A double whammy of bad primary care news hit Greater Victoria this week. The Gordon Head Treatment Centre announced it will be closing its doors in August when one of their physicians leaves for another opportunity, and the James Bay Urgent and Primary Care Clinic is losing three doctors and one nurse. We speak with Damien Contandriopoulos from the University of Victoria's School of Nursing about why the primary care network in the region is unable to provide primary care for one quarter of residents.
A double whammy of bad primary care news hit Greater Victoria this week. The Gordon Head Treatment Centre announced it will be closing its doors in August when one of their physicians leaves for another opportunity, and the James Bay Urgent and Primary Care Clinic is losing three doctors and one nurse. We speak with Damien Contandriopoulos from the University of Victoria's School of Nursing about why the primary care network in the region is unable to provide primary care for one quarter of residents.
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Disclaimer: This interview has been edited for clarity and length.
Jackie: Hi, my name is Jackie Lamport. Today is Wednesday, July 14. Welcome to the Capital Daily Podcast. Today on the show, we take a look at the doctor shortage in Greater Victoria after news that the Gordon Head Clinic is closing and three doctors and nurses are leaving their roles at the James Bay Urgent and Primary Care Clinic.
Emily: If you live in Greater Victoria, chances are that you are very well aware of one of the region's most persistent issues: primary care, specifically the inability for those without a family doctor to find one. This week, news came out that the Gordon Head Treatment Centre would be closing after one of their doctors announced they were moving to Prince George. Five of their doctors had previously retired in 2019. On top of that, Island Health also confirmed this week that three doctors and one nurse would be leaving the James Bay urgent and primary care center. All of this is happening amidst an ongoing shortage of primary care practitioners. It's only getting worse. According to Island Health, 25% of the population of Greater Victoria did not have a family doctor in 2019. That's the last time that data was published. I know we can all do the math here, but I want to put that into context. That means one in every four people in Greater Victoria relies on a patchwork of walk-in clinics and telehealth appointments to meet their medical needs. If that's you, that means the only person that's keeping track of your medical history is you or maybe your partner. It makes it a lot harder to diagnose a serious illness. And if you are someone that lives with a chronic condition, that is a really big problem. It's a similar situation across the province. When we reached out to Island Health, they said they were unable to provide a guest for this interview. However, they said that they are working hard to expand their primary care services. They also emphasize that in the case of the James Bay UPC, the patients are attached to the clinic itself and not a specific doctor. So all patients currently attached will continue to be served. As for the Gordon head Treatment Centre, it's a private practice, which the Health Authority says is "outside of their purview." We wanted to find out what these recent announcements mean for greater Victoria's already strange primary care landscape. To do that, we reached out to Damien Contandriopoulos. He's a professor and acting director of the Institute on Aging and lifelong health at the University of Victoria School of Nursing. On top of that, he's an avid health policy researcher, and he served as an applied health chair at the Canadian Institute of Health Research from 2014 to 2019. Damian joins us on the show today to offer his view on exactly what he thinks is going wrong in our healthcare system. Damian, thank you so much for joining us on the show.
Damian: If you look at Victoria, the current level of access is extremely low. And what we're currently seeing as a trend downwards, in a context of a government that's tried significant investments and efforts to try to provide people with a regular source of primary care, it looks like a failure. For any resident, it's bad news.
Emily: When I reached out to Island house, they didn't have anyone available to speak with us when we needed to. But they did say that the majority of primary care is owned by privately owned and operated clinics and walk-ins, which are not under the Health Authorities' purview. What's your take on that system?
Damian: Okay, one needs to go back a long time ago to figure out the answer to this one. If you go back to the 60s and 70s, the federal government goes with a deal with the province, saying, "Okay, we'll pay for a part of healthcare. In exchange for words, you'll have a public system and then a province's drive to organize this." And physicians went in very strong resistance modes that physicians in Canada did not want medicare to exist. They did not want to be paid by the public system, and they did not want people to have access to free health care. It went as far as strikes in Alberta, and that lasted months with doctors refusing to treat people, and this was during all provinces. But in the end, the deal that was struck was. "Okay, we'll accept work for the government in exchange to remain self-employed entrepreneurs and will keep full control on where we work. And we'll have no boss in the government. That's the deal." Like it's the birth of the Canadian medical system. And that deal stays on now; what we're seeing is that it does not work well. In the 21st century, you cannot have a medical workforce that is kind of disconnected from anything else and expect that workforce to work according to the best model to make sure every person has the care they need. And the answer you got from Island Health? Yeah, technically, it's true, but in the end, does it make sense that the system from the province that we pay with our tax money says, "Well, it's kind of not our problem."
Emily: This is not the first time we're talking about it on this show. Jackie and I took over the podcast in February. We've already done one episode on the doctor shortage because of a retiring doctor in Port McNeil. Let's talk about the situation at the Gordon Head clinic. Why is it so difficult to replace a doctor when one either retires or leaves their current practice?
