A version of this commentary appeared in the Toronto Star, Winnipeg Free Press and Canadian Healthcare Network 

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What’s next for primary care?


Healthcare is the purview of the provinces in Canada, but health leadership – setting big picture goals, helping achieve best practices across the country and providing long-term, sustainable funding models – is the role of the federal government.  As the federal election campaign wages, Canadians should be pressing federal political parties to take a leadership position on the healthcare file.  Primary care, in particular, could benefit from increased national dialogue.  If we want to improve healthcare in Canada, primary care is a good place to start.

Evidence shows that the best healthcare systems in the world are founded on a strong primary care system – practices of family doctors, nurse practitioners and others who serve as the first (and ongoing) point of contact for patients. Canada has been a world leader in many aspects of primary care for a long time, and the last 10 or 15 years have seen some important changes – mostly for the better. There are more primary care providers than ever before, they are increasingly working in multi-disciplinary teams and more of them use electronic medical records — all factors which are linked to better outcomes for patients.

Not long ago, millions of Canadians said they didn’t have a family doctor. Now in places like Ontario, as many as 94 percent of residents report having a primary care provider. While there is still more progress to be made on even this basic measure of access, there are several other ways we can and should improve primary care in Canada.

1.     Timely access

It is not enough to have a family doctor, you need to be able to see this individual promptly when you are sick. In Canada, only 38 percent of people report being able to see their primary care provider the same day or next day when they call. France, Australia and the United Kingdom all report 50 percent or higher rates, and countries such as Germany, New Zealand and Switzerland hover around 70 percent.

Improving prompt access is critical to achieving continuity of care while reducing the number of people relying on walk-in clinics and emergency departments.

2.     Doctors need to serve communities

We need to move primary care to a population based model — this means a fundamental rethink of how primary care is organized. Perhaps the easiest analogy is public primary and secondary education.  When you move to a new community, registering your children in the local public school is as easy as knowing your address and catchment area. The schools don’t have the choice of picking their students or saying they are ‘too full.’

This new approach should pay particular attention to historically underserved populations, such as those with mental health problems, the homeless, Aboriginal, and individuals at the end of life.

Moving to a population based model of primary care will require a new level of planning and coordination – but it’s doable. We already have examples in several rural communities in Canada, and Community Health Centres in some regions also provide a good model.  Entire countries, like the United Kingdom, have already achieved this.  It should be as easy to find a primary care provider as it is the local public school.

3.     A commitment to equity and improving the quality of care

We need to adopt a relentless commitment to improving quality in primary care. Canadian hospitals already have a couple decades of experience in building the skills, structures and programs to improve care –primary care can build on some of this success.

There are six widely accepted domains of quality — all of them relevant to primary care: safety, timeliness (access), efficiency, patient centeredness, effectiveness, and, importantly, equity.

In Canada, one of our great strengths is the richness of diversity represented across people and geography. It is critical that primary care, the gatekeeper and cornerstone to our health system, treat people equitably. It should not matter where you live, what language you speak, nor your age, sex, sexual identity or cultural background.

4.     Integrate primary care into the rest of the health system

Canada often ranks near the bottom of a dozen Commonwealth countries in patients’ experiences of an integrated healthcare system, including the timely availability of information across provider teams. It is about more than just getting hospital, lab and primary care computer systems connected (although this is a critical part), we need a fundamental redesign from sectors to systems while continuing to strengthen the foundational role of primary care.

Patients don’t experience their healthcare as discrete parts, so it shouldn’t function that way. The responsibility for this change is spread across all parts of the healthcare system and a wide range of healthcare providers.

While acknowledging that primary care looks different across Canada — varying payment models and structures according to the province or territory you live in — these four goals can be a unifying vision for the next, necessary evolution in healthcare.

Joshua Tepper is an advisor with EvidenceNetwork.ca, a family physician at St. Michael’s Hospital and Associate Professor at the University of Toronto.

August 2015

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