Where have all the clinics gone?

Access to primary care is a problem. Despite many programs and possible solutions, patients across Canada continue to struggle to find a family doctor. In fact, according to the Canadian Institute of Health Information, we have the distinction of having the longest wait times in the developed world. André Picard suggested in his 16 February Globe and Mail column, “More than anything else though, what Canada needs to fix [in terms of] its systemic health-care woes is to create a semblance of a system. What distinguishes the countries that have markedly better results than Canada . . . is the cohesiveness of the system, and the emphasis on primary care.” And it makes sense—if you can’t get into the system in the first place, you lose the opportunity to use it effectively.

Canada has a unique model for delivering primary care in that the majority is publicly funded but privately delivered. Physicians’ offices generally are privately owned, and these offices provide most of the primary care in this country. In BC there are alternative funding models in some smaller communities, and there are some primary care clinics that are owned and administered by the government and health authorities—but these are few.

In BC and across Canada, doctors and governments are supporting multidisciplinary team-based care and working toward developing a patient medical home. Success will require infrastructure, creative thinking, and a willingness to work together. We are moving forward, and we are designing community-based plans to expand primary care access. Much of the planning includes leveraging existing clinics and resources, and adding network linkages and supplementary support from allied health professionals.

But then came 18 July 2017, when Finance Minister Bill Morneau announced plans to change the way private corporations are taxed. “What does this have to do with primary care?” you ask. Well, remember the bit about most clinics being privately owned? And how we need a willingness to work together to ensure success? The government wants to change the rules mid-stride.

Incorporation has been a legitimate and widely used legal option for structuring a small business since 1970 in British Columbia; 67% of BC physicians are incorporated. Taxing money in a corporation at a lower rate allows business owners to accumulate money in the corporation to run the business. Owners can also use this money to fund maternity leaves and sick leaves and plan for retirement. Money in the business is taxed when it is drawn out, which does defer but not eliminate tax. Many businesses use this structure, including farmers, tradespeople, pharmacists, lawyers, and accountants.

The proposed changes generate a huge amount of uncertainty. Physicians considering retirement may be encouraged to do so immediately, or lose a significant portion of the money they have put aside for this. New graduates could be discouraged from establishing or buying into full-service family practices because of uncertainty around business viability. Becoming a locum or working in certain focused practice areas will be more stable. For new graduates with huge debt loads, stability matters.

Doctors of BC launched a communications strategy and asked for your input. We developed a toolkit to share information and help individual physicians respond to the government. We prepared a submission for the Department of Finance consultation. We worked with the CMA and other provincial and territorial medical associations to advocate for our members. The CMA worked at the national level with other affected small business people. In August, I participated in a delegation that met with the Minister of Finance in Ottawa, and in September I participated in a women’s roundtable that developed a presentation for the Liberal Caucus in Kelowna.

The vast majority of physicians we heard from oppose the tax changes as proposed. I am respectful of the fact that there are different opinions around these difficult matters. However, we are sharing stories from physicians who operate small businesses highlighting the specific ways in which this legislation affects them.

Negative impact on the infrastructure around primary care will affect access for patients to both GPs and specialists. In addition to the negative impact on the health care system and the physicians who work in it, this legislation could cripple small farms and family businesses. Our hope is that advocacy will turn the tide and modify these proposals in a way that is fair for small business people across Canada, including physicians, and for our patients. The consultation period has ended. Now we wait.
—Trina Larsen Soles, MD
Doctors of BC President