Addressing unmet need for primary care in Canada

Introduction

Primary care is generally considered the front door and foundation of the healthcare system, yet currently over 6 million Canadians ¹ cannot access care for prevention, acute or chronic conditions, mental health, or substance use without going to an emergency department or a walk-in clinic. Those settings do not provide continuous ongoing care, are challenged to follow up after ordering tests or making referrals, and do not generally have a role in care coordination over time. Consider the alternatives faced by someone with several chronic conditions who is due for routine lab work, prescription renewals, re-referral to specialists, cancer screening, and completion of forms required by their employer for benefits, who has lost their family doctor due to retirement, and no doctor or clinic in their community is accepting new patients. Despite Canada’s universal health insurance system with full coverage of physician fees, that person will find it next to impossible to meet their needs for routine ongoing care, with serious consequences for their health and well-being.

The causes of the crisis are many on both the demand and supply side. Need for care has accelerated rapidly with population growth, and Canada now has the fastest growing population in the G7. ² The population is also ageing, with Canada’s senior population expected to grow by 68% over the next 20 years, ³ and close to 40% of seniors reporting living with at least two chronic health conditions. ⁴ The adoption of electronic health records, with many disconnected systems, has added large administrative demands to primary care, as has a proliferation of required forms for referrals, testing, and benefits.^5,6 Guidelines on clinical prevention and disease management have multiplied over time, and it is estimated that a primary care physician in the United States now requires 7.4 hours per day for the provision of recommended preventive services alone. ⁷

On the supply side, there has been a substantial increase in the number of family doctors in Canada but a decline over time in their work hours, number of services provided, number in full-time practice, and proportion providing comprehensive office-based care.^8-11 Many new graduates in family medicine do not want to run a business, prefer alternate funding that is not based on fee-for-service, would like opportunities to deliver comprehensive care in team-based models, and want the ability to take time off and have coverage for their patients, ¹² conditions that are largely unavailable in Canadian practice environments. While doctors working in hospitals enjoy the benefits of government-supported infrastructure including physical space, professional management, clerical staff, volunteers, inter-professional teams, equipment, supplies, and information technology, those in the community must pay out of pocket from the payments they receive for patient care and must manage the practice themselves. New graduates often carry large debt loads, making higher-paid specialities more attractive than family medicine.

Across Canada in 2024, about 1,600 new family medicine residencies were filled, ¹³ but less than two-thirds of graduates are expected to choose comprehensive practice, representing a pipeline that is far too small to meet current demand, let alone future needs for primary care. About 14% of family doctors are over the age of 65, many with large practices of older adults, potentially leaving millions of additional Canadians without primary care when they retire. ¹⁴ Other health professionals who could serve as most responsible clinician in primary care are relatively small in number: in 2022, Canada had about 2,200 nurse practitioners working in community settings ¹⁵ and fewer than 1,000 physician assistants in all settings. ¹⁶

Responses to the crisis are partial, incremental, and insufficient

Policy-makers have become increasingly aware of pressures on primary care, and most jurisdictions are taking steps to address the crisis including new medical schools and expanded residency positions, greater access to practice for internationally trained health professionals, new payment models for family doctors and nurse practitioners, exploring ways to reduce administrative burden, enhanced use of technology such as virtual care and Artificial Intelligence (AI) scribes, and expanding the availability of inter-professional primary care teams.^17-20

Why could these ongoing efforts be considered insufficient? Given current trends, the number of Canadians without access to primary care is likely to reach 10 million within 3-4 years, ¹⁴ requiring at least 10,000 family physicians and/or nurse practitioners or physician assistants, as well as thousands of new inter-professional team members. From high school graduation, it takes 10 years to produce a family doctor, 8 years for a nurse practitioner, and 6 years for a physician assistant. When those new family physicians graduate, they will be faced with running small independent fee-for-service businesses that are of limited appeal and instead they are likely to be drawn to settings with built-in infrastructure and teams with minimal overhead including hospitalist and emergency medicine roles. Long training lead times, small pipelines, and lack of appeal mean that today’s partial and incremental policy interventions alone are not likely to address the growing challenges in providing Canadians with primary care.

