Quebec floated plan to shift doctors to most vulnerable. Are they reconsidering?

Quebec’s health minister is attempting to reassure the public they won’t lose their family doctors, following a controversial proposal suggesting the redistribution of physicians from healthy patients to the most vulnerable populations.

Minister of Health and Social Services Christian Dubé took to X in French on Thursday letting Quebecers know they will keep their family doctors following pushback from the report. He stated the province is taking all measures to improve access and streamline front-line care, but did not clarify whether the proposed plan was entirely off the table.

“Quebecers who have a family doctor will keep them. We want to reassure the population. Just as we committed to in our Health plan, our goal is clear: we are taking all measures to facilitate access and simplify the organization of front-line care, and this, for all Quebecers,” he said in French.

“Now, let’s let the negotiations run their course.”

In a report released Oct. 9, the Institut national d’excellence en santé et en services sociaux (INESSS), commissioned by Quebec’s Ministry of Health and Social Services, examined a number of scenarios aimed at addressing the family doctor crisis in Quebec.

The report suggests one approach to addressing the family doctor crisis is where healthy Quebecers would lose their registration with a family doctor. This change would free up 1.5 million appointment slots, which would then be reallocated to serve vulnerable patients, it stated.

The Ministry of Health and Social Services also previously said the idea remained just a proposal and lacked any concrete plans at this stage.

Despite the lack of legs of this proposal, Dr. Marion Dove, a family physician and associate professor of family medicine at McGill University in Montreal, has called this idea dangerous and poorly conceived, warning that it could result in worse patient care and increased physician burnout.

“It’s very problematic. Every Canadian should have the right to have a family doctor or primary care practitioner, and they should have this person to whom they can turn when they have a health problem of any type,” she told Global News.

“This idea of kind of separating people into categories based on their illness and matching them with the health-care provider based on what illness they have is removing the whole relationship aspect from health care, which is fundamentally wrong and is going to be detrimental to our entire system, to patients and to health-care workers and to the cost of the whole system,” she added.

Dove, a family medicine practitioner with 30 years of experience, reviewed the report and observed that none of its authors were family doctors. Not only is she concerned about the outcomes of this proposal, but she also mentioned that one of her patients has already expressed worry about possibly losing her as their doctor.

Before Dubé’s X post on Thursday assuring Quebecers that they would keep their family doctors, he remarked in French during Quebec’s National Assembly on Oct. 11 that it was far too early to advance any proposals from the report.

Opposition parties had demanded clear answers for the millions of Quebecers who could potentially lose their family doctors under the proposal.

“The Coalition Avenir Québec does not have the mandate to unsubscribe millions of Quebecers who already have a family doctor and who, today, find themselves with the prospect of losing this follow-up, losing this access and continuing to pay for a system that does not provide basic services to the population,” denounced Joël Arseneau, a Parti Quebecois Member of the National Assembly, in an interview with The Canadian Press Friday morning.

“Christian Dubé must absolutely clarify his position,” demanded Liberal MNA André Fortin in a telephone interview. “Is this a trial balloon or is this really the scenario he is considering today? He’s going to have to make decisions.”

In an email to Global News on Wednesday, the Federation of General Practitioners of Quebec said it would be “precocious” to confirm whether or not this is a good or bad option.

“It’s one expert scenario among many that we’re exploring with Quebec’s family doctors, who want to care for as many patients as possible, as efficiently as possible,” the spokesperson said.

“Of course, we have to prioritize the most vulnerable patients. But vulnerability is an evolving part of a person’s life. It’s not just linked to a diagnosis. We’re really open to different options, different avenues, really, but access must not be compromised by administrative categorizations of patients.”

Global News asked Canada’s Health Minister Mark Holland about the proposal, and he responded in an email Thursday, stating that the provinces and territories are primarily responsible for delivering health-care services.

“We are reviewing the report and will continue working with provinces and territories to ensure that all Canadians have access to the care they need,” he said.

