Context

Northern British Columbia covers over 500 000 km² of wild, varied and challenging Canadian landscape beset by, at times, harsh weather and natural hazards such as avalanches, floods and wildfires. It is home to many remote communities. Approximately 300 000 people live in this area. The main centre is Prince George, population around 75 000,1 the regional referral centre for most medical services with links to tertiary care services in the lower mainland of British Columbia. This area is served by a single health authority, Northern Health (NH), that works in collaboration with the province-wide First Nations Health Authority and the Provincial Health Services Authority. In 2009 Northern Health, supported by a federal Primary Healthcare Transition Fund, began a process of primary care reform encompassing whole system changes with a focus on developing multidisciplinary primary care teams across several communities utilising the concepts of the primary care home,2 3 patient centred team based care and community and physician partnerships.4 The long-term vision was to integrate care in each community so that physicians and other health professions worked together with patients being supported by team members relevant to their needs, where patient information was shared across the teams and with acute care and where there was substantive local decision-making in terms of addressing health priorities.

In 2010, the British Columbia (BC) government and the Doctors of BC, the physician representative association, created Divisions of Family Practice. The Divisions are organised on a geographical basis to provide physicians with a common voice in advocating for family medicine and resources designed to enhance patient care through providing patient, practice and physician supports (https://www.divisionsbc.ca). In northern BC, there are six Divisions that encompass most, but not all, physician practices. Physicians are remunerated by a variety of provincial mechanisms including fee for service billings, sessional payments and quality and income guarantee arrangements. Most other health professionals such as hospital and community nurses are employed by the health authority. Family physicians in rural Canada have broad, generalist practices that can include working in clinics and in hospitals, staffing emergency rooms and developing enhanced skills including surgical skills, procedures such as caesarean sections, anaesthesia, oncology and mental health skills.

Background

Previous research on health system reform consistently points to the critical importance of physician engagement.5 However, research also highlights the great difficulty in engaging physicians, particularly in primary care, where physicians often work more independently from the rest of the health system.6 This lack of engagement is critical to address because developing new ways to provide primary care, such as collaborative team approaches, is essential to sustaining an efficient and effective healthcare system.7–10 Physician relationships with healthcare organisations or health authorities provides a fundamental platform to support all other change initiatives.11–13 In a synthesis of the literature and expert panel report on physician engagement and leadership Denis et al14 identified that much of the literature on engagement was based on managed care models in the USA and that gaps in knowledge existed about how different strategies, aimed at creating environments that support physician engagement, work on the ground in different contexts. Using a social identity approach that emphasised the differences between physicians and managers, Kreindler et al15 described the importance of intergroup dynamics as part of any attempt to engage physicians. This research also emphasised how different contexts needed approaches that varied depending on local relationships particularly within the power dynamics that are in play between physicians and administrators. In general, the literature focuses on how healthcare organisations engage with physicians as individuals and leaders in order to try to facilitate system change and health improvement within those specific organisations. Engaging physicians in primary care settings, and in particular remote and rural ones, to bring about health system change, remains relatively unexplored in the literature.

This gap is particularly significant for rural Canada which, like many countries, struggles to deliver equitable access to healthcare for its rural populations, resulting in poorer health outcomes for those living in rural areas compared with their urban counterparts.16 One of the reasons for this is a continuing maldistribution of physicians to rural areas.17 18 While there are many ways of trying to provide supports to enhance recruitment and retention in rural areas19 there remains little evidence on how to engage physicians in isolated rural areas in developing ways of creating and improving sustainable rural health services.

This article examines how a rural health authority and physicians have developed, and continue to engage in the development of, a partnership for the purposes of delivering healthcare and improving population health. Specifically, it aims to deepen understanding of the subtleties and complexity of engaging in system change within remote and rural areas.

Setting

This analysis is a component of an overall study, Partnering for Change I, designed to study how Northern Health and its physician and community partners undertook the transformation of primary healthcare.20 An interpretive approach, utilising philosphical hermeneutics,21 was taken with the collection and interpretation of qualitative data from in-depth interviews from participants in seven communities and at the regional level.

