Primary Care for Everyone

Primary Care for Everyone

An Urgent To-Do List for Reform

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Worldwide, the health systems with the best outcomes are the ones that get primary care right. Canada’s federal, provincial and territorial governments are recognizing the critical importance of improving primary care in their recent funding agreements.

The time for bold action is now. New federal funding is entering the system as bilateral agreements are being signed with provinces and territories. “Family health” is front and centre, with all levels of government and people across the country on the same page. It’s time to supercharge the reform.

The Public Policy Forum’s Taking Back Health Care project is a year-long initiative to assemble and promote the best thinking about actions necessary to address Canada’s health-care crisis. This paper is the second in a series of commentaries that the project is producing. The first paper, Taking Back Health Care: How to Accelerate People-Centred Reform Now, was an overview of the urgent need and opportunity for reform.

It reminds decision-makers that health system solutions have been well studied and it’s their job to get on with reform now. It identifies primary care as a national priority and challenges policymakers to deliver change based on what people and communities across Canada value and what they require to become full partners in their health and wellness.

In that first Taking Back Health Care paper, the expert signatories said:

Everyone in Canada should have timely access to a publicly funded primary-care team within 30 minutes of where they live or work. It should be available to every person, just as public school in a local neighbourhood is available to every child in Canada. It should aim to improve the health of everyone in Canada, just as public schools aim to effectively educate every child. Team-based primary care should include virtual service where appropriate to support its objectives.

That there is inadequate access to primary care is beyond doubt, but Canada has little authoritative primary care data to fully understand access, quality and need, or to drive accountability with system leaders. Just as concerning is the lack of information about what people across Canada want to see in primary care, which is a prerequisite for meaningful change that’s responsive to the true owners of the system – all of its users.

OurCare,^[1] a national initiative recently launched to engage the public on the future of primary care, is finally providing that perspective. It has determined that more than 6.5 million residents in Canada over the age of 18 lack a regular primary care provider, a significantly larger number than previously understood. OurCare has released initial survey data and, over the coming months, will produce even more detailed analysis into the primary care expectations, needs and values of people across Canada. Those insights should be treated as critical input to reform efforts.

Here are some of OurCare’s early findings from survey responses of more than 9,000 people across Canada, to get us started on what people expect from primary care:

People at the Centre

It’s imperative that reform is built on widespread, meaningful public input that involves patients, their families and the many diverse communities that make up Canada. This includes Indigenous Peoples as well as Black Canadians, newcomers, children and youth, seniors, 2SLGBTQI+ and other communities who have been poorly served in our health system to ensure their needs underpin the design and implementation of reforms. The OurCare data offers insight into what people from a range of perspectives and backgrounds want and expect. As reform proceeds, it must be further guided by substantive public input and engagement.

Teams as the Goal

The effectiveness of team-based primary care in improving health outcomes is well-established and supported by evidence. It is long past time to confront the enormous gaps in access between different population groups and geographies by scaling up the team-based model everywhere, starting with those groups who need it most.

Practitioners in primary care teams must be connected, collaborative, informed with data and responsive to individual situations, whether care is provided in person or virtually. The experience from the COVID-19 pandemic is that teams must develop long-term relationships with those they serve and be embedded in their communities.

Data as the Foundation

Urgent action is needed to improve primary care data governance and infrastructure in Canada to achieve timely access to quality primary care for all. In a 21st-century health system, patients have a right to expect ready access to their data and to be empowered (supported by their care providers) to become a true partner in their own care. Access to such data by patients and providers helps people navigate the system with more ease and reduces barriers to access and quality at points of transition. Furthermore, in a modern data governance system, aggregated and anonymized data must also be unlocked and marshalled in real time to ensure primary care resources are available where they are most needed. Data must drive decisions about who needs and gets access, to what and what the goals of such access should be. The data must be managed in the public interest with assurance of privacy and security.

Governments have already worked to scope out a Pan-Canadian Health Data Strategy. It provides the blueprint for how health data can be created, collected, stored, exchanged and, above all, leveraged to improve the health of everyone in Canada. Implementing that strategy should be an immediate priority. When it comes to primary care, the strategy identifies foundational issues; further, specific guidance and action are needed to ensure primary care data is not an afterthought. This guidance must enable public good uses, including clinical use and patients’ access to their own data, public institution research, quality improvement at the practice and regional level, and system planning and oversight.

The ambitious call for primary care for everyone requires that team-based primary care makes real gains in the following:

• In equity by achieving consistently high quality of care across all populations, especially those who have been traditionally underserved;
• In efficiency by reducing time, energy and resources spent on tasks that do not improve care; and
• In effectiveness by better leveraging data and evidence.

