Capital Daily

Can Primary Care Networks Solve Greater Victoria's Family Doctor Gap?

Episode Summary

In late July, B.C.'s Ministry of Health announced their next steps in working to solve Greater Victoria's primary care shortage: the creation of four new Primary Care Networks, and the unveiling of a new Urgent and Primary Care Centre in downtown Victoria. We hear from Dr Kathy Dabrus, family doctor and member of the Victoria Division of Family Practice, about how she thinks this will help, and her hopes for the changes to come.

Episode Notes

In late July, B.C.'s Ministry of Health announced their next steps in working to solve Greater Victoria's primary care shortage: the creation of four new Primary Care Networks, and the unveiling of a new Urgent and Primary Care Centre in downtown Victoria. We hear from Dr Kathy Dabrus, family doctor and member of the Victoria Division of Family Practice, about how she thinks this will help, and her hopes for the changes to come.

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Episode Transcription

Disclaimer: This interview has been edited for clarity and length. 

Jackie: Hi, my name is Jackie Lamport. Today is Wednesday, July 28. Welcome to the Capital Daily Podcast. Today on the show, big changes are coming to healthcare in Greater Victoria with the announcement of four new primary care networks and an urgent and primary care center. So we speak with a family doctor to see how far this will go to address the region's primary care gap. 

Emily: As we've delved into on the show before, Greater Victoria has a serious issue with health care, specifically providing primary care to its residents. If you live here, you'll likely know how incredibly difficult it is to find a family doctor or even become attached to a nurse practitioner clinic. The number fluctuates depending on who you ask, but the last local health area profile put out by Island health in 2019 showed that roughly 25% of people in Greater Victoria are without a primary care practitioner. 

The province, however, has been working on solutions, and a big one for Greater Victoria was unveiled recently. Minister of Health Adrian Dix announced a new urgent and primary care centre in downtown Victoria on Pandora and Cook. At the same time, he announced the creation of four new primary care networks over the next four years and a mobile outreach unit that would support people experiencing homelessness and others struggling to access care. 

To break down what this all means. Urgent and Primary Care (UPC) centers are buildings where doctors, nurses, and other staff provide primary care to those who don't have family doctors. They also treat minor injuries that need attention within 24 hours but aren't life-threatening. Primary Care Networks (PCN) are linkages between family doctors and other health professionals like nurse practitioners and mental health therapists who can support family doctors already practicing. These four new UPCs will serve Victoria, Saanich and Oak Bay.

Adrian Dix (audio recording): This reflects the needs of the community that were established and put forward by the community. And I think that's a central part of what we're announcing today, what we're doing and what we're trying to do across BC.

Emily: Through these four new networks, the province hopes to hire just under 100 full-time health care providers that would serve around 200,000 people in the region. But staffing is an ongoing challenge. 

Adrian Dix (audio recording): It's a challenge to get the staff necessary, not just for these clinics. The primary care network really covers all of the existing clinics participating. I think it's 34 such clinics in BC in this area in the four primary care networks. So we're working with all of those clinics to support their staffing needs.  

Emily: In the face of a changing healthcare landscape, with fewer doctors choosing to set up independent family practices and other doctors retiring, the provinces are banking on the fact that team-based care is the way forward when it comes to attracting more general practitioners to the region. Today on the show, we're joined by Dr. Kathy Dabrus. She is a family doctor who works with the Victoria division of family practice. The division represents family doctors in the region. And they've been working closely with the province, Island Health and Indigenous community leaders on this announcement. Dr. Dabrus, thank you so much for taking the time to join us on the show today. 

Dr. Dabrus: Thank you for having me. 

Emily: So the state of primary care in Greater Victoria is something we've spoken about a lot on our show. And I wanted to get a sense of what you think overall. How will the introduction of these primary care networks change the face of primary care in the city?

