Ms. Raskin and colleagues, I wonder if some of you could help clarify
the thinking around Multidisciplinary Community Health Centres and
concepts of two tiered health care. Community clinics  seem like a
terrific idea where people from several disciplines are available to
satisfy the needs of people.

Is it two tiered medicine if some citizens in a community have access to
CHCs and others don't? Should those without access to multidisciplinary
teams be able to pay for such services?

In many parts of the country, within the same neighborhood, some people
are able to attend multidisciplinary community health clinics/centres
while others are unable to use their services.

Sometimes the privileged few have access to primary care nurses,
nutritionists and other health professionals, while their neighbors
don't have comparable access. The centres are only able to provide
appropriate care for a limited number of people (depending on their
staffing).

When clinics or primary care doctors ask for the resources to support a
multidisciplinary team Provincial governments sometimes report they do
not have the resources. Additional health care costs  means that
governments and communities will be less able to subsidize or regulate
other important areas affecting health  such as education and food and
water safety. It is understandable that some governments, particularly
in poorer provinces are reluctant to spend more on health care.

Ms. Rankin and colleagues, is it fair, in your opinion,  to encourage
citizens to purchase services, individually or as a group,  which are
accessible to their neighbors, but not to them?

Should citizens be able to spend their money and time  supporting
organizations that provide the kind of services they value, especially
when they are not services currently insured by governments?

Are Primary Care Cooperatives, supported by members, one way that people
can collaborate to gain  access to the  multidisciplinary services that
are available to their more privileged neighbors?

Dennis,  please let us know when this discussion is outstaying its
welcome and thanks for organizing this thoughtful list.

Best wishes
David Zitner


Lynne Raskin wrote:

>Dr. Zitner thank you for stimulating some thinking about Primary Health
>Care. Within the current discussion, I would like to add a model of primary
>care that often gets overlooked in the primary care discourse.
>
>I work in a Community Health Centre where multidisciplinary teams of
>professionals are all paid a salary (FPs, NPs, social workers, chiropodists,
>psychologists, dieticians, health promoters, mental health workers etc.) The
>MOH funding costs are therefore predictable, teams work collaboratively, the
>focus is on health promotion, illness prevention, treatment and community
>development.  It is a model that has been heralded by Mr. Romanow,  Dr.
>Michael Rachlis and others...including anyone who partners with,  works in,
>uses or values multidisciplinary team practice...
>
>CHCs are more than doctors' offices.  They are hubs of community based care
>and community capacity building activities.  They operate with from a
>holistic perspective, work with acute and chronic illness, offer 24/7
>access, are community-controlled by Boards of Directors and therefore
>accountable to and close to the communities in which they were created.
>Their focus in urban settings is on individuals with issues of access to
>primary health care. In rural and Northern communities they are often the
>only game in town. They reduce isolation for practitioners and
>patients/clients alike, offer a mix of social and health services and often
>work with the most disenfranchised, medically/mentally complex, non-insured
>and immigrant communities because we have salaried practitioners. In the
>case of outbreaks of concern to public health e.g.TB, SARS, they can move
>quickly to reach the unreachable to inform, connect, translate and inoculate
>with Public Heath support.
>
>CHCs are products of and advocates for the Canada Health Act, adhere to the
>WHO definition of health, and function within a social and health
>determinants perspective. The sooner we acknowledge that a broad definition
>of primary health care includes Nurses, Nurse Practitioners, Social Workers,
>therapists etc. and Health Promotion working in true multidisciplinary,
>well -resourced, partnerships with doctors, the sooner we will shift our
>concentration from an illness-focused, primarily fee for service system, to
>one which promotes building healthier, integrated communities, able to
>manage chronic health, social and environmental challenges.
>-----Original Message-----
>From: Social Determinants of Health [mailto:[log in to unmask]]On Behalf Of
>Langill, Corrine
>Sent: Wednesday, April 07, 2004 3:09 PM
>To: [log in to unmask]
>Subject: Re: [SDOH] Primary Care Cooperatives
>
>I was fascinated to read how Dr. Zitmer attempts to co-opt the words of
>Tommy Douglas into support for his Primary Care Co-operatives scheme.
>Canadians DO make significant contributions to the health care system (which
>is, in fact, an illness care system...but that's another posting!), through
>our taxes.  Dr. Zitmer uses this quote out of context, in my opinion.
>
>I was also struck by Dr. Zitmer's characterization of nurses as
>'professional assistants' to physicians, who allow physicians to 'specialize
>in higher value activities'.  Dr. Zitmer may be surprised to learn that
>nurses (along with other regulated health professionals in Canada) have an
>established, self regulated scope of practice independent of medicine.  I'm
>sure that many would question the 'higher value' of activities provided by
>physicians.  The health of Canadians is promoted by the collaborative work
>of many disciplines; with differing approaches, but certainly of equal
>value.  I'm sure that many physicians would agree that an activity is not of
>higher value simply because it is provided by a physician.  Perhaps access
>to care would be improved if Nurse Practitioners and other regulated health
>professionals could be fully reimbursed for their services by provincial
>Health Programs.  Physicians currently monopolize this billing process, and
>are rigidly opposed to opening this up to any other health profession.
>
>I also wonder to whom these proposed monthly fees would be payable?
>Physicians?  The nurses who provide the service?  I find it hard to believe
>that anyone's health would be improved by renewing prescriptions by phone,
>or getting lab results by email (most people would need to have such results
>interpreted for them anyway).  People in Ontario already have access to
>health information through a provincial telehealth phone line, staffed by
>nurses.  Many Health Units also provide the same service.  Dr. Zitmer seems
>to be proposing that people pay more for services that already exist.
>
>I suggest that Health dollars would be more wisely spent by shifting focus
>from 'illness care' to those approaches that can prevent visits to
>physicians offices and hospitals in the first place.
>
>
>Corrine Langill RN, BscN
>Adolescent Health Specialist, Program Development
>City Of Ottawa, Community Services Branch
>495 Richmond Rd.
>Ottawa, ON
>K2A 4A4
>(613) 724-4122 ext. 26258
>fax: (613) 724-4148
>[log in to unmask]
>
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