Illustration: The Globe and Mail. Sources: Getty Images.
Jane Philpott is a former federal minister for health and Indigenous services and now serves as dean of health sciences and director of the School of Medicine at Queen’s University. She is the author of Health for All: A Doctor’s Prescription for a Healthier Canada.
In Canada, we used to tell ourselves that we have the best health care system in the world. It has competed with hockey as our most powerful source of national pride. But the cozier we became with the notion that universal health care is a right of residency in this great country, the more complacent we became about the reality: that the project of building a full medicare program in Canada is incomplete.
Then, a pandemic struck and roused us from our reverie. Those of us who survived the contagion have now woken up from our state of slumber and realized that despite all the high-quality clinical services offered here, we don’t have a national health care system after all.
What we do have is a hodgepodge, patchwork, ad-hoc smattering of health care delivery units – clinics, hospitals and services – where smart and compassionate people work tirelessly and loyally to deliver the highest possible standard of care within the conditions they’ve inherited.
But you can’t call that a system. A system has an intentional design that connects its parts, ensures they operate together, and includes everyone within its boundaries. Nowhere is this lack of systemic planning more obvious than in primary health care – the foundation of any health system. As millions of Canadians struggle to find a family doctor or primary-care team, the need for a co-ordinated national approach is ever more glaring.
What we have in Canada is not nothing, but it is not enough. Medicare amounts to publicly funded, universal insurance for doctors and hospitals, and we have agreed to pool resources to pay for medically necessary care. The inclusion criteria are narrowly defined, but no one is turned away because they lack the means to pay. In Canada, we believe that money must not keep anyone from getting health care. This fundamental value is not to be taken for granted and it must be preserved – but it is not sufficient. A payment method is not an organizational structure, and no government has taken on the challenge of co-ordinating a health system – what Tommy Douglas famously called the “second stage of medicare.”
This is the root of the current crisis. There is no system that guarantees everyone in Canada has a place to receive primary care. In lieu of a strategic plan, family doctors like me have chosen our place of practice according to personal and professional interests – not according to an overarching vision of what health care should look like in this country.
For people who have a family doctor, it’s good medicine. Having a longitudinal relationship with a primary-care provider means having someone who cares for you and your family through good times and bad – someone who advocates for you, communicates with you, understands you and helps you pursue the highest attainable standard of physical and mental well-being.
But fewer and fewer Canadians are experiencing this – and family doctors are increasingly beset with moral distress because they can’t deliver this for everyone. There is almost no public support for the physical and administrative infrastructure to run a family practice and very limited public funding for team members other than doctors. The result is a piecemeal collection of practices and no structured way of ensuring that every Canadian will receive continuous, comprehensive, co-ordinated and person-centric care.
While the cost of this chaos can be measured in dollars, it is more tragically tallied in human suffering and even in premature deaths. Nearly seven million adults in Canada have no family doctor, nor any other access to primary care. If you’re one of them, you have no one to monitor your diabetes, high blood pressure or heart disease. No one is supporting you to quit smoking. No one checks that you’re up-to-date with cancer screenings. When you have an urgent health issue, you either fend for yourself, or seek care in the emergency department where both patients and care providers hold out hope against the tide of angst and despair.
It’s not too late to build something better, and fortunately, there’s a model for that systemic solution right within our own neighbourhoods. Long before we can remember, Canada decided that every child living in this country should be able to attend publicly funded primary and secondary schools. The scheme of universal access to public schooling is so well established that we barely acknowledge the miracle of its existence. Schools grow as the sizes of their communities grow. When new neighbourhoods are built, so are new schools. No government would just wait and hope that teachers, principals and support staff would just come along to start a school in a growing area.
A system like this is exactly what we need for primary care – a health home in every community and a guarantee that every person in Canada is attached to one. It’s the fix recommended by dozens of national and international reports going back decades to the foundations of medicare. You might think this would be expensive, but international evidence clearly shows that a system built on primary care offers better health outcomes and lower per capita costs. In Britain, for example, every resident can register with a local family practice of their choice, and they are directed to the closest practice according to their postal code. Meanwhile, their overall health spending per capita is lower than ours in Canada. This approach provides savings farther down the road by managing health and social issues early and pro-actively.
Imagine our possible future. In each neighbourhood, a primary-care home would be the front door to care, the first location you visit unless you have a highly time-sensitive emergency. This is where members of the care team know your name. They use it when they welcome your arrival with genuine warmth.
Imagine your primary-care home is staffed by a team that includes doctors, nurse practitioners, nurses and other workers according to specific community needs. Some homes have physiotherapists, occupational therapists, physician assistants, midwives, social workers, dietitians, pharmacists and community paramedics. Where possible, the team includes health-sciences students, as well as community volunteers. You have a long-term relationship not only with your family doctor, but with that entire team of professionals.
