delivered through the GMFs (groupes de médicine de famille) being recognized as the foundation of our health-care system.

Accessibility, continuity and coordination of care, however, are still clearly a point of great dissatisfaction for the public and frustration for clinicians. No wonder the public, clinicians and administrators are generally in agreement with most of the government’s objectives in this area.

Yet, there remains serious uneasiness. The past year has been challenging and unsettling. There have been rapid, successive and imposed changes with Bill 10, Bill 20 with the last minute compromise with the Fédération des médecins omnipracticiens du Québec, as well as two new GMF management frameworks. We have still yet to understand the full impact of these policy changes on accessibility and quality of care.

As speakers and organizers, we were actively involved in the recent symposium Toward a Common Vision for Primary Care in Quebec. Organized by McGill University’s Department of Family Medicine and Institute for Health and Social Policy, the symposium assembled a capacity-crowd of 300 clinicians, administrators, patients, students, family medicine and other specialty residents, policy-makers and academics eager to engage in respectful public policy discussion and to claim a real stake in the design and improvement of the health-care system. Participants and speakers from Quebec, Ontario and the United Kingdom all emphasized that successful policy requires developing and promoting a shared vision in the population and among front-line workers. Effective implementation also requires iterative improvement through public consultation, accountability and clinician engagement.

Participants identified the following problems in the government’s approach:

Lack of respectful public discussion;

A top-down approach based on union negotiation;

Excessive centralization and micro-management by the ministry;

Over-reliance on fee-for-service-based economic incentives for physicians;

Little reference to quality improvement.

Patients and communities feel disenfranchised as control over, and identification with, their local health-care institutions have slipped away. This has led to disengagement and discouragement felt not only among front-line workers, but also by the general public.

The recent announcement of the creation of the “super-clinics” is a telling example. There was no real discussion involving the public or clinicians, and no clear vision as to how the super clinics will fit into the still-developing GMF mission. In fact, discussion has, for all intents and purposes, been reduced to debate in the media between the minister and the FMOQ on how many hours these clinics will be open on weekends.

The symposium was filled with a great deal of positive energy with participants calling for solutions based on key elements discussed through the course of the day. Key recurrent themes identified include:

Patient, population and community engagement and responsibility with local governance of primary care, including GMFs, based on principles of transparency and accountability;

Accountability to the community and the population based upon clear quality and management objectives;

Change based upon a user-centred design process and on innovation and entrepreneurship, which promotes diversity and pluralism rather than a one-size-fits-all approach;

Quality improvement based upon peer-led process;

A collaborative, interdisciplinary approach based on the partnership between the primary-care team (physician, nurse and other health-care professionals) and on the patient experience at the core of the clinical model.

A broad discussion bringing together the general public, clinicians and administrators is required for innovative solutions, a mobilizing vision and policies that are as equally attractive to the public as they are to front-line workers. Only then will primary care become the true cornerstone of our health and social-services system.

Howard Bergman is chair of the Department of Family Medicine at McGill University. Daniel Weinstock is director of the McGill Institute for Health and Social Policy. This article is co-signed by Claude Castonguay, Jean Rochon, Michel Clair, Léonard Aucoin, Magalie Bigras, Miriam Boillat, Roxanne Borgès Da Silva, Sophie Charland, Jean-Louis Denis, Annick Gauthier, Mark Karanofsky and Anne Usher.

May 26, 2016