A Message from the Guest Editor

The foundation of our healthcare system, primary care, is in crisis. Concern about access to healthcare has become a top priority for governments across Canada and internationally. Citizens are worried they won’t be able to access care when they need it.

The vast majority of healthcare visits in Canada are to primary care. Yet, more than one in five Canadians, an estimated 6.5 million people, are without a primary care provider. We struggle to provide timely access to primary care for an ageing population, within a healthcare system that has ever-increasing options for diagnosis and treatment. The pandemic further increased strain on resources and delayed access across the system.

All of this pressure has led to additional challenges, including recruitment and retention of providers, particularly in rural regions. It is estimated that in the next five years, 10,000 new family doctors will be needed, while only 1,200 exit training annually. Family physicians also experience burnout and increasing numbers left practice during the pandemic.

Numerous factors contribute to primary care access challenges in Canada which is funded federally but implemented provincially. Provincial and territorial governments are responsible for distributing healthcare funds, including making decisions about recruitment, compensation, and regulatory policies. Primary care physicians are mobile, independent contractors, making it difficult to dictate innovations in primary care. As a result, decision makers often rely on the same policy levers such as incentives for providers who take on new patients or provide certain types of care, such as chronic disease management.

Our multidimensional system has a responsibility to organize care for individuals across the continuum, from pre-conception to palliative care, and to work with partners to improve the health of communities. Despite the critical role of primary care in our system, we have little data on how primary care providers run their practices or what services they offer. Primary care is poorly integrated within the broader health system leaving family physicians feeling unsupported, and patients are coming to primary care with more complex health and social needs. Family physicians are increasingly burdened with time spent in care coordination and administration.

Regarding equity in primary care, concerns have long been raised about “cherry-picking” patients with few health needs. Family physicians accepting new patients into their practice have reported being less likely to take on patients seeking opioids. When incentivized to take on patients with complex needs, some family physicians continue to choose patients with fewer needs. Racism and discrimination remain pervasive in primary care.

In the past 20 years, more alternative payment models have been introduced in the place of traditional fee-for-service payment models. These models support and incentivize family physicians to work in rural practices, to manage greater patient loads, and to provide comprehensive, collaborative primary care. Previous research by Lavergne and colleagues found these collaborative care models are more appealing to new doctors, but there were few opportunities for them to join one.

Given the need to rescue primary care, the theme I chose for this edition is “Better, not just bigger: Resuscitating sustainable and equitable primary care in Canada.” While we work to increase the number and types of providers offering primary care, it is critical that we also attend to equity, grow primary care models and strategies that work, such as interprofessional collaborative care teams, and provide services to support equity-deserving populations. We also need to protect primary care from encroaching for-profit options that take providers away from more effective and equitable sources of care, and avoid creating a two-tiered system. There are critically important roles for federal and provincial governments to play, along with the roles of health authorities, provider organizations, and patient partners, as we move to solutions for more sustainable and equitable primary care in Canada.

The articles in this special edition address the challenges in primary care through the authors’ diverse expertise and research, offering evidence-informed recommendations for policy and decision makers. The articles in this edition loosely fall into three themes, sometimes overlapping: (1) tackling equity in primary care; (2) primary care models and strategies that work, and the rise of those that threaten our system; and (3) building a sustainable and equitable primary care system.

Addressing the first theme of tackling equity in primary care, we start with Lavergne and team’s compelling findings from national health survey data that disparities in primary care access exist and have persisted over time. They also provide thoughtful recommendations for how to support equity in access, encouraging health leaders to design primary care transformation efforts with equity as a priority area of focus, requiring allocation of new investments and equity accountable frameworks.

Next, we have a powerful piece by Massaquoi, orienting us to address anti-Black racism and its consequences, moving beyond competence, into meaningful commitment, evaluation, assessment of accountability towards reflection, and transformative action. Massaquoi provides clear guidance and recommendations related to “racial humility” which includes a series of questions related to the goal, self-reflection, and individual and organizational accountability.

Catalyzed by the COVID-19 pandemic, Lauscher et al. address inequitable access and multiple barriers to healthcare faced by rural, remote, and Indigenous communities and provide pan-provincial services. To address inequitable access and multiple barriers to healthcare faced by rural, remote, and Indigenous communities, a well-designed mixed-method evaluation assessed implementation, patient and provider experience, quality improvement, cultural safety, and sustainability for these important communities, with remarkable success.

With thoughtful background and understanding of the “public-private” debate, Hedden and colleague dive into Canada’s growing profit-driven corporate healthcare. They identify the impacts of for-profit options on equitable access to care, increases to spending on low-value services, and how these undermine the underlying values of the Canadian healthcare systems. This topic has never been more timely as we work to improve primary care, but are challenged as we lose providers to for-profit options and continue to wrestle against inequity.

