Better Together

Primary Health Care (PHC) is often described as the foundation of the health care system. As quoted from the Nova Scotia Health Authority (2017), "a strong primary health care system supports citizens and communities to be healthy, build partnerships and flourish and enables them to receive the right type of care when and where it is needed most and over time, reducing demand for hospital-based care.” The current health care crisis taking place in Nova Scotia only emphasizes this and points out the significant need of improved PHC in the province. There are currently over 40,000 people without a family physician and the number of Emergency Room visits has doubled over the past few years from this group (www.turpinlabs.com, 2018). This health care issue needs to be addressed immediately or it will only continue to get worse.

It is important to understand what PHC consists of when looking for solutions and to ensure all stakeholders are in agreement of the system’s needs. According to Doctor’s Nova Scotia (2017), “ it is the first place people go for health-care or wellness advice and programs, treatment of a health issue or injury, and diagnosis and management of a health condition.” This definition of PHC is accurate but really only describes one level of primary health care. It reflects the intentions of the current Canada Health Act (1984), which legislates that all citizens must have access to insured health benefits. At the time of the Canada Health Act formation, the focus would have been services provided by physicians and hospitals and the treatment of injury and illness. In an article by Flood et al. (2016), they discuss the need for reformation of the Canada Health Act to meet current health care needs. Over time, it has been recognized that a change in how health is defined and achieved needs to take place in order to maintain the health system including primary care delivery. A more current definition for PHC proposed by Kringos et al. (2010) is that it is, “a multidimensional system that has a responsibility to organize care for individuals across the continuum of care and understand and work with our partners to improve the health of our communities.” This type definition adds a health prevention and promotion layer to primary care and creates the need for the issue to be addressed from multiple levels.

At the national level, the need to reform PHC was first recognized by the Canadian Government in 2000. It is suggested on the government website that the key feature of PHC reform is a shift to teams of providers and there is growing consensus that family physicians, nurses, and other professionals working as partners will result in better health, improved access to services, more efficient use of resources, and better satisfaction for both patients and providers (www.canada.ca, 2012). To start this reform process, a transition fund was created to financially support each province and territory. This reform was further supported by the Romanow Report (2002) where he defines primary care as, “a mix of high quality healthcare for individuals and services for communities.” The report acknowledges that there is not a single model that will meet the needs at a national or even regional level. Reform is needed but each province needs to ensure the changes support their needs (Romanow, 2002). Despite this national movement, the plans for the future of Nova Scotia’s PHC system never progressed and this contributes to the crisis we are in today. Over the past few years, the Department of Health and Wellness (DHW) in Nova Scotia (NS) has made a renewed commitment to changing the model and philosophy in which primary care is delivered. This continues to be a key priority for 2017-2018 with the added recognition that we are behind many other provinces in this regard further emphasizing the acute need for change.

In order to understand the direction or model that would work best for NS, one needs to examine the population of the province and the current challenges of the system. The Nova Scotia Population Health Profile (2015) is a report that gives a snapshot of the overall health of the province identifying key factors and influences. From the profile, we see that NS the second smallest province with an overall population of just over 900,000. NS has many rural areas that have been experiencing a steady decline in population. There still remains a higher percent of rural populations compared to Canada and this has shown to contribute to poorer health compared with the general population. This makes service equity and resource allocation difficult. Nova Scotia is an aging population. Recent data shows approximately 22% of the population is over 65 years old (NSHP, 2015). NS has higher rates of Cancer, Diabetes, High blood Pressure, Arthritis, and Heart Disease, and Respiratory Disease compared to most other provinces. . These Chronic diseases have a significant impact on quality of life and economic growth accounting for 70% of the total economic burden of illness (GPI, 2002). Evidence has also shown that only about 25% of a person’s health status is based on the direct health care system (DHW, 2018). Most of what determines their health are these other social determinants that include employment, food security, housing, environment and income. NS does poorly when compared to many other parts of Canada in many of these areas as well. Overall, the cost of health care is rising and approximately 40% of the NS budget is already spent directly on health care. Without an increase in budget from the federal or provincial government, innovation and transformation are required to meet and sustain the health needs of the population. Taking these determinants of health into consideration along with the current population of Nova Scotia, the focus of PHC should shift to one of health prevention and health promotion while working in parallel to treat the immediate health needs of people and their communities. The image below outlines the proposed philosophy for PHC in NS.

