Public priorities for primary care in Canada

Composition of committee

OurCare is the largest ever national effort to engage the public about the future of primary care in Canada.¹³ As part of OurCare, we hosted a series of 5 reference panels conducted in 2023 in Nova Scotia, Quebec, Ontario, Manitoba, and British Columbia. Each reference panel included 28 to 35 members of the public (panelists) who were randomly selected to represent the geography and demographic characteristics of their province, with overweighting of specific equity-deserving groups (Figure 1 and Table 1).¹⁴ Members volunteered their time but received funds to offset relevant costs such as child care, Internet, devices, and lost wages.

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Figure 1.

Geographic distribution of members of the public who participated in the OurCare reference panels

Report

What do people in Canada feel are the pillars of primary care? Figure 3 summarizes the values identified by 5 panels as foundational to the primary care system. Accessibility was a consistently articulated value closely related to equity. Panelists felt that everyone in Canada should have equitable access to publicly funded primary care when, where, and how they need it. Care should be free of barriers and discrimination, inclusive by design, and responsive to the diverse needs of patients, regardless of their ability, background, location, or socioeconomic status. They defined equitable care as care that is destigmatized, anti-oppressive, and culturally responsive; care that acknowledges the role of power, privilege, and prejudice; and care that addresses the social determinants of health.

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Figure 3.

Values to guide primary care renewal as identified by members of the public in each of the 5 provincial reference panels

Panelists in all provinces underscored the importance of a prevention-focused, wellness-promoting primary care system that aims to address health problems before they occur. Panelists highlighted the need for a holistic health care system, which they defined as care that focuses on a person’s overall well-being; addresses the physical, mental, spiritual, and social needs of patients; and provides care in the context of patients’ communities. Panelists believed the health care system should also be sustainable, equipped to handle changing and growing population needs, and support patients’ long-term well-being.

Accountability was also an important value described by 4 provincial panels: panelists emphasized the importance of trust and transparency at both the clinician and system levels. They described an accountable primary care system as one with clear standards of care co-designed with patients, and health system outcomes that are clearly defined, measured, and publicly reported.

Panelists also consistently articulated values of patient-centred care using the terms considerate, understandable, empathic, and respectful. They wanted patients to be empowered to be active partners in their care and informed of their rights and care options. They conveyed that clinicians should listen to patients and respect their unique knowledge, lived experience, values, and needs, and customize care accordingly.

What key challenges should be addressed? In all 5 provinces, panels identified 3 major challenges affecting primary care systems: a growing human health resource crisis, inequitable access to care, and fragmented care (where continuity of care is not prioritized). In addition, several panels spoke about the need to address outdated and fragmented health information systems, a lack of patient empowerment, and the lack of long-term planning and accountability. One panel (Quebec) also flagged that the quality of care in the publicly funded system was being undermined by the growing presence of for-profit care delivery and care options requiring out-of-pocket payment.

What recommendations were consistently voiced by members of the public? We identified 7 cross-cutting themes from the 5 reference panel reports (Table 2).

   Health professional retention and recruitment: All panels recognized the importance of improving working conditions for family physicians and other primary care professionals. Some panels specifically cited the importance of addressing administrative burdens that reduce 1-on-1 time with patients and contribute to burnout for clinicians. Three panels had creative suggestions for enhancing recruitment and retention of primary care professionals, from advertising campaigns to student incentives, and expansion of grassroots initiatives. Four panels recommended accelerating integration of internationally trained primary care professionals into the workforce.

   Team-based care for all: All panels strongly recommended expanding team-based care, recognizing it as a way to address clinician burnout, improve access, and provide more comprehensive care. In British Columbia and Manitoba, panels specifically recommended expanding community health centres and access centres, which are community-governed team models. Three panels explicitly recommended starting the expansion of teams in areas of greatest need. Nova Scotia made specific suggestions to integrate specialists into primary care teams; Ontario and British Columbia recommended organizing care akin to the public school system; and Ontario suggested a move toward “automatic rostering” where health teams are mandated to accept any patient from their catchment, with provisions for patient choice.

