Primary Care/Family Physicians Roundtable – Scarborough
October 7, 2013 7:00-9:00pm
Facilitators: Tom Chan and Cheryl Williams
Benefits of a merger
- Access to services (siting and location).
- Unified vision that focuses on improving quality of care.
- Unified referral sheets.
- Increased market share; increased funding.
- Developing centres of excellence.
- Attracting partnerships.
- Increased opportunity for residents
- Increased sharing of information
Risks of a merger
- Limitation to access to services.
- Siting an inevitable consideration despite commitments now.
- Current challenges faced by family physicians dealing with hospitals may be exacerbated by dealing with a larger corporation.
- Role of family physicians diminished by elimination of “community hospital”
- Was there a cancer workshop?
- Oncology is one of the groups that did get together amongst the ten, did post a Workbook.
- Developed benefits and risks if we do merger, on the website.
- I was more interested in prevention.
- Unfortunately we did not look at this, however as you know there will be more and more investment into the community with respects to creating these centres of excellence that will have an outreach component.
- Family doctors are clients of the hospitals, not the staff and as such need a marketing strategy to attract them and their referrals
- Question to ask yourself is will this merger improve your services, will it make life easier, harder for you, because you are the referring base of the hospital.
- So analysis does not occur during this phase on things such as siting? This is not part of what you are discussing? I don’t know what has happened with other mergers in the province, however, once a merger occurs, won’t there be some temptation to adjust siting at one site.
- Will I have accessibility issues with my patients who do not have cars?
- Like the idea about a magnet. However, if the hospitals are coalescing services with 20 surgeons in one place, how easy is it for a new grad to establish themselves at a hospital?
- Have concerns about where new grads fit in.
- As well, one line in a commitment does not reassure me that site closures or shifting of services will not happen down the road.
- I think a merger has to happen to some degree, but how do we sustain the status quo as much as we can?
- In terms of services, I think it is region specific.
- Certainly some hospitals have come together in a way that they have whole new hospitals. There are no plans like that right now.
- With respect to our own hospital, tremendous financial pressure placed on us to do something like that.
- Moving into the future there will be more and more financial pressures to make changes similar to a merger no matter what. We will continue to look for cost-savings.
- If look at Trillium, Credit Valley, integration was much more in the back office than clinical integration to date.
- Looking at some of those regional opportunities.
- Always need to balance questions of siting with quality issues as well as public access.
- One of the risks you are talking about is limitation to access.
- I have this concern that you have cardiac center at RV, and Scarborough is no longer the cardiac center I saw years ago. If patient that goes to Scarborough and Centenary with same risk factors, what is the outcome at both hospitals?
- With mergers it is the outcome you must look at. If outcome is good feel confident to go to either, to send your patient to either hospital.
- However, we do need to look for more money. If it is not from government, it must be from somewhere else. You see other hospitals making money from cafeteria spaces, etc.
- You touched on an interesting point; the funding formula.
- Going forward the new formula is such that the opportunity exists that the funding follows the patient.
- Notion of market share; how many patients living in Scarborough are seeking services through Scarborough hospital system.
- If we simply attract patients to come to our hospitals, funding comes with these patients.
- One of the ways we can generate more revenue is for us to get the volume back, draw patients back to these hospitals.
- What would you think we need to do to be able to do that?
- Part of the problem is the wait time; wait times are getting worse.
- Where else can they go? Problem is the outreach program to the family doctors in Scarborough, we don’t know the services that are available at these hospitals, what specialities exist.
- Leeching occurs at the borders.
- If you take look at the center of the jurisdiction, Lakeridge, they have almost no leech. Market share is almost 100%.
- In Durham we lose a portion to downtown and North York, at our eastern border we lose to Ottawa and Kingston.
- Wait times are getting worse because we have tapped out our volumes.
- We have done all the cases we are allocated, we are limited. This is part of quality based funding.
- I don’t see where you’re saving money.
- If services aren’t going to be combined, what happens is that we have decreased access.
- This is not about saving money, but about increasing efficiency.
- Focus is how do we come together to be more efficient because we have more volume, and can gain funding.
- I’m right on border of East General and Scarborough.
