Domhnall MacAuley on primary care in Canada

Domhnall MacauleyWhen Davidicus Wong (cool name) told of being asked by a fellow passenger on a plane “Are you a GP or just a just a specialist?”, it set the scene for the Impact BC Canadian Health Improvement Forum, which preceded the Institute for Healthcare Improvement meeting (10th Annual International Summit on Redesigning the Clinical Office Practice) in Vancouver. During a break, a GP who has been in practice for 30 years in Fort St John about 800 km north of Vancouver, told me he has never enjoyed general practice so much. Something is happening. These doctors enjoy their work, talk about it being fun and rewarding, and invest huge time and efforts to improve their practice.

Perhaps the secret is in the sense of partnership between the British Columbia Ministry of Health Services and the BC Medical Association – both working towards shared goals, negotiated funding, and underpinned by a practice support programme. On the first day of the IHI meeting, the Assistant Deputy Minister; Stephen Brown, the Director of Professional Relations at the British Columbia Medical Association; Dr Dan McCarthy and Dr Bill Cavers a GP and co-chair of the GP Service committee spoke on the same platform, not in an adversarial role, but at partners in practice innovation. There was a meeting of minds on policy and practice with shared values and a commitment to quality. Lest there be any doubt at the distance both sides have come, just ten years previously, the GPs were on strike. It was remarkable to see this partnership, collaboration, and efforts to work towards shared goals. It was largely due to the leadership and inspiration of individuals on all sides in building a trusting relationship, but it could not have happened without the support of the profession. In an international context, this type of partnership is rare and remarkable.

One of the challenges they will face in the future will be how to integrate the personal nature of primary care with efforts to measure the quality of practice. In the UK, the quality and outcomes framework is part of daily life but in other countries these measures are still debated. I sensed at this meeting, an increasing gap between those who value the primacy of the doctor patient relationship in family medicine and those who feel doctors should be a little more accountable for what they do. This polarisation could become a sticking point.

This was the first time this IHI meeting was hosted into Canada, which meant a mixture of Canadian and US presentations on primary care. There was considerable contrast with Canadian general practice much further advanced in organisation, outlook and ambition. The picture from the US was very depressing, not just because primary seemed to lack coherence and direction but because the UK seems to be hurtling headlong in that direction. While UK general practice was always considered to be the model of high quality family medicine, many doctors at this meeting, particularly the Canadians, no longer consider that to be so. Our Canadian cousins are enthusiastic, committed and optimistic. Where have we gone wrong?

Domhnall MacAuley is primary care editor, BMJ