Damian: Because doctors decide to make different career choices? That's the short answer. When you look at the number of medical doctor family doctors per person in BC, it never was as hard as it currently is. We never had as many doctors as we currently have. That's one thing. So when we think about doctor shortages, well, there's a lack of care, but there's no lack of doctors. The second thing is that BC has more family doctors than many other provinces and has more family doctors per person than Ontario or Quebec. So, why is it that almost everyone has a family doctor in Ontario, and a large chunk of the population is left without family doctors in BC? Well, it's not the number of doctors, so it has to do with something else. And something else is the way we organize here in BC. There are very few structuring initiatives; most of the management of how care is provided is left to doctors or BC-controlled structures that decide how to self-organize. But the trend of not meeting the demand is accelerating fast. And the reason for this is COVID; when COVID hits doctors move through practice online, this made sense for multiple reasons. No one's criticizing this. However, that trend is not going to stop care from being provided online more and more. And you have very large corporate players entering the field—Telus, Babylon Health, the Well Clinics and so on. And BC is kind of an experimental field where large change chain companies with billions of dollars investing potential, like Well Health, strictly buying off clinics, going to see the doctors and buying the clinics tell us is hiring doctors by the truckload. And those doctors are going to be mostly providing virtual care, and they're not going to work in any brick and mortar clinic. So the challenge for existing clinics to make sure that when a doctor retires, can attract a new one is huge. And without someone somewhere deciding to do something about it. This is not a problem that is going to solve itself.
Emily: So it seems like the self-regulating system is running into issues over and over again. And the province has tried to implement some solutions. The urgent in primary care networks as well as adding nurse practitioner clinics. What is your take on how well those go to fill the gap?
Damian: Well, they are very different models. The UPCs are kind of a band-aid solution, given that many people do not have a regular health professional that follows them. It's a walk-in clinic that is government-funded. And that's where there are incentives for the professionals, the nurses and the doctors to provide good quality care. The problem with walk-ins is that doctors will only see once. If you have a complex medical history, you'll have no continuity in the care. And there's no incentive to take you if you have a complex problem. The likeness is that they'll just say, "Well, good luck with this and see you next time." You UPCs is our kind of bendy solution to provide quality care for people who do not have a regular professional. Nurse-led clinics are another animal completely. They're meant to bring in patients and then hope you are going to get attached to the clinic. And they're going to be aiming to provide you longitudinal care forever and follow you with whatever you need means you have those are private, not-for-profit organizations that self-control and they are extremely innovative. When you look at the Canadian landscape, Ontario has a bunch, and then BC is the second province to really try it on. So two different approaches. If I were to gamble, I would definitely bet my money on the nurse practitioner clinic as the long-term solution.
Emily: You mentioned when you referenced doctors of BC that primary care networks are being pushed as a solution. Can you explain a little bit more about what those are?
Damian: Mostly provincial initiative where the province is trying to get up clinics and privately owned medical clinics, as well as governments funded things like up CCS, and everyone who is involved in primary care on a territorial basis to work together to talk together and to try to self organize in order to make sure that every place has a network of providers that work in synergy and on paper it looks great. Like, what can you say about it? It's great to have people coordinate; it's great if people share and collaborate. Do I think that this is going to make enough of a big enough difference to change something on the ground? No, I don't. I think those are great ways to provide the illusion of movement when basically, the system is not moving.
Emily: It sounds like the landscape of primary care is changing completely. What is your sense of how well this will meet the needs of people in BC?
Damian: Is the trend going in the right direction? The answer is no, and the current trend is going exactly in the opposite direction. People are currently losing their family doctor at a faster pace than people finding a new family doctor. And again, at one point, someone is going to have to do something about it. The fear I have is that because the government has been very reluctant to be bold enough to do something of that nature, and some are actors currently entering that void. Those actors are private companies with deep pockets and are interested in the system, an interest in being the provider of care for the future. And this is extremely troubling because those companies are not there for your well-being; those companies are there for the money. And in the short run, they might seem to be a good deal. "Oh, I now have access to a doctor on my phone." That's great. Well, yeah, that's great if you're young, healthy, and just need a prescription refilled. If you have a chronic disease, have a complex medical history, and are elderly, that's not good. You'll see a doctor on your phone, and that doctor is basically going to tell you, "Well, go see someone else elsewhere." And in the long run, you'll also have governments that are stuck with the fact that the delivery system for primary care is owned by large private companies and still control the whole thing. So it also threatens the basic Canadian tenet that healthcare is a human right, and you should be able to access it. Are you rich or poor? Are you living in the countryside or living in a city? This is also severely threatened, so I'm extremely pessimistic.
Emily: What's your sense of how able the province is to step in and create some new regulatory framework or new framework for primary care.
Damian: When you look at the levers the province has, they have all the levers that would allow them to decide to change how the system works. They are the ones who are paying for the care. They have lots of control over-regulation, and they really could decide to change things. And again, when you look elsewhere in Canada and Ontario, a leader in providing family doctors to people, about what 10 to 15 years ago, Ontario decided it's enough is enough. And he changed the way physicians are paid, and they changed the way care is organized in terms of the clinics. And this completely shifted the system and provided excellent results. When you look elsewhere in the world, most rich countries are safe, but you can see a family doctor within 48 hours in most rich countries. So is there a reason why we're structurally failing forever? No, there is no reason. Or maybe there is one, and the one is physicians are extremely well-organized interest groups that are extremely well defended by their union-like association structures. Doctors of BC, who are pushing extremely hard and doing a fantastic job of maintaining the status quo. And part of their maintenance of the status quo is always providing great lip service about how team care pays, and networking and synergy are going to solve everything but underground. Basically, very little is happening.