A population-based approach is needed but is not yet an established health system goal

Most provinces and territories track formal or informal attachment in primary care, so that each family doctor has a defined or notional list of patients that define their practice. The responsibility of family doctors does not typically extend beyond their practice into their community, and most are not accepting new patients given their current workload. This system, built on family doctors who are independent contractors running small businesses, focuses on the needs of the practice’s patients, but is rarely oriented to community needs, leaving out those who are unattached. Except in smaller communities, family doctors working in the same area are unlikely to collaborate with each other, or even know each other. These practice arrangements date back many decades to a time when populations were younger, and less complex and health systems and technologies were simpler and more straightforward. In the current environment, these outmoded ways of working mean that solo physicians and groups of family doctors often work in isolation from each other and receive little or no support for infrastructure, staffing, overhead, information technology, or connectivity to other practices and other parts of the system.

While many health professional groups are calling for increased funding as the answer to today’s crisis, paying more for the same outmoded system is unlikely to achieve different results. A central tenant of Canadian Medicare is universality, but a system that is inaccessible to millions of people cannot be said to be universal. For that reason, a key goal of primary care system transformation needs to be accessibility to everyone. That proposition seems radical in the current context, yet many countries provide primary care access to all and do so with lower per capita expenditures on health than Canada, but with higher spending on primary care. ²¹ Those countries have independent primary care doctors like Canada, but they are typically contracted to provide defined services and work together to meet community needs. Practices in those countries most commonly have geographic catchment areas and provide patient choice to move to another practice within and sometimes outside their local area. When primary care is organized locally and when practices work together, not only can universality of access be achieved, but so can increased care of patients outside of hospital settings including after-hours care, integration with local home, social and community care services, and tailoring of workforce and professional roles to the needs of local populations. ²¹ In Canada, the educational system is sometimes used to highlight the stark contrast between the ease of finding a local school when moving to a new area with the challenges of finding a family doctor or primary care clinic in that same area.^22-24

Without the goal of primary care access for all, Canada will always remain behind peer countries in health system performance and some people will always grapple with closed practices, unmet need, and long waiting lists. Inequities will persist, with racialized groups ²⁵ and Indigenous Peoples ²⁶ less likely to be attached to care. Few if any provincial or territorial governments have established the goal of primary care for all, instead choosing more modest goals and incremental investments. To achieve this goal, health systems would need to be reorganized, with new local governance arrangements, new health human resources plans, greater system integration and supports and major new investments, all likely serving as barriers to provinces and territories making this commitment. As well, concerns about threats to autonomy, becoming devalued, being replaced, and overlapping professional roles limit some family doctors’ appetite for such major changes. ²⁷ Still, primary care needs to transform to meet 21^st century needs with population health as its goal, and the current Canadian system consistently receives failing marks at that task, falling ever further behind other similar countries. ²⁷ Countries and regions with strong primary care achieve better health, greater equity, and improved experience of care at lower costs. ²⁸

Change management needs attention and resources

The challenges associated with moving from a health insurance scheme to an organized, responsive, accountable primary care health system should not be under-estimated. Elements of a future system already exist in several provinces ²⁹ including Primary Care Networks in Alberta, Ontario Health Teams and Primary Care Networks in Ontario, and Family Medicine Groups in Quebec, but those organizations are not responsible for population health and will need resources, tools, and strategies to implement the changes needed. In Canada, major system initiatives are often implemented as pilot projects ³⁰ that consistently fail to be sustained or spread and receive little implementation support or timely evaluation. Support for change management is often missing or insufficient.

