Priorities in health system reform

I feel all thin, … like butter that has been scraped over too much bread.”¹ This is an apt description for many family physicians and for the Canadian health care system lately. We are struggling within a system that does not uphold what the Government of Canada calls the right to “a life of equality, dignity and respect.”² We speak of the importance of publicly funded health care, but we are increasingly disheartened knowing that many patients in our communities no longer have timely access to primary care. For those who can access family doctors, both physicians and patients alike are confronted with substantial wait times for care beyond the office, including diagnostic testing, referrals, and procedures.

As CFPC President, I am hearing from colleagues who are distressed by ongoing moral injury stemming from this disconnect: they are suffering psychological strain from seeing aspects of patient care, or lack of care, that go against their values and cannot be explained solely by COVID-19 stressors on our health care systems. Canadian health care systems perform poorly compared with those of other high-income countries: excluding the United States, in a 2021 report we ranked dead last on overall health system performance metrics and health equity.³

Family physicians are leaders in our health care systems and experts in primary care, and governments would be wise to listen to us. It seems clear that we need major reform, and I have heard good solutions posed to help solve our many problems. If funders and policy makers were to listen, what should we prioritize?

To begin, we must make it clear that investing in high-quality primary care—including having patients engage in health promotion and prevention in addition to diagnosis and treatment—has consistently been associated with lower total health care costs in various settings.^4,5 When patients have continuity they tend to be hospitalized or rehospitalized less often, spend fewer days in hospital when they are hospitalized, and have fewer emergency department visits. In a well-functioning system, primary care would have specific funding allocations as a percentage of overall health budgets. Our health systems, commonly hospital-centric, would have accountability metrics relevant to primary care.

What does high-quality primary care look like? It looks like the CFPC’s Patient’s Medical Home vision, which we have been advocating for since 2011. More recent work from the United States demonstrates that there are important commonalities in high-quality primary care across jurisdictions: in 2021 the National Academies of Sciences, Engineering, and Medicine released a report about the future of primary care in the United States.⁶ They defined what high-quality primary care should look like and provided a list of objectives to help with implementation. Their definition refers to providing whole-person care (focusing on health as opposed to absence of disease), accessibility, equity, and accountability by interprofessional teams. Their objectives include paying primary care teams to care for people, rather than paying doctors to deliver services; ensuring that high-quality primary care is available to all, in every community; training primary care teams where people live and work; and designing information technology that serves patients, families, and teams. This sounds like the Patient’s Medical Home vision!

As we seek substantial reform in primary care systems, we must also invest in people. First, recognizing the current crisis, we need substantial retention incentives to support our health work force. Second, we need data: we need a national agency dedicated to understanding our health work force and patient needs in granular form and disseminating that information to all stakeholders. In particular, family physicians have a wide and varied scope of practice; we are not all interchangeable. Finally, we need funders to support teams in designing and staffing high-quality primary care services to meet community needs.

This is not new: at the College we have been saying this in every meeting we are able to have with politicians and other key decision makers. We must keep hammering these points home to anyone who will listen, or soon we will not have a health system. Thank you for all you do.

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