The future of general practice

Looking forward over the next quarter century, never has there been a more appropriate theme song for the future of general practice than the off-key chorus of “The Times, They are A-Changin’” sung in the nasal twang of Bob Dylan. Why? Because, without a doubt, there are changes afoot; unavoidable changes wrought by the very baby-boomers that raised Dylan to the status of an icon, and uncertain changes being shaped by the politics of dealing with the fall-out of this demographic anomaly.

The leading edge of the baby-boomer bulge is now reaching into their 50s, and from this age on health-care expenditures almost double for every 10 years of life. The compounding effect of this exponential increase in per-capita health-care expense, plus the increase in the total number of older people will dramatically impact total health-care costs. Major research facilities have predicted that, over the next 35 years, health-care costs will rise at double the rate of population growth—just to maintain the same level of care, without any increases in technology! It is this spectre that is making both provincial and federal health-care ministers reach for their antacids.

At the same time that these demographics drive the demand for medical services through the roof, they will have the opposite effect on medical staffing. The majority of general practitioners are also boomers and they, too, will be wanting to retire. And who will replace them? Dr John Cairns, Dean of UBC’s Faculty of Medicine, has gone on record [including this issue—ED.] with some disturbing statistics. In British Columbia each year over 300 physicians retire or leave practice per year, yet we graduate only 120. Canada is not producing enough medical graduates to replace losses, and BC has the fewest medical students per capita of any Canadian province. Our province relies on the rest of Canada or beyond for 75% of its physician supply.

Traditionally, that supply has come primarily from Britain and South Africa but now, due to their own demographics, physician immigration from these countries is drying up. This spells a looming crisis in physician supply. Already, this shortage is being felt across the province. Doctors in both rural and urban areas are unable even to find locums for holiday relief, let alone replacements to take over practices. It is no longer unusual for a physician, retiring or moving, to have to simply close the office doors without a replacement.

Therefore, this much is certain: At a time when the demand for our services will be rising sharply, physicians will be a dwindling resource. Because of this fact, we are going to have to re-examine the way that primary care is organized to ensure that our resources are used to the best advantage. This will likely mean a migration of physicians into group practices and the demise of the solo practitioner office. It will also likely mean some type of team approach to primary care that utilizes other health-care practitioners. As physicians have the longest training and the greatest scope and depth of training, it will be important to maintain the pivotal role of the physician in any such arrangement.

What is uncertain about the future of primary care is the political fall-out from the above inescapable demographics. Already, both provincial and federal health ministers are calling for primary care “reform,” a term that is insulting for, without the dedicated hard work of we physicians, this system would have crumbled long ago. The main pressure behind these political calls for change is fiscal certainty, and the only remedy being offered is population-based funding or, in plain terms, capitation.

Under capitation a physician is paid a finite amount per year to care for each rostered patient, an amount that varies depending upon the patient’s age, gender, and the presence of specific target diseases. This will undoubtedly provide fiscal certainty, but will it provide patient care? What is escaping the proponents of such a system is that, once a patient is successfully rostered, service to that patient becomes a liability! It immediately places the practitioner in a conflict of interest: patient service, or personal gain? What is also escaping capitation proponents is that this system has been tried in other countries and has failed. The HMOs in the United States are notorious for their poor level of patient service. Recent media coverage from Britain has focused on waitlists, overcrowded facilities, and poor patient health-care outcomes measured against other developed countries. Simply changing the way physicians are paid will not make up for a lack of adequate funding!

The important thrust in general practice over the next several years will be twofold. First, to facilitate a process that is just starting in Canada—an open public discussion on what medicare shall provide and to whom. The current situation cannot continue, but not for the reasons that our political leaders espouse. It cannot continue because we can no longer perform our jobs in a system that promises all things to all people, refuses to adequately fund the needs of these people, and yet legislates against the provisal of any other alternatives. Second, during this process we must stick to our guns and protect what we have been able to offer so well and for so long: the ability to assure our patients that we act in their best interests as their independent health-care advocates.

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Dr Cavers is the president of the Society of General Practitioners of BC.