Research ArticleReports of Committees

Primary care in the COVID-19 pandemic and beyond

Lessons from Ontario

Danielle Martin, Fahad Razak, Imaan Bayoumi, Azza Eissa, Michael E. Green, Richard H. Glazier, Allan K. Grill, Noah M. Ivers, Derelie Mangin, Elizabeth Muggah, Sarah Newbery, Onyenyechukwu Nnorom, Dominik Alex Nowak, Kamila Premji, Andrew D. Pinto, Jennifer Rayner, Janet Smylie and Tara Kiran
Canadian Family Physician January 2025; 71 (1) 31-40; DOI: https://doi.org/10.46747/cfp.710131

Abstract

Objective To understand the role of primary care in the COVID-19 pandemic to provide insight into its functioning and inform potential reforms.

Composition of the committee The now dissolved Ontario COVID-19 Science Advisory Table (Science Table) was formed in July 2020 to provide decision makers and the public with a synthesis of rapidly evolving evidence related to COVID-19. The Science Table was based at the Dalla Lana School of Public Health at the University of Toronto, and supported by Public Health Ontario.

Methods Authors worked with the leadership and secretariat of the Science Table to synthesize evidence and inputs. Authors drew on their expertise in research, policy, and front-line care delivery and coupled this with data analysis and reviews of the literature relevant to the topic areas discussed. Data analysis and literature reviews were done with the support of the Ontario Medical Association, the INSPIRE–Primary Health Care research program, and the Department of Family and Community Medicine at the University of Toronto. Experts conducted a rapid review of the briefs prior to publication, and authors presented the briefs’ content at a series of meetings attended by Science Table members for their input. As Science Table briefs were intended to provide rapid-response answers to important health system questions in real time, the intent was not to conduct a systematic review but rather to gather available relevant evidence and present it in a form that could be used by policy-makers.

Report This summary describes the work of primary care during the COVID-19 pandemic in Ontario up to September 2022; outlines current challenges in primary care capacity and structure; and makes recommendations for strengthening the sector to better address population needs for current and future public health priorities. While the focus is on Ontario, many of the findings are relevant to other jurisdictions in Canada and elsewhere.

Conclusion Universal formal attachment to an accountable interprofessional primary care team supported by adequate infrastructure should be the cornerstone of pandemic recovery planning.

Primary care is the foundation of high-performing health systems and a critical sector in effective pandemic and health emergency preparedness, response, and recovery. It is also essential for the provision of people-centred care in communities and optimal population health. Family doctors’ offices, interprofessional teams, and nurse practitioner–led models were critical entry points into care related to both COVID-19 and non–COVID-19 in Ontario throughout the pandemic, but human resources and systemic challenges strained the capacity of the sector to respond.

Lessons learned from the COVID-19 pandemic about the resilience, strengths, and challenges of the primary care sector are crucial to understand and document, not only in anticipation of future public health emergencies but also for the general functioning of the health care system. In that spirit of learning, on October 3, 2022, as its last brief before being dissolved as an independent advisory, the Ontario COVID-19 Science Advisory Table (Science Table) released its final and largest evidence brief: a 3-part series on primary care and its role in the pandemic response in Canada’s most populous province. The Science Table was a group of independent scientific experts tasked with providing advice to Ontario decision makers on scientific issues related to the COVID-19 response. The Science Table’s role evolved over the course of the pandemic, shifting from providing weekly technical updates to weighing in on complex issues such as vaccine distribution and school closures.

The objectives of the 3 briefs are outlined below. Each part of the series sought to answer a set of key questions. In this report, a subset of the authors of the briefs summarized key findings of this important topic. The 3-part brief can be downloaded free of charge from the Science Table COVID-19 Advisory for Ontario website: https://covid19-sciencetable.ca/brief-category/epidemiology-public-health-implementation.

Brief 1 described the roles of primary care clinicians and practices in the first 2 years of the COVID-19 pandemic in Ontario.

  • In what ways have the workloads of primary care clinicians (PCCs) changed during the COVID-19 pandemic?

  • What has been the role of PCCs in the COVID-19 test, trace, isolate, and support response?

  • What has been the role of PCCs in COVID-19 vaccination efforts?

  • What has been the role of PCCs in delivering ongoing non–COVID-19 care during the pandemic?

