The Romanow reforms: add to shopping cart

Prime Minister Chrétien and his minister of finance did more than browse the Romanow report1 in preparing the new federal budget: they selected almost everything in it — from compassionate leave to MRI scanners to exercise enticements — for their shopping basket. An arrangement for delivery — the newly forged First Ministers' Accord on Health Care Renewal — has been made with the provincial and territorial premiers: it won't be free, nor does it have a money-back warranty, but at least the shipment can be tracked. For there are strings attached to the federal government's 5-year, $34.8-billion health care spree: the funds must be used for the purposes intended, and there must be an annual reporting on progress. Although we might quibble about whether some of this money is new or repackaged, prima facie it represents a 31% increase over current total spending (public and out-of-pocket) on health care in Canada. If directed funding and an insistence on accountability do the trick, most physicians and patients ought to see tangible evidence of the new federal purchases in their offices, clinics, emergency and radiology departments and home care services over the next 5 years.

The string attached to the largest chunk of federal cash, the Health Reform Fund ($16 billion, or 46%), is the requirement that funds be used to institute multidisciplinary reforms to primary health care, expand home care services and relieve the burden of catastrophic drug costs. Of these, primary care reform will have the greatest impact on the practice of medicine and will probably receive the greatest proportion of the funds. We ought to pay close attention to the almost literal reading of Romanow in the federal government's designation of funds for “multidisciplinary primary health care organizations or teams, with a goal of ensuring that at least half of the population within each jurisdiction has access to an appropriate health care provider 24 hours a day, 7 days a week.”2

A shortage of nurses, not physicians

Clearly, Romanow does not subscribe to the belief that there is a shortage of physicians. The crisis, as he sees it, is in nursing: too few are graduating to replenish an aging workforce, too many are dissatisfied with working conditions, and scope-of-practice issues remain contentious. Thus, we should not be surprised if the $90 million allocated in the federal budget for “health human resources planning and coordination” is devoted mainly to remedying the nursing crisis.

Romanow attributed the difficulty that many Canadians have in finding a family physician (15%, according to a recent survey by the College of Family Physicians of Canada3) to 2 factors: maldistribution, and scope of practice. The difficulty of recruiting and retaining physicians in rural and remote areas is well known; on this problem, the Romanow report offered few new insights, and the federal budget no specifically designated cash. On the scope-of-practice issue, Romanow was succinct and blunt: health professionals, he wrote, “tend to protect their scopes of practice. Each profession appears willing to take on more responsibilities, but is unwilling to relinquish some duties to other professions.”4 The reforms that the government has budgeted for may be destined to change this. As funds for multidisciplinary primary care teams start to flow to Rimouski, Renfrew and Red Deer, physicians — particularly family physicians — should expect increasing pressure to work with other health care professionals, mainly nurses, in the 24/7 delivery of services. And, as there is no commitment to providing more family physicians, those already in practice will have to consider restricting their scope of practice to areas where their particular expertise is most needed, allowing nurses and others to take on expanded roles.

A sharper focus

Meeting the challenge will require a careful and dispassionate assessment of the role of family medicine, the dwindling specialty.4^,5^,6 It is already difficult to recruit physicians into family medicine, as this year's CaRMS match illustrates (see News, p. 881).7 As nurses are encouraged with federal dollars to expand their roles in primary care, family physicians will need to re-examine theirs. Family physicians may be facing a choice between blurring or sharpening their roles. Will family medicine become an eroded and dissatisfied specialty, or will it renew itself through redefinition, ensuring that the diagnostic and clinical skills of family doctors are put to their best, and more efficient, use? — CMAJ