Seven communities across Northern BC were selected because they represented a diversity of population size and economical, geographical, cultural and social contexts. Both purposive and snowball sampling22 were used to identify health administrators and healthcare workers within NH, along with general medical practitioners, municipal leaders and community based organisations outside of NH. A minimum of 10 participants per community were sought.

Data collection

In-depth, one-on-one, semi-structured interviews lasting 45 to 60 min using an interview guide were carried out between 2012 and 2015 by the principal investigator and a trained research associate both experienced in qualitative methods. Interviews were carried out in person at participants’ place of work. Those participants who remained in their original or related roles were interviewed yearly over the 3 year data collection period. Questions were related to participants’ experiences of the change processes, including the impacts of changes on relationships and ways of working. Interviews were audio recorded and transcribed verbatim. Written informed consent was obtained prior to initial interviews and verbal consent obtained for subsequent ones. The overall data set was comprised of 239 interviews with 122 key informants.

Participants

This paper is based on the analysis of 34 interviews from the main data set. Participants were all those who were physicians or who expressed direct experience of engagement with physicians in the communities at any time during the data collection period. The intent was not to seek data saturation from within a large sample, but to explore in depth what physician engagement meant to those who actually spoke about it in the interviews about primary healthcare transformation. Ten interviews were with family physicians, three in separate years with Division non-physician leads and 18 with primary care co-ordinators. The primary care co-ordinators were hired to support the transition by working in communities with physicians and the developing interprofessional teams, communicating with community groups and liaising with regional managers and executives. They came from administrative or clinical backgrounds (including Public Health and Community Nursing, Mental Health Nursing and Occupational Therapy). Also included were three interviews with regional health authority leaders conducted towards the end of Phase 1 of the project which contained reflections on the first few years of primary care reform and were relevant to relationships with physicians.

Patient and public involvement

Patients and public were not involved in the interviews that informed the research reported here. The public were, however, involved through municipal leaders and community consultation by Northern Health in the discussion of the primary care reforms and were key informants in the Partnering for Change I study. All study findings, including those reported here, have been fed back to Northern Health Executive and Board through regular discussion and engagement with the research team and used to inform next steps in the processes of reform.

Analysis

The qualitative approach taken was based on hermeneutics.21 23 Hermeneutics is the study and interpretation of texts and, in contemporary research, this includes the texts generated from interviews. In this study, the area of interest was that of physician engagement and the analysis gave insights into the varied direct experiences of those interviewed in order to better understand the phenomenon of physician engagement in the context of the communities of Northern BC. This approach also recognises that researchers bring to the field, and to the interpretations, their own experiences and understandings. Instead of bracketing or setting those experiences aside, the researchers constantly keep their assumptions in question. The analytical process itself is one of dialogue where the researchers’ own understandings and assumptions are questioned as the researchers engage with the participants’ transcripts. Through that process of questioning, the researchers gain a deeper understanding and new insights about the experiences expressed by the participants creating a plausible interpretation.21 24 Hermeneutics is seen as a way of better understanding interventions in complex systems25 as well as recognising the diversity of historical and cultural contexts that typify rural communities.

The first author analysed all interviews by reading them in depth and developing codes relevant to physician engagement using NVivo 11 (QSR International). He is a rural physician and experienced doctoral trained qualitative researcher who is familiar with the region and its communities having held educational leadership roles in the region. All authors had previously analysed all transcripts in the study and had identified physician engagement as an important area for further analysis.

The initial coding approach, analysis and preliminary interpretation were discussed with the other authors, the coding agreed and the interpretation refined based on further analysis and debate. The emergent themes based on the interpretation were shared with selected interviewees and found to resonate with their experience, thus further increasing the authenticity of the analysis.

Working through tensions constructively

At the beginning of the initiative physicians were seen by themselves and NH administrators as working independently from NH and the strategic direction of primary healthcare (PHC) transformation. They were also seen as having significant positional power.

You know our physicians do wield a fair bit of influence and power within the system and have the ability to move things forward or send them to a standstill if they want to…physicians are still practically in many ways outside of the system. And I’m talking about family physicians, like primary care practitioners in particular. They are their own unique businesses and so there isn’t necessarily a bridge always between those two worlds or a process to work on those issues. (PHC coordinator E)

This sense of professional power in the health system, while physicians were not actually within the system itself, created challenges for all in terms of working together.