Here is the to-do list to make it happen. These to-dos are really the must-dos. They demand leadership and substantial, collaborative work by an array of players, including provincial, territorial and federal cabinet ministers, First Nations, Inuit and Metis governing authorities, health system providers and regulators, health professionals and their associations, patient groups, technology providers, ministries, health authorities and agencies, and others. These leaders are the custodians of our health system, responsible for delivering the change expected by the people and communities they serve. They must use every lever at their disposal necessary to get the job done. This goes far beyond funding to encompass legislation, regulation, new policies, standards, convening, getting buy-in for existing organizations, measures to drive accountability and more.

All the necessary actions are complex, and no single player can make any of them happen alone. Nevertheless, with accountability comes action. The to-do list identifies urgent key actions, and the officeholders who are best placed to lead, backed by the full range of essential stakeholders.

The To-Dos

More equitable primary care, available to everyone, and focused on improving outcomes for those most in need.

1. Accelerate reform in compensation to incentivize^[2] and support teams to care for more people in their communities.

Compensation models must reflect the complexity of work and diversity of the populations and geographies served. They should support building care teams to close equity gaps, not widen them. The models should fund the clinical, infrastructure and administrative requirements of the team, enhance quality performance and respect primary care provider preferences in meeting the needs of the community. They should be linked to accountability for the services residents need. When it comes to doctors, these changes entail a transition away from fee-for-service and solo practice.

Who Should Lead: Provincial and territorial ministers of Health and Finance, with provincial and territorial medical associations and other health professional associations

2. Measure and report progress toward 100% access to appropriate primary care.

What doesn’t get measured can’t get better managed. Users of Canada’s health system deserve to know how their province or territory is doing in meeting targets for equitable access to effective primary care. They also deserve to know how much progress is occurring to close gaps in access to care for equity-deserving populations, so metrics must include more than just overall targets.

Who Should Lead: Provincial and territorial ministers of Health, supported by relevant data agencies

3. Implement the concept of “One Patient, One Chart.”

Ensuring a person’s medical information is integrated is of particular importance for people whose care needs are complex. Ensuring data are aggregated and used at the system level helps to identify and address equity gaps in care. Whether in one file, one web-viewer or through interconnected systems, an individual’s health information should be easy to access, seamless and consolidated in its application to support care. This requires modernizing patient involvement, education and consent on ethical use of their health information to reflect advancing technology, patient access and ownership clarity. Modernization also includes public good uses of aggregate and anonymized data, supported by strong and ethical data governance to assure privacy, security and appropriate use, with respect for Indigenous data sovereignty. Individuals must be empowered to opt in by deciding which providers will gain access to their personal data for their care and opt out if they don’t wish to have their data aggregated for public good uses. This entails a significant rethink of how we manage health information in Canada but is necessary to truly respect patients and improve their experience of primary care.

Who Should Lead: Provincial and territorial ministers of Health, supported by: Health Canada; Innovation, Science and Economic Development Canada (ISED); and pan-Canadian and provincial health data organizations, including the Canadian Institute for Health Information (CIHI) and Canada Health Infoway

More efficient primary care, driven by better processes and systems that increase time available for patient care.

4. Free up more time for patient care by cutting the administrative workload of clinicians.

To increase the time available for patient care and reduce provider burnout, measures must be taken to cut red tape, streamline and automate processes (electronic and paper) and have non-clinicians take on as much administration as possible. This includes making centralized intake for referrals mandatory to facilitate faster, more efficient and seamless access for primary care patients to other parts of the health system. Provincial and regional authorities must ensure appropriate technical and administrative infrastructure is in place to support co-ordination and communication essential for well-functioning teams.

Who Should Lead: Provincial and territorial ministers of Health, with medical associations and other health professional associations

5. Deploy all levers, including federal ones, to accelerate adoption of team-based primary care.

Team-based care is moving forward in some communities. Scaling it Canada-wide can be accelerated by identifying and disseminating best practices, sharing knowledge and experience regarding legislation and regulation, leading in the areas of policy, accreditation and data management, and governance. We do not need to reinvent the wheel. There are existing pan-Canadian health organizations^[3] that are well-positioned to advance adoption of team-based primary care. They must be tasked to do it.

Who Should Lead: Federal minister of Health with provincial and territorial ministers of Health, working with provider organizations

6. Make national licensure of health professionals happen.

National licensure can give greater flexibility to work across provincial lines and help address pressures on primary care professionals. Such licensure can aid multidisciplinary, full-service primary care in our communities, particularly equity-deserving populations, to help achieve the goal of timely, efficient access where people live and work, while always keeping in mind the imperative of relationship-based comprehensive care.