In recent years, incentives have been implemented to help family doctors improve access for people not registered with a family doctor. However, due to an aging population and a significant number of family doctor retirements, meeting the needs of the entire population has become challenging, the report states.

The report proposes dividing Quebecers into different health categories:

• In health. This means the person is in good health and only has needs related to life cycles. Examples include: lower back pain, pregnancy and early childhood adolescence.
• Chronic minor ailments. The person has minor chronic conditions without functional impact and without high risk of short-term determination, but requiring periodic monitoring. This includes hypertension, menopause and obesity.
• Moderate ailments. The person requires monitoring for chronic problems without significant functional impairment, but presents risks of long-term complications. This includes mental health disorders, cardiovascular disease, cancer and dementia.
• Major condition. This person presents complex conditions, including significant physical or intellectual functional impairments or severe chronic or acute illnesses with request risk of determination. This includes major cancer, organ failure, unstable angina and stoke.

Between 2022 and 2023, one in four Quebecers, or around 2.1 million people, did not have a family doctor, and around 500,000 of these individuals had major or moderate health problems, according to the report.

The report also noted that healthy individuals, who account for 57 per cent of the population, make up 40 per cent of doctor visits, often for minor acute illnesses.

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On average, people registered with a family doctor consult between two and six times more clinics than those not registered, depending on their health profile.

People who are not registered with a family doctor consult emergency departments more often, particularly for non-urgent problems.

The study presents a scenario in which 1.5 million appointments allocated to people who have a family doctor would be transferred instead to people who do not have a family doctor.

Healthy people registered with a doctor would lose 640,000 appointments and those not registered would gain 780,000.

The second category, among people with minor chronic conditions, who account for 1.4 million visits: registered people would lose 170,000 appointments and non-registered people would gain 90,000.

The third category is people with moderate conditions, who account for 5.5 million visits. Those registered would lose 570,000 visits, and those not registered would gain 340,000.

Finally, for patients dealing with major illnesses: registered people would lose 140,000 appointments, while non-registered people would gain 330,000.

In all, the redistribution of appointments from registrants to non-registrants would total 1.5 million.

Dove acknowledges the shortage of family physicians in Quebec, but she believes there are more effective solutions than simply reallocating doctors to patients they do not know.

“I have patients that I’ve taken care of through different illnesses, through cancer, through diabetes, through chronic illness, like hypertension. And when they come to see me, it is so much easier for me to take care of them that they don’t have to start at zero each time … you know their health priorities,” she explained.

“You get to know people over time, and this improves the quality of care that you can give to people, improves their satisfaction, and improves the efficacy of the care that you’re giving.”

However, she is concerned that being assigned a large number of unfamiliar patients would increase her workload and lead to decreased patient satisfaction.

She also worries that removing a patient’s family doctor could negatively impact their health.

Many patients have developed strong relationships with their family doctors, which contribute to their well-being. If healthy patients are taken away from their doctors simply because they are considered “too healthy,” they may become sick.

This reflects a misunderstanding of cause and effect, she says.

“It seems kind of like a bureaucratic answer to this problem, to say, ‘OK, if we have resource X and we have we best match it with patient Y.’ But they’re not taking the human and the relational component into account, this is not the solution,” she said.

One way she believes doctors could take on more patients is by reducing the administrative burden on family physicians.

Growing administrative burdens are leading to a shortage of family physicians, not just in Quebec, but also the provinces like Ontario, according to the Ontario College of Family Physicians.

Family doctors who soon plan to leave the profession report that they are overwhelmed with administrative work, the college said. They report spending an average of 19.1 hours per week on administrative tasks such as filling out forms, the college added.

“Some of the solutions that people have been proposing are to increase the administrative support for family doctors. You spend an awful lot of time looking for forms, faxing and trying to find ways to refer people,” Dove said.

“If they change the system to facilitate the work of family doctors then we could see way more patients.”

— with files from The Canadian Press