If you relocate, you are reliably assigned to a new primary-care home based on geography, generally according to your place of residence. You do not need to beg for a family doctor or wait for years on a list of “unattached patients.” Unless it’s close by and you choose to return for care, you do not need to drive or fly back to your previous municipality to see the family doctor you had there. Your care is delivered close to home, ideally within 30 minutes of where you live or work.
The doors of most primary-care homes could be open seven days a week, up to 12 hours a day. They would offload pressure from emergency departments and enable hospitals to discharge patients quickly and safely. They could be the co-ordinating centres for at-home care, including palliative care. When needed, someone from the team could see you at home or in the community, always ensuring the visit is linked to the primary-care home and your records are updated in real time. Your primary-care home could also be a one-stop shop for other health-related services, including public-health clinics or classes on nutrition, prenatal care or mental wellness. Other specialist physicians could see you when they make regular visits to the local primary-care home. Additional social services such as legal clinics, tax clinics and mobility services would make these homes the heart of an integrated health system.
This may sound like a dream. But this dream could be our reality. Other countries have this. We can too. Consider that in Germany, the Netherlands, New Zealand and Britain, more than 95 per cent of residents have a regular primary-care clinician or a regular place of care.
The creation of such a health system won’t happen through hand-wringing, nor through good intentions or political posturing. It won’t happen by sprinkling new buckets of funding across the provinces and territories, or making pronouncements about more family doctors with vague hopes that everyone will be able to find one. And it won’t happen by lazily letting commercial enterprises fill in the gaps with episodic visits that are offered in yet another silo of our non-system.
We need a pro-active commitment by governments to organize, fund and deliver universal access to primary care. This commitment must come with teeth. Other countries whose health systems are better rooted in primary care than ours have achieved this through underpinning federal legislation that holds jurisdictions to account through standards and conditional funding. Norway has used this strategy and legislated a right to primary care. Its people enjoy better health outcomes than Canadians and they spend less on health per capita. It’s time for us to lay down the law, too.
Here’s how we’ll get from ideas to implementation: It is time for the Canada Primary Care Act – a proposal I like to think of as a sister to the Canada Health Act.
Such a law would not be a case of the federal government exercising dominance over provincial jurisdiction. Rather, like other successful social programs, the Canada Primary Care Act would be created by federal and provincial governments working in collaboration, powered by democratic will and by a mighty tide of public opinion. Our history shows that when there is an undeniable national interest in an issue of common concern, the federal government can initiate cost-shared programs in areas ordinarily considered to be provincial jurisdiction. The federal government does this by giving provinces money with strings attached.
A federation such as Canada offers tremendous autonomy for provinces, territories and self-governing First Nations. This allows variability so that services meet the needs of each region. The federal government, however, has an obligation to create overarching plans, harmonize health systems and set national standards. In the best interests of the country, the federal government can establish the right to primary care for everyone, and back it up with an effective combination of carrots and sticks to make it a reality.
Legislating and implementing the right to primary care will take political courage, the likes of which we haven’t seen since the gritty determination of the late Honourable Monique Bégin, minister of health in the 1970s and 1980s. That was a tumultuous time in health care, marked by doctors’ strikes and an ever-growing presence of user fees and extra billing. Ms. Bégin took on the forces that were eroding publicly funded care when she delivered one of our most iconic and cherished laws: the Canada Health Act.
April 9 marks the 40th anniversary of Parliament’s vote on the Canada Health Act – a landmark bill supported with unanimous consent in the House of Commons, guaranteeing that all Canadians have insurance for medically necessary care. I’m marking that historic day by publishing a book, Health for All: A Doctor’s Prescription for a Healthier Canada. It takes a more holistic view of our health care system than just service delivery. It acknowledges the underlying social, spiritual and political determinants of health. Having offered a remedy for a system fix, I wonder who will consider its road map. Who will have the audacity of Monique Bégin in these troubled times?
Most contemporary politicians are afraid to take on the mammoth task of moving us from an insurance system to a health system for Canada. We know it can’t be done in one election cycle. But some political party, somewhere in the country, will have to put its electability on the line and get started.
It reminds me of the ancient fable about belling the cat. The story goes that a group of mice lived in fear of a cat who might come along and attack them. Together they were convinced that the solution was to attach a bell to the cat’s neck to warn of their enemy’s approach. But none of them had the courage to implement the solution, so they persisted in a state of peril. The moral of the story is that your group can only get so far with a theoretical solution. Someone must have the courage to deliver on the plan.
The path to better health care does not require any further recommendations about how it should be fixed. It requires political leadership that will “bell the cat.” Governing is not theoretical. The job of politicians is to implement actual solutions.
Forty years after the Canada Health Act found its place in our history, we are more than ready for the next act. That act could move us from an inefficient assortment of centres of excellence to a co-ordinated approach with guaranteed access to primary care – a proper system that will restore national pride. Perhaps then we could have the best health care system in the world.