Four Experiments, One Broken System: What Somerset, Alberta, BC and Ontario Tell Us About Healthcare Operations
- Occiden and Company
- Dec 7, 2025
- 6 min read
On a ordinary weekday morning in Somerset, a booking clerk opens the elective waiting list.
Two patients are due for the same routine procedure. One lives in a quiet village and has no flagged risks. The other is a young parent in a deprived estate, with an open mental health referral.
On the new waiting-list dashboard, only one name is highlighted.
It is not a “gut-feel” decision. The patient from the deprived area meets a vulnerability score of three or more, which means they are treated as urgent. They are pulled forward by three to four months. Someone else waits longer. Facebook
What is happening in that moment is the same thing happening in Alberta’s new primary care compensation model, in British Columbia’s longitudinal family physician model, and in Ontario’s community surgical centres:
Different systems are answering the same question in very different ways:
When demand consistently outruns supply, where do you move the levers?
Do you change who moves to the front of the queue?
Do you change how you pay the clinicians holding the front door?
Do you change where the work physically happens?
For medical directors and clinic leaders, these are not abstract policy debates. They show up as scheduling rules, EMR fields, billing codes and staffing plans.
Let’s look at what each model is really doing operationally – and what the caveats are.
Somerset: Writing justice into the waiting list
Somerset’s “scoring system” is a local answer to a national problem: people in poorer areas wait longer for treatment and have worse outcomes. Healthwatch+1
Their elective list now assigns points to patients who:
Have a learning disability (3 points)
Are a looked-after child in foster care or a children’s home (3)
Are under two years old (2)
Have an open mental health referral (2)
Live in an area of high social deprivation (1) Facebook
If a patient scores three or more, they are:
Flagged to booking teams and treated as urgent for outpatient appointments
Managed as the next clinical priority on surgical lists, where capacity allows
The trust reports that these patients are now being treated three to four months earlier than they would have been under a simple “time-waited” approach. Facebook
On top of that, Somerset recognised another risk: patients in deprived areas are often less likely to chase appointments or call if they deteriorate. The trust now sends 250–300 “safety-net” letters each month to people who have been waiting, with roughly 50 responses, specifically to catch silent deterioration. Facebook
Operationally, what this changes
Scheduling teams are no longer allowed to run a purely chronological list. They must act on risk flags.
EMRs and referral forms have to reliably capture learning disability, care status, mental health referrals and postcode-based deprivation indices.
The safety-net process builds a new micro-workflow: generate lists, send letters, track replies, and escalate clinical reviews.
The caveat
Deprivation alone is worth one point. It never triggers prioritisation by itself. It only matters when it stacks with another vulnerability.
Somerset is not solving capacity. It is deciding who should carry less of the pain inside fixed capacity. That is a powerful design choice, but it needs clear communication to patients who see someone “jumping the queue” without understanding why.
Alberta: Following the money into the exam room
Alberta’s experiment starts at a different pressure point: the sustainability of full-scope family medicine.
The Primary Care Physician Compensation Model (PCPCM) offers a new blended model for family physicians and rural generalists who commit to comprehensive care for a defined patient panel. Alberta Doctors+2Alberta.ca+2
The structure combines:
Encounter-based payments
Time-based payments
Clinical administration payments
Panel-based payments linked to the size and complexity of each physician’s roster, using tools like CIHI’s Population Grouper and the Central Patient Attachment Registry (CPAR) Input Health Help Centre+3Alberta.ca+3Alberta Doctors+3
Panel payments account for around 20 per cent of total income, with an average of just over $70 per patient per year, scaled by complexity. Clinic Aid
To participate, physicians need a panel of at least 500 patients and a conformant EMR integrated with provincial attachment registries. Alberta.ca+1
Operationally, what this changes
Panels matter. Clinics have to decide who is “on” and “off” the panel, and keep that current. No more vague rosters.
EMR data quality becomes revenue-critical. Coding, attachment status and complexity capture now show up on the income statement.
Schedules must balance billable visits with time blocks for non-visit work: inboxes, care plans, labs, coordination, panel management.
The model is trying to pay for the real operational work of longitudinal primary care, not just the visible encounters.
The caveat
A panel-based model rewards clinics with strong operational hygiene. Those that are already struggling with data quality, attachment discipline or team-based workflows can feel punished by the very model that was supposed to help.