In the next grouping of articles, we look at primary care models and strategies. The first is a commentary, with a deep dive into the Ontario Health Teams model of integrating care delivery to improve outcomes across the quadruple aim by Sibbald and co-authors. Table 1 boils down their success to eight essential elements, all grounded in health equity, quality improvement principles, population health, and co-design approaches.

Ashcroft and team present findings from their study describing how social workers engaged in leadership roles in primary care during the COVID-19 pandemic, having collected cross-sectional surveys across Ontario, Canada. They find most social workers in primary care are engaging in leadership activities and demonstrate needed competency dimensions, yet are still underutilized. This could be very helpful information for those looking to improve primary care, as social workers may provide significant leadership skills across teams.

A novel study examining physician satisfaction and perceptions of the relatively new addition of Physician Assistants (PAs) in Ontario is provided by Burrows and colleagues. They find PAs help decrease wait times, improve management and continuity of patient care, improve physician quality of life, and make positive contributions to productivity. A key barrier remains with a lack of sustainable funding models to support PA roles.

Breton and team next share their new and ambitious study on advance access, including data from 127 clinics with 999 family physicians and 106 nurse practitioners in Quebec. Findings include recommended strategies to enhance timely access, data-informed planning for supply, and strategies to react to offer-demand imbalances.

In this final section, we focus on how to build a sustainable and equitable primary care system involving different levels of government. First in this section is a powerful opinion piece by McCracken, on how we can address lack of access to primary care through development of a modern infrastructure and new ways of funding and organizing care, providing a helpful analogy to how we structure public education.

Next, Flood and co-authors challenge us to explore the options the federal government can and should take with a more hands-on role responding to the present primary care crisis. Countering the false premise that the federal government has no jurisdiction in healthcare, they propose that government has several avenues to respond that is both constitutionally compliant and tailored to respond to the policy problem. Prime Minster Trudeau, are you listening?

Mathews and team share their novel cross-provincial case study analysis of policies supporting the roles of family physicians during the COVID-19 pandemic. Regulation, expenditure, and public ownership policies support family physician roles across five areas, namely, leadership, infection prevention and control, provision of services, COVID-19 vaccination, and redeployment. The findings from this study highlight different policy approaches to pandemic roles and will help inform future pandemic preparedness.

Marshall and colleagues present unique data on the challenges and impacts from wait times for specialist care identified by primary care providers collected via provincial surveys in Nova Scotia, Canada. This research, from the Models and Access Atlas of Primary Care Study, found wait times were problematic and negatively affected both their patients and practice in a multitude of ways. Relevant for policy and decision makers who are trying to buoy primary care, the respondents offer recommendations. This study also implicates the delays in access to specialist care as a key barrier to primary care capacity.

Manchanda and colleagues explore international recruitment of primary care providers, based on interviews with official authorities involved in recruitment and based on an extensive literature review. The authors identify challenges from different perspectives and recommendations that include bringing legislative and policy changes to increase candidate seats and developing new pathways to bring medical graduates from other countries.

Additionally, Grundy and colleagues provide a focus on practice-based education, with their qualitative study, finding fiscal and human resource challenges prompted hospital leaders to outsource practice-based education to industry, while outsourcing generated downstream costs to the organization and undermined the goal of practice-based education.

Finally, Isenor and team share a novel report on the development of a consortium to examine organ donation legislative and system reforms in Nova Scotia, Canada. This work explored a 2019 legislation in Nova Scotia, making it the first jurisdiction in North America to pass legislation that used deemed consent for organ donation. Galvanized, this team of colleagues came together and successfully developed a consortium from national and provincial jurisdictions, providing a case example as a model for the evaluation of other health system reforms from a multi-disciplinary perspective.

I would like to thank all the amazing contributors for this special primary care edition. It brings me great hope and excitement to see so much research and policy development across Canada, with diversity in our approaches, focus, and perspectives.

In conclusion, how can we build sustainable equitable primary care in Canada? If everyone has to think outside the box, perhaps the box is the problem. Innovations have been implemented in the short term to improve access to primary care as a “band-aid” solution to systemic problems—and while band-aids may be necessary, they are not long-term solutions. Election cycles should not be the main impetus for improvement. Progress in primary care may include advancing scope of practice, particularly across professions (e.g. nurse practitioners, nurses, pharmacists, social workers, physician assistants, and other allied health professionals). In order to sustain equitable access and our publicly funded primary care system, we must battle against for-profit healthcare in Canada. As we move towards a bigger and better primary care system in Canada, it behooves us to also consider our impact on other nations, some of which we actively recruit providers from. If the pandemic taught us anything, it is that we are a global community, and our health is inextricably linked to the health of all of humanity. We have both the ability and responsibility to support equity in access to care within and beyond Canada.