  • How has virtual care been used by PCCs during the pandemic?

Brief 2 identified factors affecting primary care capacity in Ontario for pandemic response and recovery.

  • In what ways do current trends in health human resources (HHRs) for primary care affect primary care provision?

  • In what ways can different models of primary care support pandemic response and recovery?

  • How can infrastructure support coordinated and integrated primary care moving forward?

Brief 3 identified and shared lessons learned for strengthened primary care in the next phase of the COVID-19 pandemic.

  • What are the lessons learned with respect to primary care for the next phase of the pandemic?

  • What are short- and long-term recommendations informed by these lessons?

Composition of the committee

The Science Table was formed in July 2020 to provide decision makers and the public with a synthesis of rapidly evolving evidence related to COVID-19. The Science Table was based at the Dalla Lana School of Public Health at the University of Toronto, and supported by Public Health Ontario. Science Table leadership asked Dr Danielle Martin to lead the development of scientific briefs summarizing the impact of the COVID-19 pandemic on primary care in Ontario and key lessons learned. This evolved into the creation of 3 primary scientific briefs.1-3 She and the lead authors invited collaborators to participate based on their expertise regarding primary care in Ontario and their involvement in pandemic-related leadership from a primary care perspective. Geographic and professional diversity as well as a range of lived experiences and community perspectives were taken into account.

No sponsorship, grants, or other financial support was provided to the authors. A full list of authors and their affiliations is detailed in the Appendix, available from CFPlus.*

Methods

The authors worked with the leadership and secretariat of the Science Table to synthesize a range of evidence and inputs. The authors drew on their expertise in research, policy, and front-line care delivery and coupled this with data analysis and reviews of the literature relevant to the topic areas discussed. Data analysis and literature reviews were done with the support of the Ontario Medical Association, the INSPIRE–Primary Health Care research program, and the Department of Family and Community Medicine at the University of Toronto. Experts conducted a rapid review of the briefs prior to publication, and authors presented the briefs’ content at a series of meetings attended by Science Table members for their input. As Science Table briefs were intended to provide rapid-response answers to important health system questions in real time, the intent was not to conduct a systematic review but rather to gather available relevant evidence and present it in a form that could be used by policy makers.

Report

Health systems with a strong foundation of primary care produce better outcomes, more equitably4 and at lower cost.5 Internationally6 and in Canada,7 PCCs have played an integral and multifaceted role in pandemic response; but a lack of infrastructure, under-investment in teams, and a human resources crisis now threaten the ability of Canada’s health systems to meet the primary care needs of its population.

In this summary,1-3 we describe the work of primary care during the pandemic in Ontario up to September 2022; describe current challenges in primary care capacity and structure; and make recommendations for strengthening the sector to better address population needs for current and future public health priorities. While our focus is on Ontario, many of our findings are relevant to other jurisdictions in Canada and elsewhere.

What is the state of primary care in Canada and Ontario? While individual countries classify expenditures differently, Canada under-invests in general and preventive care compared with other Organisation for Economic Co-operation and Development nations as a proportion of total health expenditure (Figure 1).8 Most Canadian jurisdictions do not have a coordinated primary care system; rather it is a sector characterized by inadequate and poorly distributed HHR capacity, high variation in models of care delivery, and an absence of infrastructure for communication, coordination, and integration. Despite these challenges, on any given day, twice as many Ontarians access a primary care physician than specialist services (Figure 2).9-13

Figure 1.
Figure 1.

Spending on primary health services as share of current expenditure on health, 2018

Figure 2.
Figure 2.

Ecology of health care in Ontario: Average number of health services accessed each day (Ontario 2019-2020). Values rounded to the nearest thousand with the exception of hip and knee replacements, which were rounded to the nearest 10.

Primary care practices in Ontario include a range of practice and remuneration models. Most Ontarians are served by physicians practising either alone or in physician-only groups. Some are paid predominantly through fee-for-service models while others through capitation; there are only a few salaried models in the province. About one-quarter of Ontarians have access to an interprofessional primary care team.14-17 There is no easily accessible central registry of PCCs or clinics, which impairs communication. There are also no formal governance structures at the regional level, although this may one day be addressed by the emerging structure of regional Ontario Health Teams, which is a new approach to care organization and delivery, aiming to better connect patients with services in their local communities to ensure all Ontarians can access well-coordinated, integrated care.18 Data from electronic medical records are not routinely shared across practices for quality improvement, research, or health system planning. However, there is no strategy or related mechanisms to ensure universal attachment (ie, ensuring every person in Ontario has a primary care clinician or team they can see for timely, ongoing care).