Dr. Dabrus: Well, we know that it has been difficult to attract new family doctors to British Columbia. And partly is the style of care that has been going on in the community has a majority of practitioners working in single offices on their own, and therefore needing to look after running the business but also needing to be able to provide a lot of services to to to their patients, the idea of a primary care network is partly to, to encourage doctors to practice in groups to support each other, but also to help each other with overhead costs, running their business, but also to be there to cross cover each other, and support each other as we do on a daily basis sometimes when we have difficult cases, and things like that, so, so for the multiple levels of support, that especially new graduates are hoping to have as they go into practice, but the other part of the primary care network is recognizing that for a number of things that family doctors do in providing services, it would be possible and actually beneficial to have a dietician a pharmacist, a mental health and substance use worker council mental health counselors available on the team to provide these services. 

As family doctors, we're often trying to do some of these things ourselves. But other people in the community have training and skills and could be doing this part of the work in terms of assisting people with getting to a place of better health. And so, for many new graduates, they would also appreciate the idea of team-based care, where again, they're not trying to do everything all on their own. So PCNs have been established, and other communities in the province and Victoria are kind of in a mode. 

They used to call it wave one, wave two, and now they're proceeding as every community is ready to proceed with a primary care network. But what was really helpful in forming our primary care network was the family doctors working with Islander health working with the Ministry of Health, working with patient partners and representatives from indigenous communities. Because we have many under-served populations in the Victoria area, there are a number of people without family doctors. Still, there are certain communities or groups of people who are especially under-served. And so the idea was to bring services to patients, provide a variety of services in a culturally sensitive type of way, and give options for patients to receive primary care. And on the family doctor side, we understand what new family doctors with new graduates are looking for in practice, and they are looking for team-based care and this kind of support for themselves and for their patients. So in order to attract new doctors into community family practice, we needed to create an environment that they feel they can work in and flourishing, but also where they feel they're also providing good care to their patients because that's kind of just so important to them in their day to day work for all of us. I think I really spoke loudly with the newer graduates, saying, "Yeah, this system of care here needs to evolve so that we can move everyone forward."

Emily: Yeah. I've heard that. In my time covering this issue, you spoke about a lot of things there. I'd love to dive into more of them in depth. But first of all, I think one of the most pressing questions for myself and for our listeners. The last statistics that I found were that approximately 25% of people in Greater Victoria didn't have a primary care practitioner. How far will this change go towards addressing that gap? 

Dr. Dabrus: Well, the plan is that the change continues until the gap is filled. So the networking and deploying from Ireland health into these different primary care networks is a four-year plan. So it's not that nothing will happen for four years, but things will be evolving over the four years, year by year. More recruiting, more establishing of these things networks. It takes a little bit of time to figure out who has space for other practitioners to come in or can other practitioners work with Island Health facilities but still be supporting a network or a neighbourhood family doctor. So the plan is in place and funds allocated. 

Now, the rubber hits the road in terms of hiring people having the networks in place. So the plan is to set up websites so that patients can register. As new family doctors join some of the networks, I will also join the UPC clinics. Part of each neighbourhood is the idea that within each neighbourhood, there would be UPC clinics. So it's not just urgent care. But the idea is that these clinics would also be attracting new doctors building practices, who would be within the same facility, but also providing after-hours and weekend care to the neighbourhood, not just the doctors within the facility, but the doctors within that primary care network within that neighbourhood. 

Emily: I want to talk about that idea of attracting new doctors. I know it's been difficult to do that. Can you explain a little bit more about how exactly these networks will be different and how to go about doing that?

Dr. Dabrus: A number of changes have happened in terms of giving alternative payment options in terms of salaries or contracts for family doctors. Again, the nature of family practice has changed over the last 30 years, at least. The fee for service, which is kind of how our medical services plan works, doesn't always fit the family practice model where you need to spend more time or less time or do different things that aren't necessarily billable, and yet fall under a lot of the things that we do. So for new family doctors, they're very much interested in salary positions. 

And a lot of the new positions are salaried physicians. So you do the work that you need to do without chasing every little billing and watching how many minutes are spent on each different thing. And that is just so key to how family practices is practice nowadays, and ideally practice and that's not come from any one person's opinion, but from the College of Family Physicians of Canada encouraging all provinces to move family doctors to a different kind of pay model that works for actually being able to do their job effectively and serve patients effectively. So a change in that model happened over this last year and is going to really attract a lot of the newer graduates to this kind of position and recognizing that there's a lot of demand for generalist knowledge. 