Another key stakeholder in the changes to PHC are the users of the system. When patients were asked what the most important aspects of PHC were to them they listed accessibility, continuity, interpersonal communication and trust, health promotion, impact of care, and local health priorities (Haggerty et al, 2013). These are in alignment with what the government and health authorities also consider to be important and are present in the current direction they are taking with primary care delivery. The approach that has been presented to Nova Scotian’s is the formation of Collaborative Care Teams and ‘Health Homes’. A ‘Health Home’ is a person- centered, team-based primary health care delivery model that promotes access to timely, coordinated, comprehensive, and continuous primary health care (Primary Health Care, NSHA, 2017). The goal of the collaborative teams that are serving as health homes is to for them to be person and family centered, provide comprehensive care that is based on community needs and have timely access to the right provider. For these to be successful in Nova Scotia it must be recognized that the make up for the teams must truly reflect the needs of the specific communities and their populations. Some communities have a large proportion of elderly while others are predominately First Nations communities. These vulnerable groups are at increased risk to not having access to PHC that meets their specific health needs (Richard et al, 2016). One solution to address this suggested by Vanderbilt et al. (2015) is the use of a comprehensive team-based approach that brings extensive expertise to the local community that would otherwise not be present. This solution is found in the collaborative care team model for PHC delivery that is proposed. However, flexibility in the team composition is required to provide quality and equitable care.

Further challenges remain to improving PHC delivery using collaborative health teams. One significant concern is the access to a family physician. Although there is funding in place to create more collaborative teams, there remains an overall net family physician shortage. In a position paper by DNS (2017), it is clear that better access and greater attachment to a family physician leads to better health outcomes and they must be present on each team. In a paper by Bodenheimer et al. (2013) they do suggest multidisciplinary teams as a solution to this challenge but does indicate that the team role is not to replace the physician but allow them and other professionals to work to their full capacity completing tasks that are essential to their scope. It is going to take time and more investment in family physicians to not only attract them to our province but keep them here. Another challenge is the creation and implementation of an integrated electronic medical record (EMR). The current electronic health system records across the province do not communicate with each other, let alone with other provincial departments. For example, the EMR that the centralized lab uses is not integrated with the EMRs of family physicians. This is costing us time and the ability to provide quality care. The most recent effort to address this communication gap has been One Patient, One Record (OPOR). This project also requires further investment of resources and time but is an essential component to the future PHC in NS.

Overall, PHC issue in Nova Scotia is complex and challenging. If we are going to improve our population’s health and quality of life it will require continued investment from many stakeholders across the province and country. This system transformation is critical to Nova Scotia being able to move forward and solidify the foundation of our health system, primary health care. Watch the short video at the top to learn more on PHC in Nova Scotia.

References

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Barclay, K. & Fletcher, L. (2010). CHSRF Knowledge Transfer: Policy Priorities for Primary Healthcare Improvement: A National Conversation. Healthcare Quarterly, 13(2). Retrieved from: http://www.longwoods.com/content/21681

Bodenheimer, T. S. & Smith, M.D. (2013). Primary Care: Proposed Solutions to the Physician Shortage without Training More Physicians. Health Affairs, 32(11), 1881-1886.

Doctors Nova Scotia (2017). Fixing Nova Scotia’s Primary Health Care Problem: Physicians’ Recommendations to Improve Primary Care in Nova Scotia. Retrieved from: http://www.doctorsns.com/site/media/DoctorsNS/primary-care-position.pdf

Edwards, et al. (2017). Functions and enablers of the primary health care system. Manuscript in preparation.

Flood, C.M., & Thomas, B. (2016). Modernizing the Canada Health Act. Dal LJ 397; Ottawa Faculty of Law Working Paper No. 2017-08.

Government of Canada. (2011).What determines health? Retrieved From: https://www.canada.ca/en/public-health/services/health-promotion/population- health/what-determines-health.html#eviden

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Kringos, D., Boerma, W., Hutchinson, A., Van ser Zee, J., & Groenewegen, P. (2010). The breadth of primary care: a systematic literature review of its core dimensions. BMC Health Services Research, 10, 65.

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Nova Scotia Department of Health and Wellness. (2016). Physician Resource Plan: Base Forecast Summary by Speciality by Zone. Retrieved from: http://novascotia.ca/dhw/ShapingPhysicianWorkforce/docs/BASECASE-Forecast- TOTAL-2016-to-2025.pdf

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Primary Health Care, NSHA (2017). Strengthening the Primary Health Care System in Nova Scotia. Evidence synthesis and guiding document for primary care delivery:Collaborative family practice teams and health homes. Nova Scotia: Primary Health Care, Nova Scotia Health Authority.

Public Health Agency of Canada. (2013).What makes Canadians healthy or unhealthy? Population health approach. Retrieved from: http://www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php#gender

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Vanderbilt, A. A., Dail, M. D., & Jaberi, P. (2015). Reducing health disparities in underserved communities via interprofessional collaboration across health care professions. Journal of Multidisciplinary Healthcare, 8, 205–208. http://doi.org/10.2147/JMDH.S74129