Universal health-care systems across the world are fundamentally guided by a philosophy of egalitarianism. In other words, all people have value and everyone – regardless of income, wealth, geography or identity – deserves access to health care and the opportunity for good health.
Primary care is an integral piece of universal health systems, and is arguably the most egalitarian part of them. Delivered outside of acute and episodic hospital-based care, primary care provides relationship-based care from cradle-to-grave.
It is an unfortunate irony, then, that Canada’s definition of universal health care – our medicare system – excludes many of the increasingly important pieces of the primary care puzzle.
While public coverage in Canada is deep, it is also narrow. The Canada Health Act, medicare’s legislative framework, defines comprehensive services as hospital and physician care only. For areas outside medicare – many of which are vital for chronic disease management – the provinces and territories are left to their own devices. Instead of universal coverage for services such as prescription drugs or dental care, means-tested or age-tested programs attempt to “fill the gaps” not covered by job-linked private insurance.
Though a step forward, even a new federal dental program offering up to $650 annually per eligible child is restricted by both age (children under the age of 12) and income (family income of less than $90,000 per year). What results is a patchwork of coverage that leaves millions out, through a distinctly non-universal system.
What does that mean for primary care? While family physician care is covered, social workers and psychologists are not; physiotherapists are left out; home care is patchy at best; and access to a pharmacist is most often tied to your ability to afford prescription medication or have insurance. If by a stroke of luck, someone can access any combination of these services, there is no guarantee that each health-care provider will be able to easily communicate their care plan to another.
Yet, health-care systems that place a greater emphasis on primary care can have lower overall costs, improve access to more appropriate services and reduce inequities in a population’s overall health. Articulated most clearly in 2005 by Barbara Starfield and her research team from Johns Hopkins University, and affirmed in 2018 by the World Health Organization, primary health care is the cornerstone of a sustainable system for universal health coverage.
In 21st-century primary care, it takes more than a family doctor and their secretary to achieve this. What does the “ideal” model look like?
Articulated in Canada first in 2009, the Patient’s Medical Home model of care is considered the gold standard. This model emphasizes “the four Cs” of primary care: first contact, continuity, comprehensiveness and co-ordination. It achieves this in part by associating each patient not just with a single physician but with a team built around the particular health needs of the local community. In short, the model exists to provide a community hub for all non-emergency health-care needs.
Appropriately funded patient medical homes would be an enormous leap for primary care – but even then the thorny problem of patchy coverage would not be solved.
Often when an individual or family moves into a new community, finding a new family doctor or primary care team is dependent on personal connections or a lucky web search. What if instead it were organized like schools? That’s just what an expert panel recommended to Ontario in 2015. Imagine moving to a new community with the same assurances of primary care as a school for your child. A robust system of patient medical homes organized in this manner would unquestionably set a world-class standard for international health systems.
In fact, this model for local, integrated and community-based care is a recent incarnation of an old idea. Saskatchewan’s Swift Current Health Region #1 was born in 1947 as a community-based, regionally governed health system. It provided residents with comprehensive care, including physician services in and out of hospital; public health nursing; immunization programs; children’s dental care; and even health inspectors. All of this only a few years into the modern antibiotics era, and when health care was still oriented around acute disease and hospital care.
This early iteration of modern primary care was to be the true model for medicare. What exists today – access to physician and hospital care based on medical need and not ability to pay – was supposed to be only the first step on a longer journey.
As Tommy Douglas, the “father” of medicare, saw it, the more ambitious second phase encompassed a fundamental restructuring of health-care delivery to include a greater focus on illness prevention, health promotion and social determinants of health.
The good news is that the modern building blocks for high-quality primary care exist today.
While Canadian health care is sometimes referred to as a single entity, the reality is that we have at least 13 health-care systems. There’s one for each province and territory, and even more when federal programs for specific populations such as Indigenous peoples, the Canadian Armed Forces, veterans and federal prisoners are included.
In each of the provincial jurisdictions there are already some forms of team-based primary care, albeit of differing robustness. For example, community health centres, focused on systematically marginalized communities, are scattered across the country. Alberta has primary care networks, Nova Scotia has collaborative family practice teams and Ontario has family health teams.
However, availability remains a significant concern. For example, in Ontario while approximately 90 per cent of people have a family doctor, only about 20 per cent have access to a family health team. Within Canada, family doctors who work in group practices outperform their solo-practice counterparts on access to care (figure 1).
In international comparisons, Canada ranks near the bottom for access to same day/next day appointments, and to weekend/evening care (figures 2 and 3), and spends less then nearly every comparator country on primary-care services (figure 4).
Communities that face the highest barrier to access primary care also tend to be those with the highest health-care needs. They are low-income, new immigrants, rural, racialized, elderly and/or those with the highest degree of family or housing instability.
Attaching patients to primary care teams is not without its challenges. During the first six months of the pandemic, in Ontario alone an estimated 170,000 people lost their family doctor. The rate of burnout among family physicians tripled in 2021 compared with the previous year, with 51 per cent of family physicians indicating they were working beyond capacity. Almost one-in-four nurses reported that they intend to retire within four years, a higher percentage than physicians.
Opportunities for change are nonetheless present and promising. The number of family doctors working in team-based models is on the rise. Federal, provincial and territorial governments already jointly fund universal health care for hospital and physician care. Motivated local and regional health system leaders are ready to push for change, with ambitions to use team-based primary care to tackle social determinants of health, too.
How far they get will be determined largely by the bandwidth provided to do the work. Change cannot indefinitely be led on the margins, and money without a plan for a new model won’t go very far. There has never been a better opportunity to learn from the lessons of the past. It’s time for policy-makers to listen to those on the frontlines and build a health-care system with primary care as its true cornerstone.