This essay is part of a series of reflections on primary care during the pandemic presented by Réseau-1 Québec. Original essay published in French on September 2, 2020 is available here >>

Since March, a major health crisis has disrupted the daily lives of Quebec citizens. For many, watching the regular press briefings by political leaders is essential to better understand the government’s orientations and their implications. The current pandemic offers a unique opportunity to learn about leadership in a crisis context, and to reflect on the role that primary care leaders can play as well as on the resources needed to deal with this crisis. Here we examine the lessons we can draw from this experience in preparation for future crises.

In this respect, primary care has a key role to play, but for it to be able to exercise its role fully, certain conditions are necessary.

Recent data published on the Santé-Montréal website reveal the existence of inequalities in relation to the pandemic, particularly between men and women and in racialized populations. It has long been known that health is not only a question of access to care and services; it is intimately linked to living conditions that provide more or less access to the economic, social, and cultural capital through which individuals can benefit from environmental resources (education, a social network, financial resources, etc.) that enable them to develop and be healthy. While public health can sound the alarm about the importance of addressing people’s living conditions, it must nevertheless be supported by a strong primary care network to be able to act on them. Primary care services are clearly only one part of the possible response, but they play an important role in mitigating health risks during a pandemic, particularly for certain segments of the population.

Let’s return to the matter of leadership. In extreme situations, leadership that is concentrated at the top will only run out of steam (Hannah et al., 2009) given the complexity of the issues and their unpredictability in times of a pandemic; the need for a diversity of levers and expertise to protect health is undeniable. The government or health system must be able to mobilize actors at lower levels of governance, such as the regional or community levels. This leadership also has to decisively transcend a series of boundaries between sectors, social groups, professions, and fields of knowledge (Ospina et al., 2020). These areas of intervention need both a diversified leadership that adapts to challenges as they arise, and evolves with the pandemic, and sufficient resources to intervene effectively. Primary care refers to a more comprehensive model that is not confined to a medicalized conception of service provision, though it may include it. That medicalized approach, being essentially oriented towards access to a family doctor or to an interprofessional team that is often limited and based on exclusively clinical expertise, is insufficient to carry out effective targeted interventions and to respond adequately to the needs of populations considered vulnerable (Ouimet et al., 2015; Levesque et al., 2012).

Moreover, the knowledge and expertise required to support the development of a primary care model that can respond adequately to the challenges presented by the pandemic are extensive. They span social epidemiology, sociology, anthropology, behavioural and organizational sciences, and economics, to name just a few. Public authorities must be willing to mobilize this knowledge, sensitively and at the right time, to support and equip local authorities, such as  primary care, the local service networks (RLS), and the community, in deploying their services and interventions. Collaboration between these different sectors is only possible if there is an integrative and diversified leadership that enables interventions to be thought out in their entirety (Crosby & Bryson, 2010).

This call for integrative and diversified leadership implies, first of all, giving greater scope to the leaders of health care institutions, whose role must not be limited to carrying out the directives of central government. Here we refer not only to senior management, but also to other stakeholders who exercise informal leadership, as well as to middle managers, who can provide the necessary relay between the strategic heads of organizations and the professionals and stakeholders directly involved in the delivery of care and services. It also involves creating more substantial bridges than currently exist between public health, health care system resources, and academic communities that could potentially engage in collaborative and innovative intervention approaches. This means, as well, that primary care would become a true experimental laboratory for reflection and action to promote population health.

Numerous initiatives have been implemented here and there by front-line, primary care managers and clinicians to adapt service provision to the crisis context and adequately support their teams. For example, in several family medicine groups (FMGs), the roles of professionals, such as clinical nurses, pharmacists, and administrative personnel, have been redefined to optimize their scope of practice and to foster more collaborative teamwork. Some middle managers have used technology to hold more frequent team meetings, which has allowed them to stay in close contact with their teams, be more responsive to difficulties encountered in the field, and be able to recalibrate quickly, as the crisis gave some of them more decision-making latitude. These few examples demonstrate enthusiasm and a willingness to act, but their impact will remain limited unless they are integrated into a more ambitious plan devoted to pursuing equity. This presupposes a willingness and an ability on the part of current political, administrative, and clinical leaders to collaborate with new actors, who are essential intermediaries not only in the development of communities and an enhanced primary care offer, but also in terms of ensuring more extensive knowledge mobilization. This willingness must also translate, in the long term, into sufficient resources to support a goal as ambitious as working to reduce health inequities in the context of a pandemic.

Jean-Louis Denis, Full professor and Canada Research Chair, School of Public Health, Université de Montréal

Nancy Côté, Assistant professor and FRQS research fellow, Department of Sociology, and VITAM Centre researcher, Université Laval

Catherine Régis, Full professor and Canada Research Chair, Faculty of Law, Université de Montréal. Professors Denis and Régis are co-founders of Hub santé – politique, organisations et droit (H-POD)

References:

Crosby, B. C., & Bryson, J. M. (2010). Integrative leadership and the creation and maintenance of cross-sector collaborations. The Leadership Quarterly, 21(2), 211-230.

Ford-Gilboe, M., Wathen, C. N., Varcoe, C., Herbert, C., Jackson, B. E., Lavoie, J. G., … & Wong, S. T. (2018). How equity‐oriented health care affects health: Key mechanisms and implications for primary health care practice and policy. The Milbank Quarterly, 96(4), 635-671.

Hannah, S. T., Uhl-Bein, M., Avolio, B. J. & Cavarretta, F. (2009). A framework for examining leadership in extreme contexts. The Leadership Quarterly, 20(6): 897-919.

Levesque, J. F., Pineault, R., Hamel, M., Roberge, D., Kapetanakis, C., Simard, B., & Prud’homme, A. (2012). Emerging organisational models of primary healthcare and unmet needs for care: Insights from a population-based survey in Quebec province. BMC Family Practice, 13(1), 66.

Ospina, S. M., Foldy, E. G., Faurhurst, G. T. & Jackson, B. (2020). Collective dimensions of leadership: Connecting theory and method. Human Relations, 73(4), 441-463.

Ouimet, M. J., Pineault, R., Prud’homme, A., Provost, S., Fournier, M., & Levesque, J. F. (2015). The impact of primary healthcare reform on equity of utilization of services in the province of Quebec: A 2003–2010 follow-up. International Journal for Equity in Health, 14(1), 139.