The policy is only as strong as the clinic’s ability to execute panel management and EMR optimisation.
British Columbia: Doubling down on longitudinal care
British Columbia’s Longitudinal Family Physician (LFP) Payment Model is a close cousin to Alberta’s approach, with its own twist. Province of British Columbia+2Doctors of BC+2
The LFP model blends:
Payment for time spent on patient care
Payment for patient interactions
Panel-based payments for size and complexity
It was built with input from BC Family Doctors and Doctors of BC as a direct alternative to traditional fee-for-service for physicians providing ongoing, relationship-based care. Province of British Columbia+1
Panel payments in BC are designed to value continuity – via mechanisms like the Community Longitudinal Family Physician Payment and complexity adjustments. FPSC+2DoctorCare+2
Early data suggest that thousands of family physicians have enrolled, and there has been a notable increase in doctors choosing longitudinal practice over walk-in style work. Dr.Bill
Operationally, what this changes
Billing complexity is reduced: fewer fee codes and more emphasis on time and relationships.
Clinics can redesign schedules to protect longer, more complex visits without being punished financially.
Panel management, attachment, and proactive outreach (recalls, chronic disease reviews) become central to how the clinic runs, not “nice to haves.”
The caveat
When the system starts paying for continuity, every retirement, burnout or departure becomes more disruptive.
You are not just losing a physician. You are losing a curated, billable panel that the model relies on. That raises the stakes on leadership, succession planning and burnout prevention inside clinics.
Ontario: Moving the operating room
Ontario’s main experiment is structural rather than algorithmic.
Through Bill 60, Your Health Act, 2023, the province created a new legal category: Integrated Community Health Services Centres. OMA+4Legislative Assembly of Ontario+4Ontario+4
These centres are licensed to deliver publicly funded surgical and diagnostic services – cataracts, endoscopy, MRI, CT and similar procedures – outside traditional hospitals.
The idea is simple:
Hospitals are congested.
Building new hospitals is slow and expensive.
Community-based surgical and diagnostic centres can increase capacity and reduce waits while still billing the public system.
Centres must show how they will integrate with local partners, improve wait times and provide connected care to receive a licence. Oha+1
Operationally, what this changes
Referral pathways diversify. Physicians have a new decision: hospital or community centre, based on case complexity, wait times and location.
Workforce distribution shifts. Nurses, anaesthesiologists and allied staff may move between hospitals and community centres, which can ease or worsen bottlenecks depending on how it is managed.
New entities enter the scheduling and data ecosystem. Wait lists, quality metrics and patient experience data must now be integrated across more organisations.
The caveat
This is a capacity play that lives or dies on staffing.
If community centres simply pull scarce staff out of hospitals, the net effect can be neutral or even negative on overall system capacity. And politically, Ontario has to constantly reinforce that these are publicly funded services to maintain trust.
Four different levers, one shared lesson
If you line these models up side by side, you see four answers to the same constraints:
Somerset adjusts who moves to the front of the queue based on vulnerability.
Alberta adjusts how physicians are paid for the real work of longitudinal primary care.
BC refines that same idea, tying more of the system to time, relationships and panel complexity.
Ontario adjusts where care is delivered by licensing community surgical and diagnostic centres.
None of these is a complete solution. Together, they highlight a simple truth for anyone running a clinic or program:
Every bold policy idea eventually cashes out as a workflow.
In real life, that means:
New flags and fields in your EMR.
New rules for how the wait list is sorted every morning.
New billing codes and payment logic that force you to clarify who is on your panel.
New referral destinations that your admin team has to manage and reconcile.
The policies are interesting. The workflows are where they succeed or fail.
What this means for clinic leaders
If you are a medical director, physician owner or operations lead, there are three questions worth stealing from these experiments:
Queue design: Inside your own clinic, who quietly gets pushed to the back of the line, and how intentional is that?
Work design: Does your revenue model reflect the real work your team does – indirect care, complexity, relationship management – or only the visible visits?
Footprint design: Are there parts of your pathway that would run better in a different “setting,” even if that just means a different team, room, or virtual process?
Somerset, Alberta, BC and Ontario are all making different bets on those questions.
The leaders who will come out ahead are not the ones waiting for the “perfect model” to be handed down from above. They are the ones who understand how these levers interact on the ground – and who are willing to redesign their own queues, panels, workflows and referral habits accordingly.
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