Family physicians are angry, confused and discouraged. Sadly, many of our colleagues are stepping away from their leadership roles and others are disengaging. This does not bode well for any primary care reform being considered by the Ontario government. Family physicians want a contract. They also want to know the rules of engagement. This is not about entitlement, it is about fairness and transparency. Above all it is about the kind of trust and respect that facilitates a willingness to be part of the plan to improve the health of patients and families in Ontario by addressing issues of access, equity and quality.

Family physicians need to know what the plan is for primary care. Ontario's patients and families deserve to know as well. Residents and new graduates want to feel confident in their future as family doctors. Family physicians need to understand if they have to absorb more cuts. Family physicians need to forecast and plan as all responsible businesses do. Managing revenues and anticipating expenses allows for sound decision-making. Family physicians need to hear directly whether the Ministry of Health and Long-Term Care (MOHLTC) values their participation and is willing to engage in conversations about primary care - the sector acknowledged in Health Quality Ontario's Measuring Up report (October 2015) as "the entry point to the health system and (the) main contact for ongoing care".

The MOHLTC and their political masters are taking a huge risk with their approach to not communicating or engaging with family physicians. Any gains made, and goodwill generated in the past is depleting quickly and jeopardizing the future. These sentiments have been conveyed repeatedly to the Ministry by the OCFP, the OMA, and physicians themselves who have taken to social media in record numbers. The OCFP, like the OMA, has requested a meeting with Minister Hoskins to no avail. The Ontario government's punitive and unresponsive approach is deeply troubling for the College's family physicians. The LHINs will also find themselves in the unenviable position of trying to engage family physicians and finding no one is willing to take time away from seeing patients to support the government's agenda. Our current family physicians that are filling LHIN primary care lead roles will require the support of their colleagues to continue to be effective change agents.

The OCFP has been trying for months to read the tea leaves like everyone else. On October 1, the OCFP shared an executive summary of an evidence brief that was commissioned by the College to try and understand the concept of population-based planning and delivery of primary care. Through meetings in the spring, the OCFP came to understand that population-based planning was a concept being proposed in the report from the "Expert Advisory Committee on Strengthening Primary Health Care in Ontario" along with the formation of new structures at the sub-LHIN level. While it is not yet clear where the recommendations of the committee fit in the Ministry planning of primary care moving forward, the report identifies pressing health issues in primary care. The issue of variation in access to primary care in our province, including close to 800,000 Ontarians who have no family physician is not acceptable. The inequitable distribution of resources across primary care and variability in quality make for some significant challenges that affect family physicians and their patients. Historically, family physicians have been at the forefront of addressing primary care challenges, and while change can be difficult in a profession that seeks to minimize risk, there are shining examples of leaders across Ontario who have not shied away from bringing forth solutions and change efforts.

What is incredibly frustrating at this juncture, is the Ontario government's current lack of a well-orchestrated plan, inclusive of family physicians, to develop the vision for change through a more fulsome understanding of issues that directly affect their practice, patients and the future of family medicine. The OCFP knows that the report from the Advisory Committee on Primary Health Care is only one input being considered and not policy direction. The report attempts to move the needle forward toward a system where more integration will be needed to better serve the population - whether across home, community and primary care practices or with hospitals. The "Patient Care Groups" concept of the report adds to the 'Most Responsible Provider' a 'Most Responsible Organization' role with additional accountability for ensuring care for all people within the Group. This may have structural and governance impacts on how family physicians practise although the details have not been fully elaborated.

While awaiting a clear direction from the MOHLTC, but anticipating the Advisory committee report, the OCFP commissioned the evidence brief mentioned above. The goal of this was to understand what has enabled primary care transformation in other jurisdictions around the world in order to inform ourselves as a family physician-based organization and also inform our system partners. The full brief is now available for your review.

What did we learn through this evidence brief?

• Family physician engagement and leadership are key to any system change.
• There needs to be a balance between prescribing or standardizing change and allowing for local innovation and autonomy to reflect population needs.
• Primary care transformation efforts need to address both the change in culture and a culture of change.
• New skills will need to be adopted and education and training will be required to ensure those new skills are acquired.
• Transformation cannot happen 'off the side of the desk', it requires infrastructure to support new ways of working that will allow family physicians to continue to provide needed access to patients and time to participate in planning.

The evidence brief includes important lessons learned from other jurisdictions, including what has gone wrong. The next steps will be to tease out how to support family physicians to both think about how to serve their patients, and manage their roster, to also working with colleagues and interdisciplinary health providers to address the needs of a population. The OCFP will be sending this evidence brief to our colleagues in other primary care organizations to share the information that has been gathered in the absence of information from the Ontario government. We will also be sending this brief to Premier Wynne and Ministers Matthews and Hoskins with a message that goodwill has eroded and mutual respect and trust will need to be restored for any significant transformation to take root. The Ontario government must re-engage with the OMA. Only then can the OCFP, and our colleagues at the SGFP among others, begin to truly tackle system-wide improvements that accelerate access for patients, improve equity across the province, and enable a more equitable distribution of resources for patients and families in primary care.

Links and Resources

• OCFP's Evidence Brief: Preparing for a Devolved, Population-Based Approach to Primary Care - October 16, 2015
• Patient Care Groups: A new model of population based primary health care for Ontario: A report on behalf of the Primary Health Care Expert Advisory Committee - October 15, 2015