First contact: what does it mean for family practice in 2017?

Dear Colleagues,

In this month’s issue of Canadian Family Physician, our President, Dr David White, speaks to the importance of the GP as the enduring model traditionally associated with generalism.¹ Gatekeeping is also an important role for GPs and FPs. A gatekeeper is “a defined point of entry each time care is needed for a health problem.”² Dimensions of gatekeeping include the need for appropriate care, budget restraints, and justice in distributing care.³ Gatekeeping also speaks to first-contact access, another important role traditionally assumed by FPs. Haggerty et al describe first-contact access as “the ease with which a person can obtain needed care … from the practitioner of choice within a time frame appropriate to the urgency of the problem.”⁴ In an interdisciplinary environment where first-contact access is assumed by other providers (eg, nurse practitioners [NPs]), in addition to FPs, has the nature of first-contact access changed, and if so, how? Does having a non-FP member assume the responsibility of first-contact access affect the larger dimension of first-contact care? Is a virtual delegation of a management plan by an FP to another provider still first-contact care? Is there a point at which too much delegation might harm our own competencies as providers of first-contact access and first-contact care? Is this important?

Owing to our ongoing relationships with our patients, we are able to recognize when a clinical presentation warrants watchful waiting versus the need to actively pursue a definitive diagnosis. Although some of this can be learned formally, many of us believe that such skills are best acquired through clinical experience and reaffirmed by providing first-contact care.

Stange et al remind us that in a patient-centred medical home environment, first-contact access involves more “asynchronous communication and self-care,”⁵ as well as face-to-face interaction with practice team members; and that there are various ways of organizing practice in the manner of first-contact care (eg, electronic communication, group visits). In new models of care, the responsibility for first-contact care shifts to a degree from the individual physician to the practice. The inclusion of team members such as NPs is not new; yet, when asked, patients will often reinforce the primacy of their relationship with their regular FP, while still considering a visit with another FP or other provider as acceptable.^6,7 In a study evaluating patients’ satisfaction with access after the introduction of academic family health teams in Ontario, Carroll et al found that patients were generally satisfied with access but that opportunities for improvement remain; that patients preferred to see another FP if their own FP was not available; and that having an NP on the team was predictive of a willingness of patients to see another non-FP provider on the team.⁷

As a better understanding of the roles of providers within a team increases, it is likely that first-contact care will truly be viewed by providers and patients alike as a responsibility of the team. Stange et al explain that in a patient-centred medical home, the FP “leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.”⁵ We are aware—based on the evolution of practice models, some observations, and some conversations with decision makers—that there are discussions about FPs’ roles evolving into consultants on primary care teams, and, potentially, increasing the number of patients an FP, working in a team environment, is responsible for.

While assuming such a role might be possible for FPs, our unique value proposition comes from assuming continuity of care. Part of this continuity comes from “synchronicity,” being with our patients for anything they present with and being able to decide with them on which approach to take (eg, referral, watchful waiting). As models of care evolve, it will be important to study how first-contact access by non-FP team members affects patient care and population outcomes. I welcome your feedback on some of the thoughts expressed in this article; you can contact me at executive{at}cfpc.ca.

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