The data described successes in terms of building bridges and agreeing on new ways of working together, but tensions were evident between administrators and physicians. Participants pointed to concerns regarding who was having conversations with whom, and the historical mistrust between professionals and health authorities. They spoke of how those trying to facilitate engagement could get caught ‘in the middle’.

… cause I kind of sit in the middle, right, so I was sitting at a Northern Health table where we didn’t have Divisions at the tables and the conversations were a lot about us and them. (PHC coordinator J)

The tensions identified in the interviews were often recalled as hidden and unacknowledged in the interactions between partners, but participants also recalled efforts to bring these tensions to the surface. Local administrators and the primary care coordinators could be caught between the organisational goals and the autonomy of physicians in their communities and needed to find ways of building relationships in both directions. They also had to find ways of translating language and intent from NH leadership to physicians and vice versa. Honest conversations and structures for communication were necessary. Through conscious dialogue, they could surface and work through tensions that developed when changes were made to how services were designed and delivered. These efforts have not been easy or straightforward. They have taken a long period of time, as foundations of commonly agreed-upon and deliberately purposeful actions have required an understanding of others’ contexts.

This changed relationship with primary care and partnership between the physicians, that’s a big change in how we deliver care. Primary care physicians we think of as within their private business purview. We really respect and they highly prize their autonomy so another thing that keeps me up at night is thinking about how we get those initial critical conversations off to a good start so that we grow those teams and primary care homes together. (Regional leader 3)

In addition, coordinators had to be able to have difficult conversations in order to surface tensions:

So, I spent a lot of time a year ago calling people on the ‘us and them’ in order for us to move the work forward and highlighting that we can’t move if we’re in this, ‘us and them’. So, trying to shut those conversations down at both of those sides. Whereas now there’s absolutely none of that at all going on in relationship (between) the health authority and Division. (PHC coordinator J)

Approaches like this allowed NH and physicians to develop working relationships focused on improving care for the people they served, which allowed tensions to be identified, managed and worked through. Actions were focused on what could be done together to improve patient care, such as the creation of an unattached patient clinic, the development of a family practice clinical teaching unit and actively helping people learn about others’ working contexts, such as nurses job shadowing General Pracititoners (GPs) and GPs doing joint home visits with nurses. Not all physicians interviewed were involved in Divisions of Family Practice, which was also a source of tension.

So, there’s a tension there and different communities have different structures in place to support this work. So here we don’t have a Division of Family Practice and the Primary Healthcare language. In a lot of work they keep talking about using the Division of Family Practice to move this work forward… We don’t have that here, so you kind of find yourself in this defensive position where you’re saying all the time, ‘but we don’t have a Division of Family Practice, we have this’. (PHC coordinator D)

Tensions are inevitable in whole system change and the key for those NH administrators based in the communities was to be able to act as a go-between for physicians on the ground and the leaders at various levels of NH. Engaging physicians effectively required good listening, flexibility at the local level and support from NH leadership to allow discussion of local solutions to local problems within a framework of integrated primary care teams. Underpinning this coordinated action was the need to find ways to surface tensions in order to deal with them.

Drawing on structures for engagement

Divisions of Family Practice allowed for a structured dialogue and for a way of recognising and dealing with tensions between different elements of the healthcare system and communities. NH attempted to partner with the physicians through the Divisions to develop common plans. NH openly shared their initial goals and ideas and ensured that local administrators were aware of the need to allow some flexibility in local communities in terms of determining healthcare priorities. NH’s approach of sharing what they were trying to do at the community level was noted by a family practitioner.

… the health authority has come to the table and they’ve been good partners with openness and transparency and they have allowed us to, you know, look inside their organisation, you know, they’ve shared, they’ve shared freely a lot of the things that they’re doing. (Physician G)

The Divisions of Family Practice allowed physicians to have a common voice, as within the Divisions the physicians developed their own priorities and vision. The same family physician said.