What was the role of PCCs during the pandemic? During early pandemic response, PCCs prioritized COVID-19 and deferred nonessential care across Canada. Any COVID-19 responsibilities were often performed in addition to ongoing routine work. Across all major family physician payment models in Ontario the number of days worked substantially increased (unpublished data, Ontario Medical Association, 2022).

Virtual care, mostly via telephone,19 increased with the advent of new billing codes, and total visit volumes returned to prepandemic levels within 6 months (Figure 3).20 Clinician and patient virtual care satisfaction was high. By March 2022, 46% of care continued to be delivered virtually. While high use of virtual care within established practices was not associated with increased emergency department visits,20 use of virtual-only corporate models of care was associated with increased emergency department use.21

Figure 3.
Figure 3.

Weekly primary care visits by type from January 2019 to March 2022 in Ontario

Various pandemic responses were supported by PCCs, although poorly integrated into their daily work. Multiple barriers prevented widespread COVID-19 assessment and testing within primary care offices, including concerns for patient and staff safety, physical space constraints, workflow, billing issues, and in the first few months, availability of testing kits and personal protective equipment.22

Similarly, mass vaccination efforts were supported by PCCs but not widely integrated into primary care settings (Figure 4). This is in contrast to the United Kingdom where more than two-thirds of vaccinations were delivered in primary care offices.23 There were several barriers to integrating vaccinations in primary care, from segregated information technology systems to multidose vaccine vials and more.22 In contrast, care and treatment for COVID-19 patients in the community was successfully integrated into primary care workflows.24 As of September 2022, approximately 85% of nirmatrelvir-ritonavir prescriptions dispensed at a pharmacy were prescribed by a PCC (email communication with Dr Daniel Warshafsky, Office of the Medical Officer of Health, September 9, 2022).

Figure 4.
Figure 4.

COVID-19 vaccinations in Ontario by delivery channel stratified by public health unit: Data received via personal communication with Dr Daniel Warshafsky on August 11, 2022; and from INSPIRE–Primary Health Care (unpublished data).

A historic mobilization of resources by community-based organizations with PCCs from equity-deserving backgrounds, public health units, and hospitals was undertaken to support assessment, treatment, care and vaccination in structurally marginalized communities.

First Nations, Inuit, and Métis (FNIM)25; Black26 PCCs; and allies formed new and innovative collaborations to address vaccine hesitancy and health system mistrust to provide culturally safe COVID-19 assessment, care, and immunization to communities both in urban and rural settings. In a notable example, 42,000 vaccine doses were given in 31 remote fly-in FNIM communities and Moosonee in northern Ontario.27 Primary care clinicians also supported pandemic response in shelters and among people who were incarcerated, undocumented residents, migrant workers, and elderly people living in long-term care, retirement homes, or at home.28

Although ongoing non–COVID-19 PCC care continued, aspects such as infant immunizations were maintained, while preventive cancer screening (Figure 5A) and some chronic condition care lagged behind (Figure 5B).29 Equity-related cancer screening gaps were a concern prepandemic and it is unclear if these gaps widened during the pandemic. Precipitating factors include government direction to defer preventive care and care for people with stable disease, patients opting to delay care, and PCC accessibility. The population-level health impacts of these choices are not yet known. Fortunately, restoration is under way.30 In Ontario, testing volumes for Papanicolaou tests, fecal immunochemical tests, and mammograms rose by 32%, 52%, and 15%, respectively when comparing winter 2021-2022 with prepandemic levels in 2019.30

Figure 5.
Figure 5.

Preventive care during the pandemic: A) Changes in the proportion of eligible Ontario residents who are up to date with cervical, breast, and colorectal cancer screening. Unpublished analysis of ICES data from INSPIRE-PHC. B) Changes in percentage of Ontario patients with diabetes or hypertension who had at least 1 in-person visit to a physician within their group in the past 12 months from October 2018 to April 2022. Unpublished analysis of ICES data from INSPIRE-PHC.

