I am a solo family physician who has recognized several years ago that working in a group practice would be a far better arrangement for my patients and myself. Unfortunately there has not been the right opportunity to do this in the city where I work. I took over my practice in 1999 from another physician, who moved away and my practice had been trapped in something which is fairly well described in a New York Times article titled "Family Physician Can't Give Away Solo Practice".
I started talking to other physicians in the city about forming a group practice since about 2002. Because my current location only has enough space for 1 physician and so does most other practices in town, the discussion always came up about building a new clinic. The year 2003 was around the time that Saskatchewan (the province in Canada where I work) started to implement primary health care as defined in the Saskatchewan Action Plan for Primary Health Care. As the Saskatchewan Medical Association representative for primary health care for my health region (Sunrise), I saw the potential of team based collaborative care and wanted to be part of it. Unfortunately the implementation of it in the province was flawed and I never moved to become a primary health care site. (I don't like dwelling on the past, but the fact that the current ministry of health has started on a journey called "Primary Health Care Redesign" should be adequate for anyone to realize that even the ministry of health believes that the previous implementation was less than successful. It was not that the goal or principles were wrong, but rather the implementation strategy.)
So when I spoke to other physicians about joining up, I also discussed with them about incorporating space for other health care providers like diabetes educators, dieticians, nurses and/or nurse practitioners. I also spoke about building a facility that would have more space than the initial physicians that start working there, because we are at least 4 family physicians short. (Currently 10 of us working in a regional centre with a population of 17 000 serving a referral area of about 75-100 000). I believe that if you build the ideal facility and create the best working circumstances it would be easy to recruit more health care providers.
Unfortunately nor the ministry of health nor the health region is in the business of building facilities. Although they supported the idea of a team based group practice, they have not been able to help with funding. The city council was initially of the same opinion, but luckily that has changed in the last year and they have now committed to some funding to partner with a private investor to build a clinic. If all goes well , building will start in the spring of 2012. The dilemma that we have not completely solved yet, is that if you build a clinic in the traditional model then the physicians would fund it and have the lease as part of the overhead if they don't own the building. So in our scenario if we start with 3 physicians in a clinic with space for say 4 more physicians to recruit and also space for other health care providers, space for education sessions, group appointments, student education and visiting specialist office space, then 3 physicians have to pay the overheads for 7 and more. Even if we get to full quota of 7, it would be difficult to recruit a physician into a scenario where their overheads would go up when one or more of the other physicians would leave. (I know of another practice elsewhere in the province where 2 or 3 physicians had huge overheads to cover for other physicians that have left.). So we finally got the health region to commit in principle to provide extra funding to pay for space needed by other health care providers.
So to summarize the last few paragraphs: facilities or clinics cost a lot of money and ongoing overheads for a team based collaborative practice can be a lot more than what one would pay in a simple group practice where physicians would just co-locate. I believe that there needs to be a way to support physicians to move to such team based collaborative practices where they only need to pay a fair, stable overhead comparable to national or provincial average regardless of how many other services are provided at the clinic. What does such a clinic look like ? Well it would look like something that you would see in Alaska South Central Foundation in Anchorage. Other examples can be found at The Centre for Health Design and might look like the ambulatory practice of the future.
After several years of focussing on building the facility first with the notion "build it and they would come" and not seeing brick and mortar yet, I changed my strategy in the beginning of 2011. I came up with the idea to build the team first and then move the team to the new clinic once the brick and mortar is there. I found that suddenly the project started making progress, even though it is still much slower going than what I would like to see.
I invited interested physicians, other health care providers like pharmacists, nurse practitioners, dieticians, exercise therapists, diabetes education, optometrists, podiatrists and others, the ministry of health, the city council, the senior management of the health region, First Nations representatives and most important of all - 3 patient representatives to start up a chronic disease management team that would work in a temporary location until our facility is built. This team would then later expand its mandate to become a multidisciplinary, patient centred, team based primary health care site (wow, what a long definition.)
This was a huge success facilitated by Mary Smile, who used to work at the Health Quality Council with about 40 people attending from the region. Although progress was slow, suddenly the project started to move along.
We then selected a core group that would do the initial work of setting up the team and clinic. We met to come up with a vision statement and some principles.
The most recent session was a team building exercise for the initial provider and admin core team (there were 8 of us including 2 physicians, a receptionist/medical office assistant, a diabetes educator, a dietician, podiatrist, optometrist and the primary care director of the health region - unfortunately the mental health worker, exercise therapist and pharmacist could not make it) on 13 December 2011.
We have not started our clinic yet but we have a team already.
It was during this successful event (evening started with an ice breaker followed by snacks, drink and a board game similar to charades) that I came to the conclusion: Relationships and conversations will trump bricks and mortar every time ....
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