I think it was with the formation of the Division that family doctors have a voice as a collective group in partnering with Northern Health, to have input into how we might deal with and spend resources that were available. (Physician G)

A sentiment echoed by a physician colleague from another community also described how the Divisions provided some continuity which, in turn, provided an environment that supported and encourage partnering.

… it’s the organisation of physicians so that there’s one voice to talk about the aspirations or the needs in primary care. So that there’s somebody that the health authority can communicate with, rather than picking the champion who might be the champion this year but has moved away next year. Or is over-extended in his practice and now has kind of lost interest. Now there’s this more durable entity that you can actually talk with and partner with and that’s accelerated us in ways that I wouldn’t have expected. (Physician A)

The Divisions encouraged physicians to have collective conversations about priorities which were then shared with NH. One of the outcomes was that NH and physicians found they shared common ground in terms of improving the health of their populations, which had some interesting impacts on how family physicians felt about their work.

You start to enjoy your work. That’s the thing. That’s the main thing for me. You do a lot of stuff which actually just becomes a ritual, do prescriptions every day for diabetics and hypertension patients. Now suddenly, you’re seeing other possibilities. (Physician J)

Working with structures that were designed to give physicians a collective voice helped build relationships, find common ground, encourage dialogue and enhance continuity. They enabled the physicians and NH alike to better withstand the inevitable changes of personnel that are a feature of small rural communities.

Facilitating relationships

Trusting relationships were critical to the process. Finding effective ways of engagement helped build trust and flexibility on all sides. Physicians and NH were able to form common goals as well as act flexibly at the local community level to set appropriate priorities that were agreed on in each community. The effort required to build relationships was considerable, and in a remote and rural area this also meant finding time for physician leaders to engage with communities and to have time to be involved in planning, as the process of change took time:

I need to do way more travel, way more communication and relationship building out in the peripheral areas and sure it takes more time, but without it you can’t move…

the first 2 years we didn’t actually achieve a lot except a lot of careful planning and strategic thinking, but now it’s led to a place where we actually are acting on that strategic thinking and maybe this is the year that we’re all going to do it. (Physician A)

Where physicians, local administrators, community leaders and the other health professionals could agree on common goals they spoke of a better sharing of skills and integrating of care among different team members.

The whole process of engagement and development of common goals, however, was sensitive to the varied community contexts. This meant that approaches to reforming how healthcare was delivered were influenced by individual community priorities.

… we’re being told to and rightly so I think, that from community to community this may look different and maybe realised in different ways because of different practical realities so I’m encouraged to hear that. (PHC coordinator E)

Trust was at the heart of this sharing and took time to build through learning about the visions, goals and abilities of team members. Trust, however, only came with practical actions.

So, I think there’s more trust because we share more. It’s not silos. Even to trust the specialist. If you see a specialist here and he talks to you about patients, and have the conversation, it’s even more trust than phoning that guy, see what he thinks about stuff. It opens doors and beaks down silos. It is just funny how trust is very core. (Physician K)

The maintenance of trust could not be assumed. For some, the worry of demonstrating results was always in the background.

I think that there’s still, there’s always that element of wanting to see results and so I think right now we have the commitment and trust that they will come and we’re working towards it, but it’s always there in the back of my mind that we need to be demonstrating progress and to continue to build trust. I struggle with that sometimes, how we define progress, how we evaluate the work that we’re doing and make improvements. (PHC coordinator E)

Once trust was developed it was just as important to find some early wins to show progress was being made as described by one physician talking about improving how quickly patients could be seen in their primary care clinic.

Advanced access is a great example. It was an idea that was around when we started talking about (primary care reform). And I started talking about it with the office manager and I don’t know who mentioned it first, but it just kind of came and everyone was on board and it was total collaboration. (Physician A)

Investing time in local relationship-building, despite the strain of the required time commitment in an underserved rural area, served as a means to work through tensions.

I’d have to say overall that I feel I can sit down and talk to the local administrator and while I may not agree on everything, I feel heard. (Physician F)

Only through sound relationships and constructive conversations was sufficient trust developed to create an environment ready for major system change.

… people are developing completely different relationships and when you think that so much of our past and some of our current system, so much of what works well is because of the relationships. (Regional Leader 2)