   Patient-held health record: All panels were clear that patients should have easy access to their own medical records with provisions in place to ensure the privacy and security of patient data. Some panels suggested a common data standard to enable interoperability, and that patient data should only be used for purposes related to health care provision and not for commercial purposes (eg, selling to third parties). Nova Scotia spoke about extending their hospital-based provincial “One Person One Record” initiative to include primary care and other health professionals such as pharmacists, physiotherapists, and dentists; and recommended supports and incentives to encourage professionals to use the platform.¹⁵

   Virtual and mobile care: Four panels recommended expanding virtual and mobile care options to enhance access in rural and remote communities and for those with mobility challenges. Three panels were explicit that virtual care should only be provided as a part of a continuum of longitudinal care that includes in-person care and not as a stand-alone care modality. They wanted to see investment in infrastructure to make virtual care more accessible, including providing affordable and reliable Internet and using public places (eg, libraries) as access points. Panelists were clear that virtual care should not replace in-person care if in-person care is requested and feasible.

   Diversity and inclusion: Three panels recommended clinicians be trained in cultural safety and humility, and in anti-discrimination behaviour. Two panels wanted to see more health professional recruitment of Indigenous, northern, and other historically excluded communities. Two panels made recommendations to integrate Indigenous perspectives in training and care, while another recommended community perspectives be integrated into resident curriculum development. Manitoba specifically included an entire section of recommendations dedicated to improving primary care for Indigenous peoples.

   Patient empowerment and transparency: All panels included recommendations to strengthen community involvement in primary care policy, planning, and evaluation; education of the public on their rights and the value of primary care; and measurement and public reporting on the primary care system, including research on the impact of reforms. Panelists also had a range of recommendations to support education and empowerment, including creating a “train the trainer” campaign, collaborating with filmmakers, and developing a primary care charter that clarifies the rights and expectations of patients.

   Upstream action: Panelists recognized that health and well-being require more than the physician and hospital visits currently covered through provincial insurance plans. Four panels recommended expanding public coverage to include mental health, vision, dental, physical therapy, and medications—or to remove related financial barriers. All panels recommended addressing the social determinants of health, with some calling for stronger links between primary care and community agencies to address issues like employment, housing, and poverty. Panelists in Nova Scotia recommended primary care clinics adopt social prescribing, while in Manitoba panelists wanted a social worker or community resource worker as a full-time member of the health care team.

What are some potential next steps? Members of the public from diverse backgrounds and life experiences across Canada strongly endorsed publicly funded, accessible primary care for all. Recommendations from the provincial reference panels, along with the results from the OurCare national survey and community round tables, have been distilled into the OurCare Standard, which are 6 statements summarizing what every person should expect from their primary care system (Figure 4).¹⁴ Our aim is for the OurCare Standard to be used by health system leaders to guide meaningful change in line with patient values and priorities.

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Figure 4.

The OurCare Standard

Table 3 summarizes actions that can be taken by different actors in the system. Three areas of policy change are particularly actionable by governments. First is growing the primary care workforce. This includes increasing availability of primary care–specific training for a range of professionals and accelerating integration of internationally trained health care workers. It also means making primary care more attractive to those in practice; for example, through better remuneration relative to other specialties and decreasing administrative burdens.

Second, Canada can do more to harness the potential of interprofessional teams to improve primary care capacity. The 2023-2024 bilateral agreements are a step in the right direction,¹⁶ but Canada needs more federal investment in team-based care together with clear metrics and accountability linking provincial funding to the goal of primary care access for every person in Canada. Provincial governments should support more community-governed teams oriented to serving whole populations and ensure team funding incentivizes collaboration both within teams and between primary care and other parts of the health system.

Third, action is needed to ensure both patients and clinicians have access to patients’ health records, no matter where they were cared for previously. Federal and provincial governments should implement recommendations from the Canada Health Infoway’s Shared Pan-Canadian Interoperability Roadmap.¹⁷ This includes strong federal legislation to enforce interoperability and prevent information blocking, and a tough stance on vendors who refuse to cooperate.

Family physicians also play an important role in advancing the public’s vision for better primary care. Many are doing so already and specific actions will vary based on provincial and local context, as well as available resources. For example, there may be opportunities for family physicians to collaborate with other practices and stakeholders in their community to consider how pooled resources could collectively serve more patients. Practices can also work together to provide more comprehensive and shared after-hours coverage. Clinic spaces should be accessible, virtual care should be an integrated offering, and clinicians should support patients who wish to access their own records (where feasible). Clinics can collaborate with community agencies to address the social determinants of health and educate patients to better care for themselves and navigate the health care system.

Building a primary care system aligned with public values will require additional investment. We need a robust public dialogue to understand how much more people in Canada are willing to pay for better publicly funded health care, where these funds could come from, and potential trade-offs, whether or not these investments are made. We need to sustain the type of public engagement modelled in the OurCare initiative to ensure the system we have meets the needs and priorities of those it is meant to serve.