What is the capacity of primary care today? Canada faces a profound mismatch between the size and distribution of the primary care workforce and population needs. As of March 2022, approximately 2.2 million people in Ontario were either completely unattached or only loosely connected to primary care31 and a survey from fall 2022 estimated more than 6.5 million people in Canada did not have a family physician or nurse practitioner.32 These needs are not equitably distributed; FNIM, new immigrants, and people living with low incomes are less likely to be attached. The situation is poised to worsen owing to an increase in physicians stopping work early during the height of the pandemic33 and a substantial proportion of the population attached to a family physician 65 years or older who is nearing retirement.34

These physicians will not be replaced easily: among Canadian graduates, the Canadian Resident Matching Service reported a decline in the number of medical students ranking family medicine as their first choice of residency, from 38.5% in 2015 to 30.7% in 2022—the lowest since 2008.35 In 2022, more than 200 family medicine spots (15.7%) remained unfilled in the first round of residency matching compared with 85 (6.4%) in 2015. In addition, an increasing proportion of Ontario family physicians is shifting away from comprehensive practice to focused practices, such as emergency medicine, sports medicine, or palliative care.36 The overall proportion of Ontario family physicians providing longitudinal care to a group of patients dropped from 74.9% in 2002-2003 to less than 70% in 2014-2015.36 Similar trends were observed in other provinces.37

Among the reasons for shifting away from comprehensive primary care is the increasing work complexity (eg, operating an office practice). The average PCC would have to use 26.7 hours of each 24-hour day to provide the services recommended by clinical practice guidelines relevant to primary care.38 The College of Family Physicians of Canada reports the rate of burnout among family physicians tripled in 2021 compared with the previous year, with 51% of family physicians indicating they were working beyond capacity.39 This complexity is exacerbated by a lack of administrative and operational supports. A 2021 Canadian Medical Association survey found nearly half (45%) of all family physicians surveyed spend, on average, 10 to 19 hours per week on administrative tasks.40

In Ontario, access to team-based care did not expand between 2011 and 202315 despite evidence that teams improve patient outcomes, enhance clinician joy at work, and have the potential to increase PCC capacity. In response to COVID-19, interprofessional primary care teams inherently had more flexibility and resources to meet the needs of their patients and communities. Unfortunately, access to teams is inequitably distributed in Ontario and does not align with needs.41 Patients living in urban areas, new immigrants, and those who are more sick are less likely to be in a family health team, the predominant team-based model.42 Figure 6 demonstrates that access to team-based care is highly dependent on where one lives.43 These trends in the size and distribution of the workforce are particularly concerning given the health care needs of an aging, growing population with increasing rates of multimorbidity.

Figure 6.
Figure 6.

Percentage of patients not attached to family health teams by region

How can we ensure we learn from the pandemic experience in primary care? The following suggestions are based on analyses of detailed data from Ontario, but can be applied to all of Canada and beyond. Regional primary care HHR plans that are data-driven, clinician-informed, and equity-oriented are urgently needed to address widening gaps in access to primary care. These should include training and integrating more primary care nurse practitioners and physician assistants, and other interprofessional PCCs, into practices; providing supports and incentives to encourage new PCC graduates to enter comprehensive practice and current PCCs to stay in practice; and identifying appropriate accountability levers to ensure additional resources open up care for a greater number and complexity of patients.

As the traditional workforce contracts, advancement of team-based primary care can be paired with clear expectations and accountability for access, equity, and continuity at the team and individual levels. Nurse practitioners, physician assistants, mental health workers, pharmacists, nurses, social workers, and other health professionals linked to every practice are especially critical to address population needs. Regulated team members could also be coupled with nonregulated health workers who can assist with administrative burden (such as care coordinators, system navigators, scribes, and medical office assistants) or build equity and cultural safety (such as link workers, community health workers, and peer ambassadors). In rural areas, team members capable of supporting PCCs virtually might be recruited to work remotely if necessary.

While virtual care has been helpful in sustaining relationships between patients and primary care team members, it can detract from the goal of comprehensive primary care when delivered through services decoupled from a primary care team providing longitudinal care. Clear guidance that builds on early work aimed at PCCs and the public about where virtual care should (and should not) be used is needed. Professional colleges should provide clear guidance and policies on how best to balance access and quality of care.

