It’s time to have the difficult conversations and take the innovative risks to develop a health-care system Canadians deserve.
Primary care is failing many Canadians in terms of universality, comprehensiveness and accessibility, despite the enshrinement of these core principles in the Canada Health Act.
Canada currently has a hodgepodge of independent primary care practices, operating without clear performance expectations or accountability. It is more by design than by an unforeseen circumstance that so many primary care providers are burned out and 6.5 million Canadians have no regular source of care.
In addition, with some exceptions, comprehensive, person-centred primary care is neither accessible nor effective for those with complex needs. An exhausted workforce and a demoralized public seem oddly tolerant of the dysfunction.
A strategy of tepid incrementalism — with elements such as short-term pilot projects, more international recruitment, new medical schools — is wasteful, ethically dubious or simply implausible. It will not bring the change that is needed.
The federal government has a unique and timely opportunity to make a difference with its 2024 budget. Investment is needed in team-based primary care education and the development of performance indicators and accountability standards. In addition, Ottawa should focus on 21st-century technologies and leading by example in a complicated field where jurisdiction is shared with the provinces and territories.
Despite the inertia that plagues primary care “reform” in Canada, there is considerable consensus on what needs to be done — a large-scale reorganization of our health system and real accountability, buttressed with substantial and targeted funding that is sufficient to make a difference.
Report after report has called for a primary care system that moves beyond its cottage industry roots to one that provides every Canadian with a continuous source of care and timely access to health teams that utilize the full skill sets of all practitioners.
In an ideal world of more collaborative federalism, Ottawa and its partners would negotiate significant increases in the proportion of federal transfers that would go to primary care. History suggests that such an outcome is unlikely.
The alternative is to seed transformational change.
Job 1 is to make primary care fit for purpose. Today’s population is on average 20 years older than it was at the dawn of medicare.
Millions of Canadians have more complex needs, especially the frail elderly; people with multiple chronic conditions; marginalized socioeconomic and cultural groups; and people with mental health and addiction challenges. No family doctor or nurse practitioner can manage this complexity alone.
To succeed it takes a village — interdisciplinary primary care teams. Comprehensive primary care must include mental health, rehabilitation, pharmacy, dietetics, an array of diagnostics and partnerships with other community agencies. It also needs good infrastructure: buildings designed to support teams and a first-rate health information system.
The federal government should be health care’s source of “venture capital.”
Smart money looks to release and harness organizational and clinical leadership potential, facilitate difficult conversations and support a combination of top-down and bottom-up innovations.
To this end, the 2024 budget should take steps to support large-scale innovation in our health system by putting more money on the table for provinces and territories with the most ambitious plans for fundamentally new primary care models designed to serve those in greatest need.
Here are four specific transformative roles the federal government should incorporate into the budget:
1) Invest in new approaches to primary care education. There will be no fully realized interdisciplinary, team-based care if providers continue to be trained in isolation. Instead of medical schools, nursing schools and physiotherapy schools, there should be schools of primary care where students learn the basics of health, illness, population health and the social determinants of health together.
Students should also learn how to work in teams from Day 1 and how to organize and deploy team resources and talents in the interests of their patients (and their own sustainability).
Schools of primary care should not be ports of entry on the way to specialty roles in institutions. They should be the training centres for a growing and much more capable primary care sector that also provides the great bulk of lifelong education.
2) Invest in the development of performance indicators, workforce optimization strategies and policies to make primary care genuinely accountable for quality, efficiency and outcomes.
These supports should be co-designed and embraced by governments, providers, researchers and the public, with data generated in real time and widely available to all involved in improving performance.
Through its pan-Canadian health organizations, the federal government could also upgrade its public reporting on performance as a key element of continuous quality improvement. This would support enhanced accountability and a better-informed public. Concurrent robust and integrated research and evaluation initiatives would enable the spread and scale of the strongest approaches.
3) Support the adoption of 21st-century processes and technologies to make primary care more accessible, convenient and effective. Already, many people prefer virtual appointments, want access to their electronic health records and welcome connection to high-quality, evidence-based websites that support self-management and that help guide their decisions.
The notion of patients as partners has the potential to become the new normal. There are, of course, uncertainties, risks and unintended consequences in these developments. Both providers and the public will have to work through the adaptations.
4) The federal government should lead by example by developing the most innovative and cutting-edge forms of primary care.
Its responsibility for Indigenous health services is the greatest opportunity to make the most dramatic impact. There is a particular need for Indigenous-led, team-based care that integrates and recognizes the essential roles played by elders, herbalists, Indigenous midwives and others in innovative interdisciplinary teams.
Canadian Armed Forces medical, dental and physiotherapy centres throughout Canada and abroad could support the spread of primary care service innovations by adopting and showcasing leading team-based practices.
Of course, federalism means that Ottawa cannot impose solutions on the provinces/territories or unilaterally attach strict conditionality to its cash transfers. But it can support the work needed to kickstart significant change.
By the standards of other wealthy OECD countries, Canada spends far too little on primary care.
It’s time we think bigger than the federal primary care transition funds of two decades ago, which focused on microprojects not big enough to spread and scale, and which lacked a coherent set of principles and accountability tying them together to create system transformation.
Canadians also need to step up, expect more, demand more and be open to innovation, acknowledging that primary care can be more than just access to a family doctor. Don’t applaud when governments add more money that simply props up the status quo.
Show no patience with governments that simply want more federal dollars without any accountability for how it would make things better. After all, it is citizens’ money and it is the citizens to whom all levels of government are accountable.
Demand that both levels of government get along because health and health care are everyone’s business. The key to mobilization is to show that transformation is not a quixotic fantasy, but rather is both necessary and achievable through sound strategy, prudent investment and effective design.
It’s time for everyone to step up, have the difficult conversations, take innovative risks and develop the system Canadians deserve.
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