- When my patients go to Scarborough, unsure of how long it will take to get information back– I feel more connected to East General.
- Unfortunately that’s my experience as far as consult goes.
- Question what they are doing at East General that makes the experience so much more seamless.
- If you want feedback immediately, know to go to East General.
- I’m a strong supporter of both Scarborough hospitals, always send patients here first unless reason not to.
- My part is easy, my staff had headaches.
- If you can clean it up the referral process and feedback towards family physicians, that would be a huge help. Should develop a uniform, simplified process.
- Know we need to make it easier to gain access, also have to give proper feedback. We have looked at the referral forms we have in the hospital and are clear that this is a problem.
- Dream is to reduce and unify forms throughout the province, make it easier for family doctors.
- Each hospital has standard form; different questions, different ways; make form the same.
- When some consultants want to have their own referral forms, not going to use it.
- Can’t figure out which consultant wants what information a certain way.
- If they don’t like the way I fill it out, I’ll fill it out for somewhere else.
- Unfortunately, younger consultants are the ones who tend to not consider family doctors to be informed and part of the team.
- I have to call them repeatedly, eventually have to call or fax the hospital.
- Right now two sites are in competition.
- Cardiologists at RV have their two competing groups, but they have a single form that you can send to 8 or 10 cardiologists, need them to be seen in a few days, will be seen.
- At TSH, cardiologists haven’t gotten it together. In terms of how do you garner market share, this is one example however you have to get specialists, not just cardiologists in general, to work together.
- If physician wants a certain one that’s fine, but one form for a referral, someone else navigates the patient.
- Once you send referral in it goes into the black hole.
- Question is in this amalgamation, the big fight is over acute care, is it anything to do with community care?
- It will be both.
- With regard to the interaction with hospitals, simplified forms, although you may want specific consultant, without having someone chase them.
- That is the ideal.
- Didn’t realize the frustration to you guys.
- If I don’t hear from specialist, decide not to use them again.
- Only thing about hospital is that form has to be faxed to the hospital, patient cannot do that.
- Trying to think, if you want more patient loyalty, have to facilitate the booking process easier.
- What do you perceive are benefits of a merger?
- Hospitals may start to have a unified vision; if start to share referral process I don’t mind if it is either site but is a faster process.
- If all consultants buy into that and it is distributed, huge benefits that way.
- Siting one of the benefits patients look for.
- Don’t want to talk about it but do have to look at siting: speaking to access and location of services.
- Downtown hospitals are all merged, patient referred down there and they don’t do x service.
- The problem here is there is no money, can try to do whatever you want but there is no money in the system.
- Don’t want to have leakage of system, but you can’t accommodate them here anyway so you’ve capped out.
- Only way to retain those patients is to make them wait longer for services, can’t get it anywhere.
- In terms of patients, wait times going to get longer, care is going to get poorer, and that’s the way health care is going in that province.
- Don’t see this improving ever.
- If we do nothing, we would lose out on wait times. We have to do something.
- Encouraging stories of American systems. They have identified weaknesses in the system, improved them and usually end up with improved systems for little cost.
- We also know that for practitioners; want to know what is in the hospital.
- If not appealing, practitioners are less likely to set up practices in the areas.
- You’ve given us lots already in terms of what we can do to improve services. Are we in a better position together to try to achieve that?
- Hearing concerns loud and clear around siting and access and scope for patients.
- Also heard we don’t treat you well as clients or customers of the hospital.
- Did hear from one family doctor that you also put your reputation on the line when you feel you don’t get good service from us for your patients.
- Example of what happened. I needed a follow-up on fracture clinic.
- Called orthopaedic surgeon, argued with secretaries.
- Told my patient they h ad to go through emergency to get a follow-up.
- Have patients go to emergency, they wait there six hours, then are seen and told they need to go to fracture clinic.
- Huge access issue we are facing.
- Patients concerned you might close ob/gyn.
- Lot of things going around in community of what type of change is going to occur.
- Adult mental health consolidated at Birchmount site.
- Child/adolescent outpatient services – send a referral for a patient – week later you get a letter back saying they don’t fit your criteria and send you a long list of alternative choices for you to call
- Should be forwarding your referral on for you.
