Dr. Robert Bell is the former deputy minister of health for Ontario. Dr. Matthew Chow is the former president of Doctors of BC.
Primary care is the foundation for all health care services in Canada. Primary-care providers address most health concerns for their patients, offer preventive care to keep people healthy, and when necessary, co-ordinate referrals to specialized services, such as surgery.
As former leaders of organizations that are often adversaries across negotiating tables, the two authors (one formerly a provincial medical association president and the other a former deputy minister of health) might be expected to disagree on what ails health care in this country. However, we find ourselves in agreement that primary care is in crisis in Canada. We also agree on taking three critical steps that will help us in finding a resolution.
About 15 per cent of Canadians do not have a family doctor, and Canadians who do have a doctor can experience difficulty getting an appointment, especially since the pandemic began. On the other hand, family doctors have been vocal about experiencing burnout from overworking, increasing overhead costs and inadequate pay despite their important health system role. This year, a significant number of family-doctor training positions were left unfilled across Canada, suggesting that medical graduates recognize these problems and are choosing other career paths.
Robust primary care is essential to the sustainability of our health care system. Aging Canadians often develop chronic conditions such as diabetes, heart or lung disease, and arthritis. These conditions require self-management (for example, sticking to a diabetic diet) that is enabled by a strong relationship with a trusted primary-care professional. Absent this relationship-based care, treatment of chronic diseases occurs in hospitals and emergency rooms, where care is both more expensive and less effective in the long run. A failing primary-care system, therefore, overburdens other elements of Canadian health care.
How is primary care organized in Canada today? The most common model is provided by family doctors operating their clinics as small businesses. These doctors are usually compensated by fee-for-service payments that are billed to provincial governments for each patient visit. Family doctors may also work full- or part-time shifts in emergency departments; providing care for hospitalized patients; or participating in other areas of focused practice. These roles can provide better pay and work-life balance than office-based primary care. And these services are also essential to our system.
In recent years, family doctors have reported that fee-for-service payments are falling behind the growth of expenses in their small business practices. They also face pressure from the growing complexity of their patients’ medical needs (we are getting older as a country), and the demands on their time required by electronic health records and the completion of an increasing number of medical information forms.
Many fee-for-service physicians would like to be compensated by alternate pay models – for example, by receiving a salary, a flat hourly rate, or a yearly fee for each patient. In British Columbia, one study found that 40 per cent of established family doctors would prefer these alternative compensation models; that number jumped to 70 per cent for newer graduates. One alternative model is the capitation method (where the majority of income is provided by annual payments for each patient in the practice) enjoyed by about half the family doctors in Ontario. This model is attractive to doctors in other provinces because it is thought to provide fairer pay and a more even workload. Other provincial governments, however, are leery of moving to the Ontario model because of the potential for increased costs, as well as a concern that too many patients in Ontario currently still end up in walk-in clinics or emergency departments.
Both authors agree on three solutions for the primary-care crisis; all of these approaches have seen partial implementation across Canada, but need to be more widely and rapidly adopted in order to address our national health system crisis.
First, governments should offer family doctors alternatives to fee-for-service models. These alternative models should support the relationship-based care necessary to keep people healthy and must be competitive with fee-for-service models to ensure uptake. While fee-for-service is unlikely to disappear any time soon, it needs to be modernized and we need to listen to the doctors who want other options.
Second, medical associations, in partnership with provincial governments, should define and enforce measures for mutual accountability, to ensure that patients have appropriate access to primary care, regardless of the funding model.
Finally, we should recognize that we desperately need more primary-care professionals across the country. On this note, additional health care professionals, such as nurse practitioners, could share the primary-care load with family doctors. Nurse practitioners require two years of further training after an undergraduate nursing degree and can provide most primary-care services across Canada. In contrast, family doctors require four years of medical-school instruction and two years of residency training after completing their undergraduate degrees. Primary-care nurse practitioners generally work in teams with family doctors where everyone can complement one another’s unique skill sets, allowing every team member to practise to their full capability or “scope.” Training and recruitment of primary-care providers also needs to be part of a pan-provincial strategy to promote the desirability of health care careers to younger generations.
Improving primary-care access is the most important challenge that Canadians face in achieving better health outcomes. Overcoming this challenge will require courageous collaboration between Canadian medical associations and ministries of health, but as a country we are more than capable of achieving this.
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