Given the size of Canada’s unmet need for primary care, demographic trends, and limited pipeline of new graduates, the only way to achieve full population coverage is through team-based care with nurse practitioners joining family doctors in the role of most responsible clinician, and direct access to other health professionals on the team such as nurses, physiotherapists, social workers, psychologists, addiction counsellors, and pharmacists. New roles such as system navigators, community health workers, medical office assistants, and outreach workers will be needed depending on the setting. These care innovations require changes in roles and relationships for all the clinicians and staff involved and will need support in order to be implemented well. For example, Alberta family doctors are at varying stages of adoption of team-based care, with some considering team members as helpers or those who can take referrals rather than fully fledged integrated members of the same team. ³¹ Effective transitions to team-based care cannot happen without attention to stages of change ³² and supports such as those provided by practice facilitators. ³³

The transformation needed to provide primary care for all includes team-based care but also establishing voluntary local networks of family doctors, information technology and data supports, relief from the burden of paperwork, shared after-hours care, community and patient engagement, workforce plans for effective recruitment and long-term retention, and governance and accountability models that are responsive to community needs while supporting clinician control over their own day-to-day practice environments. To attract and support family doctors, practices and networks will need to offer flexible work arrangements and a variety of funding plans aligned with system goals including capitation, salary, and sessional fees, optionally blended with payments for complexity, time spent, overhead, and patient volumes. Reimbursement will need to be competitive with hospitalist, emergency medicine, and other focused practice roles, and with specialists. In networks and larger clinics, it will be desirable to have professional practice management support, freeing up physician time for patient care. These changes are major departures from solo or small group independent practice and will need to offer benefits such as greater access to resources, better supports, enhanced patient care, improved system navigation, and interoperable information technology systems to interest local family doctors. Establishing the goal of primary care for all is necessary but insufficient unless it is accompanied by appropriate resources, infrastructure, governance, managerial capacity, and change management supports.

Judging policies and programs by their results: Implementation, evaluation, continuous learning, and adjustment

In Canada, new healthcare policies and programs are often announced with fanfare but without defined and measurable objectives, timelines, or a plan for evaluation to support implementation. The impacts of many programs remain unknown and in the absence of evidence many succumb over time to lack of interest with the end of their funding. The profound transformation and major commitment of resources needed to provide primary care for all Canadians demands thorough attention to outcomes in ways that are rarely found in Canadian healthcare initiatives. Instead of post hoc “big dot” indicators, implementation and evaluation plans need to incorporate timely realist perspectives that address the questions of what works, for whom, in what settings, and why. ³⁴ This is especially true for team-based care, new governance structures, alternate payment models, and community engagement that will need to be tailored to local community needs and for which no fixed templates or playbooks currently exist. Health systems are complex, and interventions often result in unanticipated consequences, ³⁵ so evaluative efforts need to be broad, ideally extending to other sectors within and beyond healthcare with attention to potential adverse impacts such as exacerbating workforce shortages in other areas. Attention to equity is important given the propensity of healthcare initiatives to benefit the most advantaged members of society who can more readily learn about new programs and resources and navigate the health system to find them. ³⁶

Implementation needs to be supported with planning and attention to change management. It also needs dedicated resources for real-time continuous qualitative and quantitative measurement, course adjustment based on results, feedback loops, and public reporting and accountability. When these elements are integrated into healthcare planning and delivery, the result is sometimes called a “learning health system.”^37-39 There is every reason to believe that primary care investment will result in better health, improved equity, and lower costs,^40,41 but these outcomes depend in large part on how well change is managed, how effectively transformative initiatives are implemented, and how well outcomes are measured and results used to maximize the chances of success.

What else is needed?

