Brilliant health economist, Bob Evans, occasionally spoke of ‘zombies’: policy and health funding prescriptions that were constantly refuted by evidence but kept coming back.
One such zombie is the idea that equity and effectiveness are incompatible. New research from ICES comparing primary care models, however, demonstrates that Community Health Centres, whose fundamental goal is improving health equity and supporting some of the most health disadvantaged populations, also provide highly effective care.
One indicator of high quality primary care (which also reflects a crucial contributor to overall system effectiveness) are lower numbers of emergency department visits. When people don’t have access to primary care or their health care providers are not accessible, they can end up in the emergency room; not the best or most appropriate care for them, and very inefficient from a health system point of view. Canada and Ontario do not do well as compared to other leading jurisdictions, but this research points to how this can be improved.
The ICES study observed that Community Health Centres (CHC) served populations from lower income neighbourhoods, with higher proportions of newcomers and with greater and more complex health conditions. Yet CHC patients had significantly fewer emergency room visits than expected, faring better than other primary care models. By way of explanation, the ICES report noted that, “possible factors include health promoting services, community engagement, longer appointment duration, the presence of long-established interdisciplinary teams, extended hours, client preferences, provider practice styles, practice location in relation to existing services and the nature of appointment scheduling” (p. 24). I would add that CHCs having physicians on salary, carefully integrating nurse practitioners, and working in community collaborations to address underlying social determinants of health are also critical. The ICES report noted that capitation-based models such as Family Health Teams (FHTs) tended to serve more advantaged populations and had higher emergency room visits than expected. This does not mean that FHTs are not a valuable part of primary care reform, however it does highlight that more careful policy attention has to be paid to incentive, payment and other structures that shape location, service practice and case mix.
Ironically, the recent Drummond Report correctly highlighted the importance of integrated, comprehensive primary care, but referred only to Family Health Teams — and neglected the issue of equity almost entirely. CHCs provide a proven and solidly established network that can be built upon to advance equity, system effectiveness and patient-driven quality.