The need for primary care networks that are better connected has never been more clear: Amid a public health emergency, it is unacceptable that regional health leaders were unable to connect with all local PCCs. Contact information should be provided through professional colleges to key health services and public health organizations to be used for coordinating regional health efforts.

Backlogs for specialist and diagnostic test appointments create stress for patients and coordination burdens on primary care. Enhanced implementation supports for electronic consult and referral, and other local solutions to enhance system integration and access to specialized care in an organized manner can help, as can evidence-based initiatives to reduce wait times, such as centralized intake and triage for specialist and diagnostic appointments at the regional or provincial level.44

Partnerships with local hospitals have been useful to ensure appropriate access to personal protective equipment and Infection Prevention and Control Canada advice in primary care.45 These collaborations can also support regional efforts to improve care integration, along with other community partners. With the pandemic transitioning to an endemic phase, COVID-19–related work—including vaccination, testing, COVID-19 care, and management of long COVID-19—can take its place alongside other aspects of routine work. However, this shift will require an ongoing commitment to fund and support primary care teams appropriately, including creating infrastructure that supports quality improvement and community outreach.

Coordination cannot be achieved without a holistic approach to data collection and governance in primary care. Provincial leaders should create infrastructure allowing practices to contribute to provincial data holdings and all PCCs should be provided with practice data to help them improve care. This will require electronic medical record vendors to provide real-time data free of charge for use in quality improvement, research, and system oversight. The eventual goal should be interoperability so there is 1 digital health record for each patient (this is being pursued in the European Union).46 Without these solutions and resources, burnout will remain a huge risk to the primary care specialty.

Conclusion

In the words of World Health Organization Director General Dr Tedros Adhanom Ghebreyesus, “Primary health care is where the battle for human health is won and lost.”47 Universal formal attachment to an accountable interprofessional primary care team supported by adequate infrastructure should be the cornerstone of pandemic recovery planning, both in Ontario and around the world.

Acknowledgment

This work is based on 3 reports produced for the now dissolved Ontario COVID-19 Science Advisory Table. We acknowledge and thank the full list of contributors to those briefs. Some of the data and analysis were conducted at ICES, which is funded by an annual grant from the Ontario Ministry of Health (OMoH) and Ministry of Long-Term Care and produced by the INSPIRE–Primary Health Care (INSPIRE-PHC) Research Program funded through the Health Systems Research Program of the OMoH. The opinions, results, and conclusions reported in this report are those of the authors and are independent of the funding sources. No endorsement by ICES, the OMoH, or the Ministry of Long-Term Care is intended or should be inferred. We thank Eliot Frymire, Fangyun Wu, Kirsten Eldridge, and Marisa Schwartz for assistance with figures; and Dr Daniel Warshafsky and the teams at INSPIRE-PHC and the Canadian Institute for Health Information for the provision of data. We also thank Tharani Jeyaram and the DFCM Research Program at U of T for support throughout the process of editing and formatting.

Notes

Editor’s key points

  • ▸ Primary care was and remains a critical entry point to both COVID-19 and non–COVID-19 care.

  • ▸ Despite fixed resources, primary care clinicians played an important role in the pandemic response by testing, treating, vaccinating, providing wrap-around supports, and maintaining and restoring non–COVID-19 care.

  • ▸ Canada faces a profound mismatch in the size and distribution of the primary care workforce and population needs.

  • ▸ Realizing a vision of primary care for all will require the expansion of team-based care and other supports to increase clinician capacity, improved integration with hospitals and other sectors, and robust health human resource planning.

Points de repère du rédacteur

  • ▸ Les soins primaires étaient et demeurent un point d’entrée essentiel vers les soins liés à la COVID-19 et les autres soins.

  • ▸ Malgré leurs ressources fixes, les cliniciens des soins primaires ont joué un rôle important dans la réponse à la pandémie en procédant au dépistage, au traitement, à la vaccination et à la prestation de soutiens connexes, de même qu’en maintenant et en rétablissant les soins non liés à la COVID-19.