Who Should Lead: Provincial and territorial ministers of Health, with health profession regulatory colleges

More effective primary care, enabled with data and digital infrastructure to improve health outcomes.

7. Build Canada-wide primary care data capability.

To better track performance and enable improved understanding, primary care should be supported by data equivalent to that available for hospitals.

The data systems should enable public good uses of data, including: clinical use and patient ability to access their own data; real-time data for quality improvement at the practice and regional level; and use of aggregate, anonymized data for public institution research and system planning and oversight. These uses need to be backed by appropriate legislation, regulation and policies to safeguard privacy and security, while respecting Indigenous data sovereignty. In addition, data collection should be automated as much as possible and not create additional burden on primary care providers.

Who Should Lead: Federal, provincial and territorial ministers of Health, with CIHI and Canada Health Infoway

8. Set quality indicators for team-based care.

With better data and information systems, we should be able to develop performance indicators that enhance the accountability of providers, support quality initiatives to improve health outcomes and better demonstrate the benefits of team-based care. Measuring the impact of team-based care beyond attachment of patients is important to ensure it is contributing to better health outcomes. Such indicators must be co-developed with patients, communities and primary care providers who understand the front line, and their use must consider local realities and needs.

Who Should Lead: Federal, provincial and territorial ministers of Health, with health authorities and relevant health professional associations focused on primary care

9. Designate a lead practitioner for each patient using the “most responsible provider” approach, so that non-physicians can co-ordinate care.

To ensure people have a primary care provider who knows them and looks out for their individual needs, team-based care should attach a lead health professional to each patient. This removes the challenge of relying solely on the physician to direct access to care for all patients attached to that team. It allows other primary care team members to work at their full scope of practice and manage patients, creating more capacity for the team to serve more patients overall.

Who Should Lead: Provincial and territorial ministers of Health, with health profession regulatory colleges

10. Compel technology vendors to open access to primary care data.

Unlike in many other jurisdictions, core primary care data across Canada has been locked in a patchwork of systems largely run by private vendors. As a result, accessing, analyzing and using this data for the four key good public uses has been difficult.^[4] To establish a modern, effective primary care system, this needs to change.

Who Should Lead: Federal, provincial and territorial ministers of Health, with the minister of ISED

i Question 49: How important is it to you that you are able to look at your personal health information online?

ii Question 50: How important is it to you to have one personal health record that all health professionals working in the province could see and use when they are providing care to you?

iii Question 19: How important is it that every person living in Canada has a relationship with a family doctor, nurse practitioner or team of health care professionals that they can see regularly if they need to?

iv Question 45: Some family doctors and nurse practitioners work with other health professionals as part of a team. Think about your own care. Which health professionals would be most important to have as part of the team?

v Question 20: How important is it that your family doctor, nurse practitioner, or team of health care professionals works close to your home? And Question 51: Do you think teams of family doctors and nurse practitioners in Canada should have to accept as a patient any person who lives in the neighbourhood near their office?

vi Question 25: When you think about getting care from a family doctor or nurse practitioner and the practice they work in, how important is the following to you? And Question 26: When you think about getting care from a family doctor or nurse practitioner and the practice they work in, how important is the following to you?

1. OurCare is a national initiative to engage the public on the future of primary care in Canada. Over 15 months, the initiative will hear from thousands of people living in Canada about their hopes and priorities for creating an equitable and sustainable system that delivers better care for all. OurCare is led by Dr. Tara Kiran, vice-chair of the Department of Family and Community Medicine at the University of Toronto, a primary care physician at St. Michael’s Academic Family Health Team and a scientist at MAP Centre for Urban Health Solutions, Unity Health Toronto. Learn more about the OurCare study: OurCare.ca. Sign up for study updates: OurCare.ca/signup ↑
2. Incentives tied to compensation should recognize factors such as caring for underserved groups, time spent with a patient due to medical or social complexity, the number of patients being seen overall and ease of access to service. They should consider the administrative costs of running a team-based practice and the need for infrastructure in practices and regions. ↑
3. Pan-Canadian health organizations could include Healthcare Excellence Canada, Canadian Institutes for Health Research, the Canadian Institute for Health Information, the Canada Health Infoway and Accreditation Canada, among others. ↑
4. The four key good public uses include: clinical use and patient ability to access their own data; real-time data for quality improvement at the practice and regional level; use of aggregate, anonymized data for public institution research; and system planning and oversight. ↑