Trust as the foundation: thoughts on the Starfield principles in Canada and Brazil

Composition of the committee

Since 2012, the Besrour Centre of the College of Family Physicians of Canada has hosted the Besrour Conferences to reflect on its role in advancing the discipline of family medicine globally. The Besrour Papers Working Group, which was struck at the 2013 conference, was tasked with developing a series of papers to highlight the key issues, lessons learned, and outcomes emerging from the various activities of the Besrour collaboration. For the current Besrour Papers series, a subgroup of Besrour Centre members developed connections with colleagues in Brazil and collaborated to undertake a between-country comparison, comparing and contrasting various elements of both countries’ efforts to strengthen primary care over the past few decades.

Canada and Brazil—on the Starfield journey

Currently, 70% of Canadian health care is publicly funded, with the bulk of that spending being concentrated on physician and hospital services.⁷ Nearly all residents of Canada have universal access to physician and hospital services through public insurance plans. Care is free at the point of service.⁷ When Canadians are sick, they can see a doctor. When they are very sick, they can go to the hospital.

In contrast to the National Health Service in the United Kingdom, care in Canada is not publicly delivered. It is largely delivered privately by physicians functioning as independent contractors and in non-profit hospitals that are not run by governments.

The strength of the Canadian system is that physician care and hospital care are delivered based on need rather than the ability to pay. One of the structures that supports this principle is the fact that family physicians fulfil the role of gatekeepers and navigators. As patient populations have become increasingly complex, team-based models of primary care have begun to proliferate across Canada. These teams aim to provide holistic, interdisciplinary care to fully meet patient and population needs, but they are not universally accessible across the country. For example, in Ontario, 25% to 30% of patients can access team-based primary care.¹⁴ A large proportion of the population still receives their primary care from solo-practice, fee-for-service physicians whose fees are paid by the government, but who function as independent entrepreneurs and who do not have access to the benefits of an interprofessional team.

Brazil developed a universal health care system in the 1980s, 2 decades later than Canada. The Brazilian system is much more decentralized, with municipalities carrying the responsibility for health care management.¹⁵ Unfortunately, in the original design of the publicly funded health care system, family medicine and preventive care were not a priority. Realizing the need for this care, in 1994, the Brazilian government developed the Family Health Program.¹⁵ This marked the transition from a traditional solo-practitioner model to a team-based comprehensive model where primary care is delivered to a population in a defined area. The teams include one family and community doctor, a nurse, a nurse assistant, and 4 to 12 community health workers who serve as the point of first contact for the population, and in most cases teams include a dentist and a dental assistant.¹⁰ To these core teams, the municipalities can also add other professions as needed, such as psychologists, nutritionists, pharmacists, physiotherapists, and others, with federal funding. However, the implementation of these teams has been challenging, and ultimately 40% of the population is without an assigned family health team.¹⁰

Despite their differences, both systems face similar struggles. Access to primary care remains a challenge in rural areas in both countries. Family medicine is better established in Canada than in Brazil but it is only emerging as a distinct and rigorous academic discipline in both countries. Both countries also show an increasing trend toward adopting interprofessional team-based primary care rather than solo-provider models. In Brazil’s case, there has been a statistically significant decline in hospitalizations related to chronic illness such as asthma, diabetes, and hypertension in areas where these teams have been implemented.¹⁶

Public trust: the prerequisite condition for Starfield success

Despite both countries having adopted and embodied the Starfield principles in different ways, primary care in both countries still fails to live up to its full potential (Table 1).¹² We contend that this is in part because there is an additional factor underpinning primary care’s success or failure: trust. To be successful, primary care systems must be constructed to engender trust at both the local and the system levels.

Trust exists primarily at the local level. If patients cannot trust their individual providers, they will not trust the health care system. This trust must be earned, not assumed.

In Canada, this trust manifests itself in unique ways.¹⁷ Patients will refer to their family physicians as “my doctor” and might only undertake medical decisions with input from their personal, trusted physician who helps them navigate the health care system. Patients will commonly return from a non–family physician specialist’s office or a hospital admission for “translation” of the experience by their family doctor.¹⁷ For family physicians to maintain their gatekeeping and navigator role in the Canadian health care system, the maintenance and strengthening of that local trust is paramount. The increasing prevalence of teams, which is largely welcomed across the country by providers, raises the need to think about how trust can be built with teams rather than individuals. This goes hand-in-hand with the Starfield principles of first contact and longitudinality, which are crucial components of successful primary care.

On the other hand, this type of trust is just emerging in Brazil, where only a handful of municipalities have promoted longitudinal relationships with an individual provider based in the community. In general, this degree of trust does not exist with a family physician, but with community health workers. Structurally, there have been considerable challenges to retaining physicians in geographic areas for extended periods of time. Instead, physicians stay in the regions for a short period before moving elsewhere, limiting the opportunity to engender trust at the local level.

A second layer of trust exists at the system level. Simply put, the public must have their expectations met by the outcomes of the system or they will not support it. This relates to the Starfield principles of comprehensiveness and coordination. A well designed system is able to provide patients with timely, responsive, and integrated care, both within the primary care universe and in transitioning people into and out of other parts of the system. These are assumptions resonant in international models of primary care, including the Patient-Centered Medical Home.¹⁸

The public’s trust in the institutions of the Canadian system is maintained in various ways. These include rigorous academic standards for training health care providers, accreditation of organizations by national and international accrediting associations, regulatory bodies that protect the public and ensure competence, and legal and regulatory structures that protect patients from physician profit-seeking.

When trust in the system and its institutions is eroded, collateral pathways are created that are detrimental to system sustainability and population health. In Canada, for example, the perception that it is difficult to find a family physician has threatened an erosion of public trust in the capacity of the system to provide for the needs of the public. This might have contributed to the advent of “concierge family medicine,” where patients are expected to pay often large fees for “concierge” services that give the perception of VIP-style treatment, but that are in fact often linked to harmful overtesting and low-value care.^19–22

In addition, Canadians have high rates of emergency department use, often for “ambulatory-sensitive conditions”—issues that could have been addressed in primary care.²³ A similar phenomenon is seen in Brazil, with patients bypassing primary care and seeking help from urgent care centres unnecessarily because of wait times to see their primary care team. This understandable behaviour reflects a lack of trust in the ability of the primary care system to deliver what patients need, and there are important ramifications for health equity and sustainability for both systems.