Rebuilding the primary care infrastructure one research project at a time

Diversion of resources

Because there were few decent measures of performance in the primary care sector, public debate focused on what was happening in our hospital system. As a result, resources for the foundation of our health system were diverted to hospitals and specialties, to “sexy” subjects the media would splash across front pages—wait times, ED lineups, and transplants. Governments expanded EDs and funded more specialists; primary care continued to crumble.

This diversion was wrong-headed. Quite simply, fewer people would need such things as heart surgery and hip replacements if excellent primary care were provided. Quadrupling the size of EDs and spending next to nothing on primary care sectors do not solve the problem. Caring for people in the ED who can be cared for in the primary care setting costs much more and the care is not as good. International research shows that countries that do not put their money into the rest of the health care system until their primary care sectors are working properly have better outcomes: their citizens live longer and live better.

When Canada inevitably hit the bottom of the list—along with the United States—with respect to quality of primary care among industrialized nations,⁵ everybody could finally see what was happening. The public was fed up and the government realized that the status quo was unsustainable.

We need to restore balance in the system. Specialists cannot be specialists without family doctors to care for the patient as a whole. Health care systems simply cannot work without a solid, stable foundation of primary care.

Playing catch-up

Efforts are under way to play catch-up with our international counterparts. Indeed, a transformation is required. In the past 10 years, hundreds of millions of dollars have been invested across Canada to reform the primary care sector, from electronic health records to changes in systems of remuneration for family doctors to multidisciplinary team building to accountability requirements. But has this money been well spent? The only way to be sure is through research—studying the effects of increased funding, comparing results from jurisdiction to jurisdiction, and examining the data on patient outcomes.

In 2008, eminent US researcher Dr Barbara Starfield noted the following: “Canada seems to have stalled in its commitment to strengthening primary care. One reason for this lack of movement may be the poor investment in primary care research and evaluation. In this regard, Canada is probably at least 10 years behind.”⁶

Fortunately, this problem is also being addressed—the Canadian Institutes of Health Research (CIHR) has contracted a serious case of primary care–itis. In January 2010, the CIHR’s Institute of Health Services and Policy Research brought together researchers, health care professionals, administrators, and decision makers for a 2-day summit to discuss the state of primary health care research nationally and internationally and to explore innovative models that can be applied in Canada. Twelve months later, the CIHR approved a 10-year research initiative supporting the delivery of high-quality community-based primary health care across Canada.⁷ Its objectives are to develop strong primary health care research evidence, build new research capacity, and increase consideration of research evidence by policy makers. As part of this initiative, the CIHR will soon be announcing $60 million in funding for multisector and interdisciplinary primary health care research and capacity building (CIHR, oral communication, July 2011). This is more than the cumulative amount spent on the primary health care sector by the CIHR since it was created in 2000.

Moving forward

Within months, more opportunities will become available through the CIHR’s Strategy for Patient Oriented Research (SPOR), a plan to improve the research environment and infrastructure; set up mechanisms to train and mentor health professionals and nonclinicians; strengthen organizational, regulatory, and financial support for multisite studies; and support best practices in health care. Primary health care research is one of 2 priority areas targeted by SPOR.

To prepare for the SPOR competition, Canadian primary health care researchers have come together and created the Canadian Primary Health Care Research Network (CPHCRN), which was officially launched on October 3, 2011, in Edmonton, Alta, at the Accelerating Primary Care Conference. By coordinating and enabling multidisciplinary primary care research efforts across the country, the CPHCRN will improve the quality, accessibility, and cost-effectiveness of the Canadian health system. These efforts will be strengthened by the CPHCRN’s strong partnerships with international researchers, all Canadian primary care disciplines, government decision makers, industry, quality councils, funding agencies, health charities, and patients.

Just as the microscope facilitated miracles in understanding infectious diseases, modern information technology tools and new analytical techniques will unlock our understanding of what makes primary health care effective and inform us of what is needed to improve the quality and cost-effectiveness of the entire health care system.

We can now link data from patients and electronic medical records in community-based primary care practices across the country to provincial and national health administrative databases. We finally have the tools and resources to drive our discipline forward, reinforce the underpinnings of Canada’s health care foundation, and rebuild our primary care system. In time, we will catch up with our international counterparts and resume our position in the world as primary care leaders.