Feature Article July 31, 2002
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Primary care reform at Sydenham Medical Centreby David Brisen, Karen Brison Dr. Steve Ingo joined the Sydenham Medical Centre three years ago because the clinic was going to be part of a Family Health Network pilot project. One element of the family networks especially appealed to him a method of paying physicians on the basis of the number of patients on their roster, not on the number of visits those patients make to the doctors office.
Ingo says that this system, called the capitation method of payment (as opposed to the fee for service method), fits in better with my philosophy of practice. The focus is more on preventative health care. We are able to focus more time on the people who require it, rather than having to churn through more people to pay the bills. Under the capitation system, Ingo explained, doctors can manage their time more efficiently by seeing patients who need to have office visits, and by not bringing in people for unnecessary follow-ups, or just to renew a prescription.
When he was asked whether his approach to his practice had changed, he said, When I compare now to what I was doing five years ago, I can see that there is a huge difference in the way Im practicing in not sort of focusing as much on getting the patient in front of you so you can bill the government $25.
In an earlier series of articles, we have looked at the primary care reforms in Sharbot Lake, which along with Verona, Tamworth, Newburg, and Sydenham comprise one of the 13 pilot projects which the Ontario government, in conjunction with the Ontario Medical Association, has started. These pilot projects are intended to guide a series of reforms in primary care announced by the government and the OMA in January 2002.
Dr. Jack Raleigh has been with the Sydenham clinic since 1989. He and Dr. Ingo, along with Dr. Daphne MacLean, who is on a leave of absence, and Nurse Practitioner Bonnie Sparrow (whose services are shared with the clinic in Verona), are presently on the staff at Sydenham.
The aspects of the primary care reform that interested Dr. Raleigh were: Information technology (IT) and the global capitation system which I thought would be advantageous to us in that we dont have a revolving door kind of medical practice where we churn through 40-50 patients a day. Dr. Raleigh went on to say that the capitation system, rewards physicians who practice preventative medicine and keep patients healthy so they dont need to come into the office.
In regard to information technology, Raleigh says that the system in place does not meet the expectations he had initially. He anticipated that he would be able to access electronically all lab reports, hospital reports, reports of specialists, and to be able to access records of patients in the other clinics in the network - in other words that he would be able to do away with paper records. This hasnt happened because the hospitals that the clinics in the network use (with the exception of the Perth hospital, which is used by some in the Sharbot Lake area) are three to five years away from being able to transmit files electronically. Patients ask me if I have X-rays which were done at KGH, and I have to go out and get the paper file and see if they are there. We get 150 documents a week in this clinic and most of them come by mail and are much harder to access, Raleigh says.
On the other hand, although he, Bonnie Sparrow, and Steve Ingo had to spend many extra hours converting charts electronically, the system is now working well within the clinic. Reports from the private lab they use are put directly in the patients computer files, and that has proven to be very useful.
Nurse Practitioner Bonnie Sparrow and the two doctors have been pleased with the ways they have worked together to make use of Bonnies special expertise. Bonnie brings a wealth of experience to the clinic: at KGH she worked in maternity and was head nurse on the moms and babies ward; she is certified as a breast feeding specialist and operated her own consulting business in that field. She also worked as a health educator for eight years at the North Kingston Community Health Centre as part of the Better Beginnings program.
At Sydenham, Sparrow sees babies for well babies check-ups and needles; does routine prenatal care; sees women for yearly check-ups; sees lots of adolescents for a range of problems; does periodic diabetes check-ups (for stable patients); sees children with sore ears, rashes and coughs; and in addition, does a lot of health promotion and preventative work.
In the nurse practitioner field, we like to say that 1 + 1 = 3, that the whole is greater than the sum of the parts, say Bonnie; I think we have achieved that in Sydenham by working together.
The physicians both say that they have been satisfied with the telephone triage system and the sharing of on-call and after hour duties that they have done with the other physicians in the network. As a result, hour duties have been much more palatable.
The Sydenham clinic does not, however, offer the extended office hours (from 5 to 8 p.m. four days a week and three hours on Saturday) that are part of the new family care network plans. The extended hours are offered in Sharbot Lake, but patients in the Sharbot Lake area dont have the easy access to emergency departments and walk-in clinics that are more readily available for Sydenham residents.
Dr. Raleigh has been pleased overall with the new plan and has extended the clinics contract through to November 2004. However, the province has been able to sign on only a handful of other family physicians. One reason might well be that some key elements of the new family networks, such as the provision of nurse practitioners, have not been finalized by the government. Bonnie Sparrow chairs the Nurse Practitioners Association of Ontario and she sits, along with Mary Woodman of the Sharbot Lake clinic, on the committee which has made recommendations to the government on funding for nurse practitioners. An announcement is pending, and according to both women is expected before the end of the summer. The government has trained 100 NPs and there are jobs for only ten, says Bonnie Sparrow.