Emily: Last time we spoke about this issue, we spoke with a representative of doctors of BC, Matthew Chow, and he emphasized that this was a Canada-wide problem. It wasn't just a BC problem. It was a Canada-wide problem. What's your take on that?
Damian: If you look at Canada as a whole, Ontario is the outlier. Pretty good metrics on accessibility and continuity. The rest of Canada is a mixed bag. I would say some provinces like Quebec struggle but have been putting that question front and center on the agenda for a long while and have tried to do stuff. It's not always easy, and they have the same structural constraints, a very good medical association, very powerful, and so on. But I would say BC's current level of access is really, really bad. I'm someone who moved from Quebec to BC, and I'm still impressed by how, at least in Victoria, how bad the capacity to find a primary care doctor is. So I would say BC is on the lower side of the spectrum when it comes to access. And at the same time, as I said, BC has more family doctors than average in Canada. So no excuse there. And furthermore, I would say it's now crucial for the government to do something that is structured in the long run. This is the kind of problem that if you leave on its own and just let it rot, the amount of work and effort and money you will need afterward to solve it will be of an even bigger magnitude. So it's not working as a strategy to say, so why not just wait and see. That's not what we should expect from taxpayers as patients as residents.
Emily: How does Vancouver Island stack up in terms of primary care access compared to the rest of BC.
Damian: I would love to know. BC is not a jurisdiction where good-quality data is made available for research purposes. So it's anyone's guess there are some research teams that probably have good data. I don't have access to that data. And so we don't know, some provinces are pretty good. If you look, again, Ontario or Quebec, if you want to find a list of all in every single medical clinic that provides care to its population, you go online, and the ministry has a list. Every single medical clinic that doesn't exist in BC. Google is your friend.
Emily: It seems like so much of the onus is on the patient here. It's on you to find a family doctor. If you don't have a family doctor, anecdotally and in my personal life, you look up your symptoms on Google, and you talk to your walk-in doctor and tell them what you think you have. They don't provide that overarching care throughout your lifetime. So you're left to guess. So it just seems like it's continually on the individual, which is deeply unfair. And again, it comes back to the same fundamental elements if you're well educated, wealthier, likely to be whiter, likely to be a healthier person.
Damian: Well, the current system is going to be doing an okay job for you. First of all, if you have all those characteristics, it's likely that you currently have a family doctor. But if you happen not to, you will be able to navigate the current shortcomings of the system. Not too bad, as you said, you're going to figure out mostly what you need, you're going to be able to explain it to the doctor, the walk-in clinic, and it's not going to be great, but it's not going to be awful. But look at the other kind of person, someone who has a long medical history, has complex illnesses, might not speak English fluently, might be new in the province and does not know the ins and outs; those people are going to struggle a lot more. And that's unfair. That's not the basis. The real reason Canada went with a public health care system was that whether you're rich or you're poor, health care is a human right. You should have access in a timely way to the care you need. That's just basic decency. When the system makes it much tougher for some groups to get quality care, the system is failing.
Emily: What kind of steps would you like to see right now or in the next couple of years?
Damian: There's a bunch. One, the way physicians are paid. Currently, they're paid in a model called "fee for service." Every time they see a patient, they get money for the visit they've done. That model has been proven to be underperforming. It's not the way to the future everywhere else in the world; people are moving away from fee for service. So agreement should give some strong indications as fee for service is not the way forward. Beware of virtual care and private companies. Those are not models that are likely to provide good quality care for the population. So governments should also step down and say, "It's not going to be the way forward. We are not going to invest lots of public money to pay private companies to provide care." And the government should give a warning to dogs of BC, saying, "Well, you can self organize, but only to the extent that you provide you deliver, if you don't deliver, we'll intervene." When you look at some of the things that governments have done, like the nurse practitioner, this has the potential to disrupt the status quo at two levels. First, I think those clinics are going to provide excellent care for the people that roaster, but there's only a few pilot projects, it also gives stocks of BC kind of a warning. "Hey, you're not the only one here. If you don't solve the problem, someone else will." So I would say yeah, right now, the government would have a hard time just solving the issue for next month. But a government definitely has the power right now to form a plan and make something happen. We're not going to go over and over like Groundhog Day. Or we don't have family doctors, but we have a kind of great lip service to provide you, which has been happening for as far as I can remember being in a province.
Emily: That's how it feels now trying to cover the story. I've only been a reporter for two years, just over two years, but this just keeps coming up and I keep getting the same answers. Was there anything else you think is important to bring up?
Damian: After that interview, I think my only chance to get care would be to find a nurse practitioner. I mean, I'm toast.
Emily: Change your name, maybe?
Damian: It’s kind of recognizable. Good idea.
Emily: Damian, thank you so much for joining us on the show. Again, I appreciate it.
Damian: My pleasure.