People who graduate from family practice are in demand in the hospital to be a hospitalist are in demand at the cancer clinic to look after patients and assist oncologists. So there are just so many different areas where that generalist knowledge is now being there; there's competition for it. Previously, when you graduated from family practice, your main option was to go into community practice. But now there are a lot of competing demands. And so, the family practice in the community needs to be made attractive enough that it can compete with all of these other kinds of options available to the generalist who is graduating.

Emily: You had mentioned, and we've seen that there are many PCNs and UPC centers that have been set up in other parts of the province. Do we see results from that? Are we seeing more people become attached and more doctors being attracted to these areas as a result? 

Dr. Dabrus: So certainly in BC, we are starting to see those results. So we see an evolution and a move into more group practices. And new graduates are really gravitating towards those group practices where clinics are set up, and there's support, and there are nurses, so we are seeing new graduates move into those kinds of positions. So we're very excited in Victoria to be ramping up our primary care networks and be competing and attracting people into our community as well. But this type of model has been present in other provinces for many, many years. And say, for example, in Alberta and Ontario, you don't tend to see quite the same difficulty attracting family doctors to community practice.

 It's a little bit of a Canada-wide problem in attracting family doctors to community practice, but really, probably the most acute in British Columbia. And interestingly, one of the most acute places you think is a lovely place to live. But it's an expensive place to live in Victoria as we have one of the largest attempts at what they call attachment gaps in terms of numbers of patients without a family doctor and in the province. So we're very excited to be moving forward on problem-solving and looking at what has worked in other jurisdictions and in other communities—and moving forward in that positive direction.

Emily: These four primary care networks will serve 200,000 people. How manageable is that ratio? 

Dr. Dabrus: So the PCNs will be family doctors who are already established to keep them in practice as long as possible, with as much support as possible and to continue to attract family doctors to the community. Some of the numbers you're seeing are contracts that are available for new to practice physicians. So when physicians are new to practice, and you're building a practice, it takes a fair bit of time to get old files and go through them and create a patient chart for four people and kind of move forward in that direction. And so some of the numbers that you're seeing are directly for some of these contracts for new to practice doctors, but it does not hold back. So there's no kind of a fixed cap on the numbers. It will be a number of contracts and attracting new practice physicians trying to keep physicians in practice, and perhaps even being able to expand their panel a little bit, perhaps if they have some more help within the practice, such as now, there's a nurse practitioner. She's able to see a certain number of patients each day. So the practice itself is able to expand. 

The practice expansion is partly from new family doctors, partly from registered nurses in practice, partly from nurse practitioners. And there are numbers around that to just kind of ground us a little bit in reality about how many practitioners can take on how many patients and how we are going to fill that attachment gap. But there's no kind of fixed ceiling. The goal is to have a constant attraction of new doctors. And part of the issue why things are a little bit more acute in Victoria is, is our ageing demographic of family doctors. So we just had a large demographic shift in terms of weight. Within our own community, a family doctor is facing a large number of retirements that have already started and will continue over the next couple of years. It's unfortunate, but family doctors want to retire as well.

Emily: You're only human, of course. I was wondering about that. When we see issues like with the Gordon head treatment center, they have a doctor moving, they had a number of doctors retire previously, and now they're being forced to close. 

Will those kinds of situations continue to come up? Or is the hope that these primary care networks will support these clinics to remain open? 

Dr. Dabrus: Part of the shift occurring is that the Health Authority is taking more responsibility for the primary health care of the people within the Health Authority. And that's part of the reason for having an urgent and primary care clinic within each PCN. It is a foundational piece of infrastructure that is managed by the Health Authority so that they're responsible for recruiting and having doctors. So when you see the Gordon Head Clinic closing, certain family doctors are running their own kind of private business, when they've decided that for whatever reason for a number of personal reasons and professional reasons that they're going to leave the community. They can do that. It's not that they've signed a contract with the community or to the communities that have provided services for a number of years, but now they're going to go do something else. Because doctors are in the community, individual private practitioners run their own kind of business. So part of this shift also is a responsibility for the health authority to say, “Well, community family practice has kind of stayed afloat and worked really well and was fairly independent over the last number of years.” But actually, there was no oversight, and it was by good grace. And also people looking out for each other and their communities that we had walk-in clinics and family practitioners and things like that. 

