Home-grown health care

by Leslie Campbell, August 2010

A new community co-operative provides a model for primary health care, one emphasizing local control, accessibility, collaboration, and prevention.

From my perspective as a child of elderly parents making frequent use of the health care system, it’s easy to imagine the system being totally swamped when I and my fellow boomers hit 75 or so. We obviously have to take a different tack, but few—and especially those in power—seem willing to ignite the serious conversation we need to have, let alone propose creative solutions. 

A 2009 study, jointly-funded by the BC Medical Association and the BC Ministry of Health, showed that if five percent of those with chronic disease had access to a primary care physician or nurse practitioner, BC would save $85 million per year.

So the government is motivated to get more doctors on the case—and has recently pledged to ensure all of us have one by 2015—but many are questioning whether the government has the ability or will to make that happen. For one thing, the plan seems vague; and with the aging population among both doctors and patients, the dearth of GPs is only likely to grow without an ambitious but realistic plan. We have more health problems as we age, so where once a GP could handle 1200 patients, with an older demographic he or she might only be able to handle a list of 800 patients.

To make the 2015 plan is at all realistic, says one doctor, you’d have to attract a huge number of young doctors to become GPs. Unfortunately, it’s not the “sexy” or most lucrative choice by far. 

If anything, the government appears to be going backwards in some ways. Health systems researcher Simon Carroll wrote in the Times Colonist recently: “BC has a long history of real and successful efforts at building truly collaborative primary health care in its community health centres; yet for 32 years successive governments have ignored, neglected and even actively undermined these community-based attempts to provide comprehensive, co-ordinated and equitable health services to their populations.”

What’s happened to the James Bay Community Health Centre is a good case in point.

I’ve been fortunate to be an infrequent patient there since my arrival in Victoria 25 years ago. I have rarely seen a physician. Instead, annual check-ups and routine stuff were all dealt with by a nurse practitioner, at less cost to the system. It’s always seemed sensible to me. And to others too; people from around the world have studied how the clinic operates. 

But over the recent decade or more, this sensible way of providing health care has received blow after blow. Where once the doctors accepted a basic salary (which saved taxpayer dollars), they were recently forced to implement the standard fee-for-service model. And last fall it was announced that the funding for the last remaining nurse practitioner was cancelled. (The doctors at the clinic have since redirected some of their fees to rehire that nurse practitioner.)

Dr Mark Sherman, a physician at the James Bay Community Health Centre for seven years, says there are 88 unemployed nurse practitioners in BC, and if the government was serious about a solution, they would immediately integrate them into primary health care services. Having worked with them for years, he has total confidence in their abilities. The government’s recent press release stated: “The minister also hopes [to] include the broader use of nurse practitioners in integrated primary and community care and will ask the BCMA to explore this with government.” But their actions speak loudly in the opposite direction.

Dr Sherman and others, I am happy to report, are way ahead of the government. They have formed the Victoria Community Health Co-operative (VCHC) and on September 1, the Co-op officially takes over the space occupied for the past 35 years by the James Bay Community Health Clinic. Four doctors and a nurse practitioner (including those who practised at James Bay Health Clinic) are ready to start in September and more will come aboard in 2011. Most of the Co-op’s members want to volunteer in some capacity. Right now, a few of them are painting and redecorating the space.

Sherman and fellow Co-op founders realized a few years back that a transformation in health care was needed. Given current realities, including demographics, either more public funding is needed— “that’s not going to happen anytime soon,” he admits—or private health care delivery will be allowed to grow, putting profit before people.

There must be a better way, they reasoned, one that would provide universal access to affordable, high-quality health care. They soon discovered the co-operative model. They learned that one million people in Canada already get their care via a health co-operative (Saskatchewan is a hotbed for them). “It gives people a third option, one that is community owned and controlled,” says Sherman. Because each co-op reflects the community it serves, a co-op based in Tofino will likely be quite different from one based in Victoria.

Six community forums were held to determine what Victorians want in a health co-op. This vision is reflected in the co-op’s mission and mandate (see http://victoriahealthcooperative.ca).

Besides access to family doctors and nurses/nurse practitioners, access to other, complementary modalities was seen as key. The Co-op has embraced that type of integration and collaboration as crucial to true health. It has member practitioners in fields such as acupuncture, Alexander Technique, chiropractic, psychotherapy, energy work, Feldenkrais, herbalism, homeopathy, massage therapy, naturopathy, osteopathy, and Traditional Chinese Medicine. Some will be renting space within the new clinic. A small compounding pharmacy on premises might be in the mix as well. Sherman is excited about the possibilities of working together, doing “case conferencing”—the new clinic will have spaces that encourage that collaboration.

Education is viewed as a crucial component of the Co-op. “Our education program will be a whole thing on its own,” says Sherman, who believes the usual funding model is upside down, “The vast majority of funding now goes to drugs, doctors and hospitals,” he says. And about 85 percent of it is eaten up in tackling chronic illness. Instead, he argues, health promotion, disease prevention and episodic primary care should get the lion’s share. “If we do that right, we won’t need to be always putting on bandaids.”

Though the Co-op will still have to rely on the imperfect fee-for-service funding model, Sherman says it can and will be stretched to provide education for Co-op patients. Take a group of patients with the all too prevalent hypertension. Instead of the doctor repeating educational information to each patient, he can schedule group visits for this function. “It’s cost effective and care effective,” he says. He notes the therapeutic value from just being part of a group, sharing one’s struggles and successes in coping with a health challenge. Low back pain, diabetes, and stress reduction are other examples of common ailments that could be partially addressed this way. 

With this model, Sherman says other types of practitioners (depending on the problem, nutritionists, physios, psychologists) can be involved in the educational component as well. The Co-op is also developing innovative ways to help fund non-MSP-covered treatments, especially for those who wouldn’t be able to afford them.

Such measures both help prevent more serious (and costly) problems developing, and by using each physician’s time more judiciously, increase access to them—something we need in Greater Victoria where thousands of people do not have a family doctor and must rely on Emergency or walk-in clinics.

Dr Sherman hears sad stories around access to treatment regularly. A believer in “mind-body medicine” who teaches courses in stress reduction, he’s especially concerned about treatment for mental illness which he terms “horrid” in Victoria. Cases deemed “urgent”—suicidal, even—take up to three months to get into care.

Of all the dollars spent federally and provincially on health care in Canada, only five percent is spent on prevention. Under the new Co-op’s model, “Prevention is built in upfront,” Sherman says proudly.

“We have to start implementing prevention given our serious demographic shifts,” he says. The demands on the system, he warns, are “only going to increase. We don’t really have a long-term plan for this.”

Fortunately, Dr Sherman and the Community Health Co-op are at least clearing a sensible and compassionate path towards one.

Leslie Campbell has so far avoided costing the health care system much and isn’t keen on changing that. She’s got the downloadable membership form for the Co-op on her desk. Everyone is welcome to join.

Copyright© 2010, Focus Magazine