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Go Teams! a Situational Analysis of Interdisciplinary Primary Care Teams in Ontario

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Go Teams! a Situational Analysis of Interdisciplinary Primary Care Teams in Ontario Go Teams! A Situational Analysis of Interdisciplinary Primary Care Teams in Ontario by Susan M. Haydt Submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy at Dalhousie University Halifax, Nova Scotia September 2014 © Copyright by Susan M. Haydt, 2014 Dedication Page For you, my beautiful family and in loving memory of: Anastasia Oleksyn (1913-2007) Theresa Haydt (1965-2009) Steven Larkman (1969-2010) ii Table of Contents List of Tables....................................................................................................................vii List of Figures.................................................................................................................viii Abstract.............................................................................................................................ix List of Abbreviations Used ...............................................................................................x Acknowledgements...........................................................................................................xi Chapter One: Introduction...............................................................................................1 Provincial Context and the Models of Focus...................................................................... 3 Research Questions..............................................................................................................9 Situational Analysis as Method and Theoretical Framework..............................................9 Central Thesis and Chapter Outline...................................................................................13 Notes about Terminology..................................................................................................16 Chapter Two: Literature Review and Historical Context...........................................17 Introduction........................................................................................................................17 Part One: Interdisciplinary Care Literature .......................................................................17 Positivist Approaches............................................................................................17 Contextual Approaches.........................................................................................26 Critical Approaches...............................................................................................31 Part Two: Health Care Reform in Canada and Ontario.....................................................37 Cost and Efficiency: Early Talk of Teams............................................................37 Primary Health Care, System Reform, and the Health Professions......................40 Chapter Three: Methods.................................................................................................49 Situating the Researcher....................................................................................................49 Modified/Limited Situational Analysis.............................................................................50 Data Sources ...................................................................................................................53 Textual Data Collection.........................................................................................53 Textual Data Analysis............................................................................................56 Interview Data.......................................................................................................58 Interview Participant Recruitment Procedures and Challenges.............................59 Interviewee Characteristics....................................................................................60 Interview Techniques.............................................................................................60 iii Ethical Concerns....................................................................................................62 Chapter Four: Government Social World.....................................................................63 Introduction.......................................................................................................................63 Primer on Ontario Politics.................................................................................................64 Governments and Leaders (2003-2011).................................................................64 Previous Government Approaches........................................................................65 Agreement on Primary Care Reform, Teams, and Role Expansion..................................67 The Liberals’ Strategies for Implementing Teams: An Overview....................................74 Introduction of FHTs.................................................................................................74 "Our Model"...........................................................................................................74 FHTs as Physician-centered Models.....................................................................76 Issues raised in Responses to the FHT Model...........................................................77 FHTs are Just Rebranded PC models....................................................................77 Why Not CHCs?....................................................................................................82 FHTs as Substitute for CHC Requests?................................................................83 Challenges to Claims about the Interdisciplinarity of FHTs.................................85 Back Room Deals with Doctors?..........................................................................88 Expansion of Community Health Centres …………………………………………..91 Introduction of Nurse Practitioner-led Clinics (NPLCs).............................................96 Claims about Communities, the Ontario Public, and Teams...........................................102 Public Demand for Teams: Textual vs. Interview Data....................................102 Determining Community Needs......................................................................108 Justifying Actions with Teams.........................................................................................112 Discussion........................................................................................................................115 Chapter Five: Medical Professional Social World......................................................123 Introduction...................................................................................................................123 Primer on Physician Organizations ..............................................................................124 Acknowledging the Need for Primary Care Reform and Teams...................................126 Taking Charge of Primary Care Reform and Teams.....................................................129 Highlighting Political Leadership in Primary Care Reform.....................................129 OCFP Claims to Leadership in Primary Care Reform......................................131 OMA Claims to Leadership in Primary Care Reform......................................133 iv Distinguishing Primary Care from Primary Health Care..........................................135 Maintaining the Primacy of the Patient-Physician Relationship….…...……..…....145 Calling for Evolutionary, Not Revolutionary, Change.............................................153 Prescriptions and Proscriptions: the Role of Non-medical Health Professionals.....158 Beyond FHTs and CHCs: Prescriptions for Other Team Models…………………173 Discussion………………………………………………………………………........181 Chapter Six: Non-medical Professional Social Worlds..............................................191 Introduction.....................................................................................................................191 Primer on the Organizations............................................................................................192 Nurse Practitioner..............................................................................................192 Dietetic..............................................................................................................193 Chiropractic.......................................................................................................194 Agreements and Commitments to Primary Care Reform and Teams.............................195 Nurse Practitioner Profession..........................................................................................201 The New Health Care World: an Opportunity for Nurse Practitioners.............202 Defining and Defending Nurse Practitioner Scope Expansion in the Name of Teams.......................................................................................................205 Inequities between Nurse Practitioners and Physicians in Teams.....................216 Dietetic Profession...........................................................................................................222 Primary Care Reform and Teams as an Opportunity for the Dietetic Profession.................................................................................................222 Scope Expansion of Dietetics in the Name of Teams...........................................226 Inequities in teams for Dietitians..........................................................................244
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