With an ageing demographic, and a change in the style of practice, that is desirable by new graduates and the competition for new graduates to be in other fields, rather than community family practice. There had to be a bit of a foundational shift between government and health authority and the family practice community to say we all need to work together. There needs to be some infrastructure and some planning. So, the idea of UPC seeing within a network is that there will be this bricks and mortar structure that we will staff. And this is part of the mandate, from the Ministry of Health to the Health Authority, so that it's not left up to an individual practitioner who said, "Well, I'm going to move my family and myself to a different community. And, and I'm sorry, but this particular clinic is no longer going to work here." And again, that's kind of what happens when a family doctor retires or changes their locations. 

So some of this, this kind of oversight to make sure that the community has primary care available is something new that has not been there previously. So I do think it's I think it's an important kind of shift in terms of health authority having responsibility for the health, the primary care or health needs, not just the hospital needs, or their surgical needs, but the primary health care needs of their community as well.

Emily: That sounds like a foundational shift.

Dr. Dabrus: That foundational shift then kind of goes to how we organize things in the community. So this works to supply primary care for everybody.

Emily: How do you hope to see these changes reflected in your own practice? What are you hoping for personally?

Dr. Dabrus: So personally, I was part of a pilot project where we did have a mental health and substance use mental health counsellor available to the practice through Island Health, which has really actually transformed the mental health care for my patients to have someone available and who can also triage, like, see which services might be best, and also help to connect them with other island health services, but also get support them as they're waiting to see a psychiatrist or waiting for an addiction counsellor. So all of those kinds of steps have meant that the patient is supported. 

They have someone who is there to help them to support them to work with me. I'm not doing it all by myself, but also someone who knows the other side of things and how to access and where to access, they have a whole suite of things that they're able to offer their patients. So it has been quite transformative in terms of being able to offer that level of professional support to my patients. For me, it's made some of the work that I do a little less stressful because I feel I have some help. And I think it's been so beneficial to my patients because they have someone right in the centre of that system and can help them navigate and get them the help they need. 

And when I need to speak with someone, well, I have to go to a person. It's not like, "Oh, I have to know 20 or 30 different people within the system. I have to go to that person. They know me, I know them, we have a conversation, we can kind of sort things out." So we already know from bits and parts of this that have already started to change or transform that it's positive for both the primary care doctors and foundationally it's positive for the patients. They get the services that they need. That's fantastic.

Emily: It sounds like you're strongly in favour of this system, and it does sound like it's addressing quite a few of the issues. That I've seen raised in the media and conversations around this topic, but are there any potential flaws? Is there anything that you're concerned about with this approach? 

Dr. Dabrus: Whenever something is new, there are some growing pains and things that didn't work out as you expected or unintended kinds of consequences. So those are likely to show themselves whenever there's change; it's often a little bit bumpy. But that's kind of how you make progress. And we do, again, have a bit of a roadmap from other provinces from other jurisdictions in the province, where other practitioners have told us the positive impact that it's had. And I have seen other communities where I'm going, "Wow, there's a whole bunch of young doctors at this meeting, and they're from this community, and they've chosen to start working in community practice. 

And isn't it interesting that there's already a PCN-established community that has these things in place and has encouraged doctors to work in groups and put those supports in?" So there are some bumps along the way. But we do have a roadmap, and we have done our best in terms of working with patient partners and working with Indigenous partners and trying to get as much information from other communities who have already gone through the process about some of the pros and cons of things that did work and didn't, didn't work. So we don't have to repeat this at the same time. Where we're at right now is a pretty desperate position in terms of waves of retirement, and no new doctors are coming in. Primary care is foundational to your well-being. And so, to not have a third of the population, even without basic primary care, it absolutely has to change. 

