There are many challenges which face us in delivering quality healthcare in the community. I will outline some of these challenges in this article, but first I want to provide some background and illustrate how we came to be where we are today.

In the early days, after World War II, our current health care values of social justice for all were firmly established. In those days, most Canadians had a personal family doctor and family doctors were the main providers of care throughout the system.

With the growth of our population, and rapidly expanding technology, more and more emphasis was placed on hospitals and specialist care. Gradually, it became obvious that this was a hugely expensive way to deliver care and efforts to control costs were introduced. These included reduction in the numbers of physicians and hospital restructuring. The reduced number of physicians that we trained and an exodus of family physicians to the United States have led to a critical shortage of family physicians and other physicians within our system.

Thus, the first challenge facing our delivery of quality primary care is the shortage of family physicians. This critical challenge has to be corrected.

The College of Family Physicians of Canada's position statement is that: all Canadians should have access to a personal family physician. Ninety-five percent of Canadians should have access to a personal family physician by 2012. The best possible health outcomes can be achieved by the above plus enhanced access to collaborative care with other health professionals.

This statement is backed by strong evidence. At the University of Western Ontario, studies have shown that patients who have family physicians and have good relationships with those physicians recover faster from illness, require less testing and experience fewer consultations. They are also more satisfied with care than those who do not have such a relationship with the family physician. Studies done internationally by ¹ Barbara Starfield from Baltimore have shown that those countries with the strongest primary care systems in place have the best population health outcomes and spend less health care dollars achieving those outcomes. ²

With hospital restructuring, there was a requirement for more people to be treated in the community. Patients were being discharged from hospital earlier and sicker than before. In addition there was a substantial increase in our geriatric population. This continues to be an increasing challenge as the baby boomer generation faces retirement.

Currently, 12% of the population is over 65. This group counts for one third of the hospital admissions, two thirds of the hospital days, and their length of stay is double that of the younger population. The frail elderly, which represent 3% of the population, are using 30% of the healthcare resources, 25% of emergency department visits and 53% of the admissions through the emergency departments. These patients also have a high incidence of co morbidities. The chances of two or more disorders, existing in the same patient, over age 65 is 50%, and 75%, if they are over 75. These patients, with multiple co morbidities, utilize a lot of our resources and stretch our wait times.

As illustrated above, managing older and sicker patients with multiple co morbidities is a second major challenge for our system. With the shortage of family physicians, these challenges have to be met with a team-based approach to care. Primary care reform has provided us with a potential solution to this problem. The Family Health Team, at least in Ontario, is the mechanism by which allied health professionals work together with family physicians delivering care to a defined group of enrolled patients. Currently, over 8 million people in Ontario are enrolled in a primary care model.

This is one way of meeting the vision of the College of Family Physicians of Canada regarding interprofessional care:

All Canadians will have access to a family practice/primary care setting, where there is opportunity to have care provided by a personal family physician and a registered nurse and/or nurse practitioner. Other health professionals, including pharmacists, physiotherapists, occupational therapists, dietitians, social workers, physician and medical office assistance, may also be part of the practice.”

The Ontario College of Family Physicians has made this a key initiative: to provide support for family physicians practicing in primary care enrolled models. We believe that this is one of the most effective methods to deliver strong primary care to a large and needy community. We are supporting family physicians in these endeavors by enhancing the opportunities to acquire leadership skills, and the skills required for collaborative and integrated care.

Once again there is good evidence to support this mode of care delivery. The Integrated Physician Services in the Home, (IPSITH) was a pilot project in London, Ontario, through which patients who might otherwise have required hospitals admission were provided home-based services for up to two weeks by a multidisciplinary team, including a case manager, nurse practitioner, family physician and other health professionals as required.  Evaluation of this project was carried out by the Center for Studies in Family Medicine at the University of Western Ontario.³ Patients enrolled in the project were compared with patients utilizing home care services that were not part of the project. The findings were:

• Costs were more than those requiring usual home care services, but less than what would have been experienced had the patients been hospitalized.

• The patients involved were sicker than those requiring usual home care services.

• The patients treated in IPSITH utilized emergency services less.

• All participants in the model reported excellent satisfaction levels.

• This model provided a framework for integrating nurse practitioners with family physicians and providing community care.

In order to function efficiently, safely and collaboratively, the Family Health Team requires quality information technology. This is another major challenge facing those endeavoring to deliver quality community care, and, is a strategic initiative of the Ontario College of Family Physicians. We believe that appropriate information technology will enhance the quality and safety of patient care by having the right information available to all health providers at the right time. An integrated electronic patient record, with one record per patient that is shared by all health professionals would provide the best quality health care in our opinion. We do have some concerns however that this goal will be difficult to reach for several reasons. There appears to be the lack of an E-health strategy in some current government policies. Only 26 % of physicians in Canada were using an electronic medical record in 2007. Canada lags behind many other countries in providing information technology systems to support primary health care. In Ontario, there is a move to establish chronic disease registries. While this initiative is laudable, we don't want it to deflect attention from the goal of an electronic health record for all.

In Ontario, there is a move to establish chronic disease registries.In summary, the challenges facing our primary care health system today include lack of family physicians and increased complexity of care in the community. The strategies that will help us deal with these challenges include:

• Strategies to increase the number of family physicians to meet the goals outlined by the College of Family Physicians of Canada.

• Strategies to promote the Family Health Team and other methods of family physicians collaborating with other health professionals to meet the challenges of complexity of care in the community.

• Strategies to improve the quality and availability of appropriate information technology such as the electronic health record for all patients.

Attention to the strategies outlined above will go a long way towards helping Ontario's family physicians meet our goal: to integrate with Community Care Access Centers and other community agencies to improve the health of our patients and our communities.

references:

1. Stewart M. Reflections on the doctor-patient relationship: from evidence and experience. British Journal of General Practice 2005; 55(519): 793-801.
2. Starfield, Barbara. http://bostonreview.net/BR30.6/starfield.html
   
3. Stewart M. et al. Evaluation of an Organization for Integrating Physician Services in the Home. June 2002. http://www.chsrf.ca/final_research/ogc/pdf/stewart_final.pdf

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