- This is called partnerships and sharing the patient.
- We hear clearly there is an opportunity to address and improve quality, ensuring more patient centric care.
- I have patients in all 4 catchment areas, what would be helpful is to have some sort of navigation.
- Respect time spent filling out referral, help to find the correct location
- Some opportunities around chronic disease management or urgent issues – need to partner with you to gain better access
- Need improved direct access
- Over time, family physicians have removed themselves from hospitals.
- Should have a website for family physicians, anything that would be helpful in terms of referrals.
- For information not readily accessible could be useful for family doctors.
- Part of the outreach that is going to have to occur, especially if you amalgamate, you will have to hire someone that is communications and advertising.
- Advertising to community doctors that are disconnected from the “mothership”.
- Everyone is specialized and we need to know this.
- Unless the hospital really coordinates its advertising, information campaign, going to have trouble increased volumes.
- To capture family doctors, as we get bigger with centers of excellence, hard to keep track of which doctor is where.
- As this unfolds, if can strengthen that connection, which keeps both you business flowing of family physicians and increasing market share for hospitals.
- Any more benefits?
- Benefit to programs, centres of excellence.
- More preceptors for medical students and residents.
Community Participant: NEXT TWO COMMENTS ARE WITH REGARD TO ACADEMIC TEACHING
- With regard to resident training, certain speciality rotations are taught by one person, so very lucky to have that person but having difficulty if that person is ever gone or sick.
- If expansion wouldn’t be much expansion beyond that – one resident for each session, etc. unless commitment by departments to education is established.
- Offer electives as well.
- Sustainability issue, currently with one person we’re vulnerable.
- A lot of peripheral sites for residents (Barrie, Markham, etc.).
- Expanding to Centenary would be a potential to deal with limited preceptors.
- Other hospitals teaching sites are growing as they become established
- May be a desire to do this here?
- Getting outside family medicine?
- Listening from feedback from the residents will improve teaching.
- What we’ve heard from others is that this shared sense of values and the other piece is similar business lines.
- Either you merge because you did similar work or similar values, or merge because trying to find someone that does something completely different from you.
- Look at work between RV and Scarborough, very similar.
- We have very similar values.
- There are cultural differences now between the four sites.
- Not going to control all aspects of culture, might be what gives some of them something unique and connects to community.
- What if this hospital gets too big? How much do family physicians mean to hospital?
- This has always been a community hospital that valued the physicians in its community.
- Some personal connection which helped, if this place gets a bit too big the role of family physicians might be diminished to some degree.
- CME’s – if you want more family physicians to refer to hospital, have CMEs and invite them in.
- Get an opportunity to meet consultants who are doing the lecture.
- Website currently hard to navigate.
- Set up a relatively simple and interactive website.
- Some Pediatricians that gave their talk at TSH sponsored CME had special interest.
- If going to capture family doctors, whole idea is simple referral section that shows who you should refer your patient to based on special interests.
- I am hearing the big concern is that if hospitals get too big, lose relationships, and lose relations to community.
- However, with or without a merger your comments have provided a great opportunity to fix certain issues.
- Hospital needs to find ways to highlight special interests, whether on a cheat sheet or website.
- Maybe opportunities to increase revenue to looking at ways for hospitals to be better utilized.
- We need to look for community partners.
- Need to promote hospital more, if community knew these great things about our hospitals the community is more likely to rally around us.
- North York advertises well.
- Have to have good support, but no matter what need financial support.
- Don’t necessarily think bigger is better.
- Are we still going to have the same problems in a bigger organization?
- Think going to be positive to force consultants to look at how they work with family doctors.
- Perhaps pushed on them a bit, but still a positive.
- Streamlining referral process is key
- Educating the public too is key, as it falls on physicians currently who aren’t always aware.
- Hope to achieve balance, we want hospitals to work in partnered way with a family practice, don’t want to build something competitive to family practices.
- People should be pushing information out – have invested a lot of time into our EMR system however this just keeps you more in the loop.
- Integration would be helpful as it would hopefully help push information at you.
- Hospital cannot just be an acute care centre but must integrate with the community providers through outpatient clinics and other aspects of shared care that is supportive of patient centred care.