To effectively address the primary care workforce shortage, thousands of new family doctors, nurse practitioners, and many others are needed. As previously noted, training pipelines take many years and are inadequate to meet needs. Where will all these new clinicians and staff come from and with high burnout rates, how will they be retained in primary care? Realistically, primary care for all is a 10- to 15-year project that needs to start immediately as the situation continues to deteriorate. No single strategy will be sufficient, and a combination of approaches is needed that could include incentives for focused practice family doctors to spend time in comprehensive care, maximizing practice entry of internationally trained graduates in all disciplines, and rapid scaling up of nurses, nurse practitioners, physician assistants, social workers, pharmacists, physiotherapists, psychologists, and others in team-based primary care. It requires 2 years to train some of Canada’s more than 400,000 experienced nurses to become nurse practitioners and 2 years after an undergraduate degree for training of physician assistants. Within the team context, nurses, pharmacists, and physiotherapists can independently contribute to the care of a proportion of patients including those with diabetes, hypertension, and uncomplicated low back, knee, and shoulder pain, thereby freeing up most responsible clinician time. ⁴² A variety of health professionals would ideally train together with future family doctors in primary care and not in silos as is currently the case. ⁴³ AI scribes appear promising to save time for documentation of clinical encounters, ⁴⁴ and medical office assistants are able to perform a wide range of duties including completion of forms and helping with system navigation. ⁴⁵ What would help to retain all these clinicians and others in primary care? Well-supported team-based care, with everyone working at their top of their skill mix, and with appropriate administrative support, can bring joy to work and relief from the drudgery of paperwork.^42,46

Resources such as data collection platforms, use of electronic record data, data linkages, survey capacity, and analytical supports and expertise are much less commonly found in community primary care settings than in hospitals and universities, necessitating the development of partnerships and networks to support these functions. Canada already has several existing data, analytical and research networks in primary care, and health systems in provinces and territories that can be leveraged for these purposes.^47-50 A key strategy to advance learning health systems is embedding doctoral and post-doctoral trainees and early career researchers in health system organizations with the goal of bringing evidence close to where decisions are made. ⁵¹

Finally, patients, caregivers, and communities are of paramount importance in health system transformation and need to be engaged in system co-design, implementation, evaluation, governance, and continuing improvement. A recent extensive country-wide patient and community engagement project called OurCare ⁵² has identified patient needs and expectations and has proposed the following standard: everyone has a relationship with a primary care clinician within a team; everyone receives ongoing timely care from their primary care team; primary care teams are connected to community and social services; everyone can access their health record on-line and share it with their clinicians; everyone receives culturally safe care from clinicians that represent the diversity of their communities; and the primary care system is accountable to the communities it serves. Only by committing to the strategy of primary care for all can these needs and expectations be effectively addressed.

Taking action

Bold new initiatives are needed to resolve the worsening crisis of access to primary care. These initiatives will require political, professional, and public support for new ways to organize and deliver primary care. As the situation becomes more dire, increasing support for change becomes more likely. The many unknowns, such as how best to organize and incentivize teams, how they can be aligned with local population needs, what scale of investment is needed, what the return on investment will be, and what governance and accountability arrangements are most promising, call for a new approach to implementing, testing, and spreading innovation. There have been calls for Canada to implement a healthcare innovation fund and agency ⁵³ and to drive innovation, evaluation, and scale-up of successful experiments through approaches similar to the Centre for Medicare and Medicaid Innovation in the United States. ⁵⁴ As an example, different approaches to team-based primary care at the neighbourhood level could be tested for their reach, equity, cost, cost savings, and quality, examining a variety of different funding arrangements, team models, accountability measures, and governance structures. These evaluations could be implemented as cluster randomized controlled trials involving different clinics and neighbourhoods. Billions of dollars have been committed in new bilateral federal agreements with provinces and territories that include data sharing, performance targets, and reporting, including primary care. A small fraction of those funds dedicated to innovation, implementation support, evaluation, and adaptation and scale-up of successful efforts would inform widespread adoption and spread of effective solutions.

Conclusion

Canadian healthcare is at a crossroads with the system performing poorly, leaving millions of Canadians out in the cold. While new investments are needed, they must buy change rather than more of the same system that has produced the current results. Ensuring that primary care is available to everyone requires a complete re-thinking of where resources are deployed and how care is organized, delivered, and held accountable. Key to the success of this transformation is implementation that meets community needs, supports joy in work for clinicians and staff, and measures results and uses them to attain goals. New dedicated supports for innovation, implementation, and evaluation are needed to understand, advance, and spread the most effective interventions and models of care. Primary care for all is necessary, feasible, and affordable and is the norm in many countries. A commitment to work towards this goal is needed now to ensure that Canadians have access to high-quality well-organized care for everyone.