In 2003, British Columbia created a joint committee of doctors and government representatives to reverse the deterioration in full-service family practice, particularly evidenced in poor morale among family physicians. The committee introduced an array of innovative programs into the province’s fee-for-service system of solo and small-group practices, focusing on operational rather than structural changes. Incentive payments for managing chronically ill patients were followed by maternity care bonuses, training to enhance clinical skills and to support practice redesign, recruitment incentives for new family doctors, and other patient care initiatives. The programs, which are open to all general practitioners, have reduced health care spending on high-needs patients, research shows. Moreover, British Columbia now has the lowest hospitalization rate in Canada for seven medical conditions. The experience demonstrates that coordinated, operational reform of full-service family practice can improve care and reduce costs without radical restructuring of the primary care system.
ERRATUM: Incorrect budgetary information inadvertently appeared in the original version of this issue brief. The annual budget of the entire General Practice Services Committee (GPSC)—not the Practice Support Program alone—is approximately $149 million, with a total cumulative budget of $800 million allocated until the spring of 2012. The Practice Support Program's budget is $10 million a year. This error was corrected on August 24, 2011, and can be seen in the revised pdf.
AUTHORS’ NOTE (September 6, 2011):
In our recent Commonwealth Fund issue brief, Reviving Full-Service Family Practice in British Columbia, certain phrases have generated dialogue that, in retrospect, should not have surprised the authors. The concern expressed stems from any intimation that “guidelines” somehow take precedence over holistic, patient-centered care. Such was certainly not our intent, nor did we ourselves believe the brief conveyed such implications. Perhaps the expressed fears arise from a time when “guidelines” were (arguably) given relative primacy, or used to narrowly define “quality,” or even fears they might drive physician reimbursement (although the latter has never been the case in British Columbia). There was no intent to imply in the brief that new fees were dependent on anything other than consideration of guideline application.
It is apparent that sensitivities continue to exist, despite the fact that the various governmental, professional, and licensing bodies unequivocally endorse the principle that, in general, “guidelines inform but in no way compel.”
Perhaps further complicating this issue is that some initiatives are “disease-focused,” and this was not universally considered to equate to “patient-focused,” particularly given the fact most “guidelines” are themselves “disease-focused.”
We believe this discussion to be a healthy one; in some ways, it is illustrative of the differences between specialty care and family practice. Family physicians, in practicing holistic care, must repeatedly consider, accept, reject, or modify guidelines depending on patient values, goals, culture, fears, capabilities, readiness, and understanding. The process of negotiated treatment planning provides a fertile environment to inform, challenge, debate, and ultimately arrive at a management plan that is “right” for each patient, at that time, in the context of a long-term relationship that encourages review and revisit.
We are interested in hearing from others on this matter.