The disorganized state of primary care

CMAJ 1998;158:865

Until now, directives concerning Ontario's contentious Health Services Restructuring Commission (HSRC) have been restricted to the hospital system. Since the eventual success of HSRC recommendations to reduce the number and size of hospitals requires an expanded and reoriented primary care system, the commission's chair has stated that it should have begun its work by restructuring the primary care system. Surprisingly, public complaints about hospital closures have included serious concerns about the loss of the easily accessible primary and ambulatory care provided by emergency departments.

In 1973 I wrote a memo to Ontario's deputy minister of health. At the time, I was executive director of the ministry's Treatment and Rehabilitation Division, and my memo concerned complaints by small-town hospitals. "Who is to pay for the increasing use of hospital outpatient departments by physicians who see, and perform services for, patients, where the visit or service could have as well occurred in the doctor's office?" I wrote. The Health Insurance Act of 1972 did not allow hospitals to charge for this use of their facilities. "It involves, fundamentally, the place of hospital outpatient departments in the provision of primary care in a community," I added.

Retrospection suggests that when patients needed care before 1972, they called or visited their doctors. By that year, however, some of their primary care was already being shifted to hospitals, initially by doctors. The study by Mustard and colleagues identifies some patients who do not appear to consider doctors their primary providers of any care.

I am retired and now live in Port Hope, Ont., a small town of some 12 000 people. It has a good 50-bed hospital and a large medical office building that includes elaborate offices for solo GPs and visiting specialists, as well as private diagnostic and rehabilitation services. The office facility is partly in competition with the hospital, but all after-hours and holiday requests for service are referred to the hospital. The building's doctors otherwise provide no off-hours services for each other.

Cuts in hospital budgets and the perceived menace of the HSRC have disrupted the provision of care in many parts of Ontario. Abundant anecdotal evidence indicates that an important number of Ontarians simply go to the hospital when they are sick.

The disorganized state of primary care and its comparative costs warrant assessment. Anecdotal evidence and the public belief that small-town hospitals are major and direct providers of primary and ambulatory care are insufficient to justify policy changes. However, the care provided by general practitioners may be more ephemeral than they admit.

We need a study on the use of emergency departments as a component of total ambulatory care in small-town Ontario hospitals where the population is less diverse than Winnipeg's. Perhaps such a study is already under way. I hope so.

John S.W. Aldis, MD
Port Hope, Ont.
draldis@eagle.ca

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