Emily:  I personally don't have a primary care practitioner. And I know a lot of people I work with, my friends as well, don't have one either. So I think for myself and for many others, we have our fingers crossed that this will work out. I wanted to bring up something I discussed in an interview that we did a couple of weeks ago with Damien Contandriopoulos from the UVic School of Nursing. He talked about the shift to telehealth and some of the structural issues, especially with TELUS Babylon, and how the shift to telehealth, in general, is being controlled a bit more by major corporations. Do you think this move towards PCNs will bring back more of a balance and pull healthcare back a little bit more into the realm of the province? 

Dr. Dabrus: The pandemic has shifted so many ways of communicating to the virtual care world. And virtual care works best, really, with the person on the other end of the line having background information on you or knowing you. And it's even more important when you're doing virtual care that you have a background relationship with that patient. You have a sense of where they're coming from because you are missing some of the body language or missing the big picture. If you have that historical background out, it's so much better. Part of our plan is to embed virtual care within the PCN, but that virtual care would be with the doctors within the PCN for after hours and weekends. 

So again, the hope is that it's a community family doctor in Victoria, who you're connecting with. So it's not someone in Ontario who doesn't know how our system in BC works or how to access an ultrasound or where your local PCC is so that virtual care can work well. We expect that we will continue with many of our visits being virtual. It makes great sense for people with disabilities, mobility problems, the frail elderly to not necessarily come into the doctor's office on every visit. You need to be communicating with someone who has some background access to you, who knows the community how to access services, and hopefully someone who knows you. 

I urge a virtual care component being addressed through the primary care network plans to have a virtual care hub, again, staffed by local family physicians who hopefully will have access to your records. That's it. There's a technical technology leap that needs to happen to the network. But it's surely better to have someone in the community who knows how your local community works, the specialists, where the hospitals are, and how you order a scan versus someone from another province who has no idea how things work in Victoria. 

Emily: Yeah, certainly. One more thing I wanted to ask you. One of the high-priority services identified in this announcement is creating culturally safe care and experiences for indigenous peoples, which is important and especially necessary following the In Plain Sight report. Can you explain how these UPNs will go about doing that? 

Dr. Dabrus: So, there is a plan for all members of PCN to have specific education in culturally sensitive care. So that's part of all PCNs. The majority of the care for our Indigenous communities seems to take place more in the downtown area. And so there's even more emphasis on putting more services to the Native Friendship Centre, more doctors, more support into the Native Friendship Centre to make it a community health center type of hub so that Indigenous people feel comfortable where they're going or have a place where they feel this is my medical home on multiple levels, but also that that takes place through all of the PCN. So it's not like, "Well, I have to go to that centre to receive culturally appropriate or safe care." 

It is embedded in all PCN work, recognizing that the issues permeate primary care and all communities' hospital care and EPCC care. It needs to be embedded all the way through. So again, it's really important that patient partners were present at the planning table for the Victoria PCNs Indigenous partners and had a voice that was heard.

Emily: Well, is there anything else you think is important to bring up that you wanted to touch on in this interview?

Dr. Dabrus: I think it's exciting the changes that are happening, but they're going to be evolutionary over the next few years. The hard part is that our PCN is launching and we have a building for the downtown UPC. We are now in the process of hiring, but it is competitive. You bring people in, build a practice, build a team, and you get everyone working together. And unfortunately, it takes time, especially the hiring and the competitive kind of hiring part, because you sometimes have people come, and they don't feel it's the right fit.

And they go to hire someone new. So it is a process, but an iterative process in terms of year by year building more and more and more. So that as we're making these changes, no one feels overwhelmed or that there's too much going on, and no one knows what's going on. 

There definitely is a four-year plan in place moving forward right now. It's hard when you don't have a family doctor to be patient, especially if you're becoming more ill or feeling the longer that you don't have care that things are deteriorating further. But that is a process that won't be changing next week. It is changing next week, but step by step by step, but hopefully, three to four years from now, things look very different from where they are right now.

Emily: Certainly, well, we will be keeping an eye on how things unfold on the podcast. It's a topic that always resonates quite a lot with our listeners. So I thank you for taking the time to speak with us today. I really appreciate it.  

Dr. Dabrus: Thank you for having me.