  • ▸ Le Canada est aux prises avec un profond décalage entre la taille et la répartition des effectifs en soins primaires et les besoins de la population.

  • ▸ La concrétisation d’une vision de soins primaires pour tous exigera l’expansion des soins en équipe et des autres soutiens dans le but d’augmenter la capacité des cliniciens et d’améliorer l’intégration avec les hôpitaux et d’autres secteurs, et une robuste planification des ressources humaines du secteur de la santé.

Footnotes

  • ↵* The Appendix is available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.

  • Contributors

    Dr Danielle Martin drafted the initial analysis paper with substantial guidance and input from Drs Fahad Razak and Tara Kiran. The full author group led the data collection, analysis, and interpretation of the Science Briefs that formed the foundation of the manuscript with input from the rest of the authorship team. Dr Michael E. Green also contributed to data collection and the figures. All authors revised the analysis paper critically for important intellectual content and approved the final version. Extensive work on references and figures was led by Dr Kiran. International unpublished data were provided by Drs Kiran and Green. Robust revision and feedback were incorporated by Dr Martin with oversight and support from Dr Kiran. All authors revised the parts of the analysis on which they are named for critically for important intellectual content.

  • Competing interests

    Dr Danielle Martin is Professor and salaried Chair of the DFCM at U of T. Dr Fahad Razak was Scientific Director of the Ontario COVID-19 Science Advisory Table. He holds a salary award as Canada Research Chair in Data Informed Healthcare Improvement at U of T and is a salaried part-time employee of Ontario Health. Dr Razak has also received grants (outside the current article) to study COVID-19 from the Canadian Institutes of Health Research (CIHR), Canadian Frailty Network, U of T (including the Department of Medicine, St Michael’s Hospital, and the Sunnybrook Health Sciences Centre), the Digital Research Alliance of Canada (Data Champions Pilot Project), and the Royal College of Physicians and Surgeons of Canada. Dr Dominik Alex Nowak is an Assistant Professor in the DFCM and the Dalla Lana School of Public Health at U of T. He has received honoraria or consulting fees from Alliance for Healthier Communities, Canada Health Infoway, Centre for Effective Practice, the Ontario College of Family Physicians, the Ontario Medical Association, and TELUS. Dr Kamila Premji receives salary support as the Junior Clinical Research Chair in Family Medicine at the University of Ottawa and as a PSI Knowledge Translation Fellow. She has received honoraria and consulting fees from the Centre for Effective Practice, the Ontario College of Family Physicians, the Ontario Medical Association, and the Kids Come First Ontario Health Team. She has received research support from the CIHR, PSI, the OMoH, INSPIRE-PHC, the Institut du Savoir Montfort, and the University of Ottawa Department of Family Medicine. Dr Andrew D. Pinto is supported as a Clinician Scientist by the DFCM at U of T, St Michael’s Hospital, the Li Ka Shing Knowledge Institute, and a CIHR Applied Public Health Chair. Dr Sarah Newbery is Assistant Professor and Associate Dean of Physician Workforce Strategy at NOSM University. She is a past president of the Ontario College of Family Physicians and has received honoraria for that work. She is a current member of the Ontario Medical Association Physician Human Resources Committee for which she received an honorarium. Dr Richard H. Glazier’s salary is derived from ICES, the MAP Centre for Urban Health Solutions, and the CIHR. He has received grant support from the CIHR, OMoH, and Ontario Health. Dr Tara Kiran is the Fidani Chair of Improvement and Innovation in Family Medicine at U of T. She is also supported as a Clinician Scientist by the DFCM at U of T and at St Michael’s Hospital.

  • This article has been peer reviewed.

  • Cet article a fait l’objet d’une révision par des pairs.

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Primary care in the COVID-19 pandemic and beyond
Danielle Martin, Fahad Razak, Imaan Bayoumi, Azza Eissa, Michael E. Green, Richard H. Glazier, Allan K. Grill, Noah M. Ivers, Derelie Mangin, Elizabeth Muggah, Sarah Newbery, Onyenyechukwu Nnorom, Dominik Alex Nowak, Kamila Premji, Andrew D. Pinto, Jennifer Rayner, Janet Smylie, Tara Kiran
Canadian Family Physician Jan 2025, 71 (1) 31-40; DOI: 10.46747/cfp.710131
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