Renee Primeau, Systems Navigator at London InterCommunity Health Centre, speaks with her colleagues Psych Co-ordinator Carol Wat and Client Care Support worker Margarita Ramirez at their office in London, Ont., on May 29.Geoff Robins/The Globe and Mail
When Alika Lafontaine, the president of the Canadian Medical Association, imagines creative ways to rescue the country from its family doctor crisis, he thinks of public schools.
Schools are organized in a way that guarantees every child a spot in a classroom. When families move or teachers retire, parents aren’t forced to call multiple schools looking for a teacher who is accepting new students. They’re never told that every local school is full, or that an education is only available to their children on an emergency basis.
Why shouldn’t primary care work the same way, Dr. Lafontaine wonders?
“We’ve allowed the health care system to grow into a choose your adventure, where folks have to figure out how to access care themselves,” said Dr. Lafontaine, who is also an anesthesiologist in Grand Prairie, Alta. “The education system is designed to be streamlined. It wants your kids to be part of the learning and education that occurs in your community.”
The idea of reorganizing primary care so that it works more like public schools isn’t a new one, but it is enjoying a renaissance as Canada struggles with a shortage of family doctors that is about to get worse.
An estimated 6.5 million Canadians don’t have regular access to a family doctor or nurse practitioner, according to a national survey conducted last fall. Other data suggest an exodus of family doctors is right around the corner. Nearly one in six in Canada are 65 or older. In May, the Ontario College of Family Physicians released a survey of more than 1,300 family doctors that found 65 per cent are planning to leave office-based family practice or reduce their hours in the next five years, largely because they feel crushed by the weight of unnecessary administrative work.
Matt Wannan, Project and Communications Specialist, and Isma Malik, Governance and Leadership Assistant at London InterCommunity Health Centre.Geoff Robins/The Globe and Mail
Dr. Lafontaine is one of nine expert advisers working on a series of papers about health care reform this year for the Public Policy Forum, a non-partisan think tank. The first, released in January, identified as a top “modernization imperative” that every Canadian should have the right to a relationship with a primary-care team within 30 minutes of their home or work, “just as public school is available to every child.”
Separately, University of Toronto primary-care researcher Tara Kiran is leading a series of national surveys and provincial focus groups called Our Care. The effort has found broad support for reorganizing primary care along the lines of public schools, so long as patients can retain some choice in providers.
As Dr. Kiran pointed out, other countries with high-performing medical systems already do this.
She and some of her colleagues are working on a study exploring how Britain, Finland, the Netherlands and Norway achieved primary-care attachment rates – the share of the population with regular access to a general practitioner or health centre – north of 95 per cent. Canada, by comparison, has an attachment rate of about 85 per cent, according to the most recent Statistics Canada data, although Dr. Kiran’s Our Care survey of more than 9,000 Canadians suggests the figure is closer to 77 per cent.
In Finland, residents are automatically registered with the publicly funded health centre closest to their home. In Norway, all residents are assigned to a general practitioner, but are free to choose a different GP twice a year if their preferred doctor has space. Britain encourages residents to register with local practices based on their postal codes. In the Netherlands, where residents are obligated to buy health insurance from private providers, insurance companies are responsible for finding patients GPs if the nearest doctor’s practice is full.
None of these countries have flawless primary-care systems, added Dr. Kiran, who also practises family medicine in Toronto. But European countries with high attachment rates have set a goal of providing primary care to all, and designed their systems with that aim in mind.
“In Canada, we have not set that goal and we have not designed the system to make sure that happens,” Dr. Kiran said.
Canada’s primary-care system is less a system than a collection of small businesses owned by physicians, most of whom work as independent contractors who bill provincial and territorial governments.
Former federal health minister Jane Philpott, another adviser on the Public Policy Forum’s year-long health project, is part of a Kingston, Ont., group that is striving to turn the concept of public-school-style primary care into a reality, at least at the local level.
The group, led by the Kingston Community Health Centres, submitted a business plan to the provincial government last fall that proposed expanding the organization’s operations and hiring more staff so that it could offer primary care to everyone in a defined geographic area who didn’t already have a doctor.
Community Health Centres, or CHCs, are publicly funded clinics staffed by physicians, nurse practitioners, social workers, dietitians and other health professionals. CHCs usually differ from other models of team-based primary care in two important ways: They aim to serve the most marginalized patients, and they provide salaried jobs with benefits, pensions and vacation time for family physicians.
The Kingston proposal, which is backed by the municipal government, local hospitals and the Faculty of Health Sciences at Queen’s University, where Dr. Philpott is dean, envisions the CHC growing to provide universal primary-care access to everyone in a specific catchment area, not just the poorest and most vulnerable patients.
Dr. Philpott acknowledged that changing the primary-care model to cover everyone would carry a hefty upfront cost, but she believes it would produce savings by keeping people out of emergency departments and hospitals.
“It will require a shift in where money is spent,” she said. “Ultimately, there’s lots of evidence to suggest that it will mean we could be spending less money rather than more.”
Scott Courtice, Executive Director at London InterCommunity Health Centre.Geoff Robins/The Globe and Mail
Supporters of the Kingston proposal also believe that flexible, salaried positions will be popular with young doctors such as Jaclyn Vanek, a 31-year-old doctor in Peterborough, Ont. who wants to practise in the city but isn’t keen on becoming a small business owner. She is a member of a group pushing for the creation of a traditional CHC in Peterborough, a city where about 13,000 people don’t have family doctors or nurse practitioners, many of them low-income patients with complex health needs.
Asked about the status of the Kingston and Peterborough proposals, Hannah Jensen, a spokeswoman for Ontario Health Minister Sylvia Jones, said the provincial government has committed $60-million over two years to expanding existing primary care teams, with a call for proposals due this month that is open to family health teams, nurse practitioner-led clinics, CHCs and others.
In the meantime, some creative solutions are already in place to support doctors who aren’t part of a team. London, Ont.’s InterCommunity Health Centre, for example, has one clinic that provides health services – including counselling, physiotherapy, diabetes education and respiratory therapy – to the patients of 54 nearby doctors who practise solo, or in small groups.
A more ambitious overhaul of primary care is likely necessary, according to Scott Courtice, the centre’s executive director. “Sometimes when things are at this level of crisis it’s the right time to sort of radically re-conceptualize how we’re doing things,” Mr. Courtice said.
David Price, the former chair of family medicine at McMaster University in Hamilton, echoed that. He and nurse practitioner Elizabeth Baker led an expert panel that in 2015 urged the Ontario government to create patient care groups that would be obligated to serve everyone in a neighbourhood, just like public schools.
Their proposal wasn’t adopted. Dr. Price thinks one of the reasons it didn’t gain traction was that primary care wasn’t top of mind for politicians and voters in 2015 the way it is now, with family doctors in shorter supply than in the recent past.
“This is the first time I’ve seen that it’s the topic of dinner conversations everywhere you go,” Dr. Price said.