Oct. 7, 2016

Pulse on Family Medicine: Primary Care Policy Update

Reintroduction of the Patients First Act, 2016

Please note, the following does not represent a legal opinion about Bill 41, but is an initial internal analysis of the reintroduced bill.

The Patients First Act, 2016, Bill 41 (formerly Bill 210), was reintroduced in the Ontario Legislative Assembly on October 6, by Dr. Eric Hoskins, Minister of Health and Long-Term Care. There are several amendments to the bill, and in particular, to sections that affect family physicians. Bill 41 proposes to expand the current mandate and role of the local health integration networks (LHIN) for hospitals, long-term care and mental health to now include primary care and home and community care.
 
What has changed and how does it affect family physicians?
 
Previous version, Bill 210
The original version of Bill 210, included a section (Section 29) which received much physician feedback. It would require family physicians to provide information and reports to their LHIN for planning, performance management and other duties. As stated, this included reporting:
  1. Physician resource issues such as opening and closing of practices, transitions and changes to practices, retirements from practices and change of location of practices.
  2. Physician practices in the local health system such as policies for accepting and discharging patients, practice profiles, practice wait-times, and practice coverage for after-hours services, vacations, leaves and other absences.
Additionally, the bill noted several other powers for LHINs for directives, audits, reviews and investigations of health service providers (HSP). A family physician is not considered a health service provider. However the technical definition of HSP was expanded to include non-profit entities such as family health teams, nurse practitioner-led clinics, Aboriginal health access centres and hospices among others. Health service providers are identified in Section 3 of the bill.
 
At the time of the introduction of Bill 210 in June, the OCFP was surprised that such a prescriptive and overly bureaucratic approach was in the legislation. The College, and other stakeholders such as the OMA and OHA, among others, advocated for changes in the proposed legislation.
 
Revised version, Bill 41
The reintroduced bill has considered stakeholder feedback and notably, Section 29 has been changed, addressing the intent to support collaboration among family physicians in sub-regions of LHINs with others in the health system. The purpose of collaborating will be for primary care planning, including local health human resources and service capacity. Section 29, 37.1 now states:
 
The Lieutenant Governor in Council may make regulations respecting the provision of information from prescribed persons and entities to a local health integration network in order to support collaboration between health service providers, local health integration networks, physicians and others in the health care system, and to support planning of primary care services, including physician services, that ensure timely access and improve patient outcomes, including information to facilitate understanding by the network of,
  (a)  transitions in practice, including opening, closing, retirements and extended leaves; and
  (b)  practice and service capacity to address population needs of the local health system in the geographic area of the network.
 
Patients First Act, 2016, Bill 41, notes that certain provisions will only come into effect on proclamation and not royal assent.
 
After a bill receives its third reading, it is considered passed. The bill becomes an act once it receives royal assent - this is when the Lieutenant Governor, acting on behalf of the Queen, agrees to the bill. It is at this point that the bill becomes law however certain elements may not yet be considered to be “in force”.
 
In the case of several sections in Bill 41, including section 29, 37.1 described above, this will only come into effect on proclamation. This means that although the bill may be an act, there will be another time set for these provisions, or sections, to take effect as opposed to the day that the bill becomes law.
 
It should be clearly noted that in no way do the OMA’s current representation rights change under Bill 41.
 
Some questions you may have about the impact of Bill 41
  1. If Bill 41 becomes law, does this mean you need to report practice changes to the LHIN?
    After the bill becomes law, there is nothing that will change immediately for family physicians and reporting about your practice. The bill states that family physicians may need to provide information subject to regulations, which are not yet defined.
     
  2. Will you need to provide information to the LHIN regardless of your practice model?
    As the OCFP understands, if the bill becomes law, and only after proclamation, all family physicians may need to provide information about transitions in practice (such as practice openings and retirements) for the purpose of local planning, subject to regulations. These regulations are not yet in place. Collaboration among family physicians and colleagues in local communities to identify gaps in primary care services and to better plan for the primary care needs of patients is a stated intent by the Ministry.
     
  3. What opportunities are there for family physicians to have a voice in planning?
    Focus groups and engagement sessions are taking place across all LHINs. The opportunity to participate in local planning so that your practice realities and population needs are part of planning considerations will be essential to develop local solutions. Good planning based on population-health data must be informed by the front-line experience of family physicians.

    The OCFP recognizes that there are significant frustrations about how services are organized and supported and these need attention. It is the OCFP’s hope that family physicians can work together with their specialist colleagues, with interprofessional healthcare providers, and with other sectors like hospitals to determine how supports can be better coordinated and available for both providers and patients.

    The OCFP encourages all family physicians to attend these meetings to help shape the future and ensure your practice realities are informing sub-region planning. 
     
  4. Is the LHIN going to be managing entry into practice?
    LHINs do not have accountability for family physician service contracts, so there will be no changes to existing contracts. It is not clearly stated what role LHINs will have with managed entry or identifying underserviced areas within the LHIN related to planning.
     
  5. Will a LHIN be able to access patient health records?
    Section 21 of the bill notes that a LHIN “may appoint one or more investigators to investigate and report on the quality of the management of a health service provider, the quality of the care and treatment of persons by a health service provider or any other matter relating to a health service provider where the local health integration network considers it to be in the public interest to do so.” A health service provider is a technical term that does not refer to a family physician. However, the LHIN may access records from a health service provider (e.g., FHT, CHC, NPLC). The proposed legislation, Section 21 (11) also clarifies that before any report is made public, the LHIN must ensure all personal health information in the report is redacted.

    The bill also calls for the potential to investigate LHINs as well as HSPs. The issue of privacy and patient health records was the subject of another bill, Health Information Protection Act, 2016, Bill 119, which passed in May 2016.
The OCFP recognizes that the last months have not been without challenges for family physicians. Along with our colleagues at the OMA, we have advocated that the unilateral cuts and funding changes have not supported a trusting relationship through which to engage in primary care transformation. Despite this, you have not wavered in your commitment to providing high-quality care for your patients and families. Family physicians will continue to be good stewards of health-care resources, and have an important and unique role to play given your training, clinical expertise and work across many health-care settings. Primary care transformation can only be successful if Ontario’s family physicians are part of the solution, and the OCFP will be with you on this new path forward.
 
If you have additional questions, the OCFP will try and get answers for you. Keep in mind, the bill is not yet law, and many provisions will not change even when the bill passes. Please email the OCFP at ocfppulse@cfpc.ca.