Accessibility and Continuity of Care: A Study of Primary Healthcare in Québec : research Report
Generally, users of primary care have a favourable opinion of their experience of care. Organisational and geographical accessibility remain the aspect that is the least favourably perceived by the population. We should be concerned with the fact that residents of urban areas in general, and Montréal in particular, have a poorer perception of their healthcare experience.
The adult population is served by primary care medical clinics that have adopted different organisational forms. In the regions studied, we observe five primary care organisational models, four professional and one community. Professional models—single-provider, contact, coordination and integrated coordination—serve 90% of users. These types of organisations are privately governed, and their objective is to respond to the medical needs of who come to clinic, or of people for whom these clinics are the regular source of care. The community model includes organisations integrated into public healthcare institutions; their goal is to improve the health of the population in a given region. We should keep in mind the following:
- The professional single-provider model, the “solo physician”, shows the best performance when it comes to perceived experience of care. This finding reminds us that a personal doctor-patient relationship fosters a better experience of care. And yet, solo practice is fading and being replaced by group clinical practice. It is important to preserve the relational character of this practice when reorganising primary care since reforms will undoubtedly lead to more complex and larger organisations.
- The professional integrated coordination model stands above the other models in all aspects of performance and should be considered for implementation of new models of primary care organisation. This model includes, for the large part, “Family Medicine Groups” (FMG) implemented in the two regions at the time of the study. These highly effective organisations are responsible in part for the integrated coordination model's high ranking when compared with other organisational models. Consequently, our results support ongoing implementation of FMG which, by inserting themselves into existing organisations, seem to contribute to improving the latter's performance.
- Implementation of “walk-in medical clinics” is not the solution to the current problem of accessibility to primary care. Indeed, organisations that follow the professional contact model and prioritise accessibility of services are shown to be the least performing in all aspects of the experience of care, including accessibility. Accessibility is considered more positive by users of the other professional and community models. Finally, these organisations are poorly integrated into the health services network. Therefore, this model does not represent an organisational basis for primary care reform. Specific efforts must be made to ensure this type of organisation contributes to an overall plan designed to enhance the population's access to primary of services.
- It is troublesome to note that the professional contact model, which posts the worst performance, includes a significant percentage of FMG and future network clinics (in the accreditation phase in 2005, at the time of the study). Development of emerging types of organisation must be guided by their capacity to improve the performance of primary care.
- Overall, results converge to demonstrate that apart from the professional contact model, organisational models are equally equitable when it comes to services rendered to clienteles who are disadvantaged on a socio-economic, educational or health level. Nonetheless, our study suggests that certain socio-economic factors have a negative impact on perception of experience of care and reporting unmet healthcare needs, especially among people who perceive themselves as poor or very sick. However, older people and those who are less educated tend to report better experience of care and fewer unmet needs for care.
Optimal organisation of primary care in a territory or region should take into consideration historical and contextual factors. It can hardly be based only on a single organisational model. We should remember the following:
- Greater availability of primary care and specialized resources at a territorial level is not a guarantee that primary care will perform better, especially in terms of the population's experience of care. Superior performance is associated with organisational models and their integration into the healthcare system. This finding suggests that in addition to favouring certain organisational models, reconfiguration of primary care must seek to create coordinated care networks.
- Models that ensure organisational accountability and patient management, particularly of clienteles with chronic diseases, and that offer a mix of consultation options (e.g., walk-in or by appointment and telephone consultations) seem to be the best way to ensure both accessibility and continuity of care.
- Rather than having isolated FMG organisations, having a certain number of FMG in a territory appears to have greater impact on the population's experience of care, which suggests an implementation strategy that involves saturating rather than scattering FMG.
Organisational and contextual taxonomies developed in this study allow a better understanding of the organisational realities of primary care. They provide a useful frame of reference for decision makers and administrators who wish to characterise delivery of primary care in the territories and follow their evolution over time. In addition, the knowledge generated by this study can be used to anticipate results of changes to the organisation of PHC.