More than 15% of Canadians lack access to appropriate and effective primary care.1 That is roughly 6.5 million Canadians who do not have a long-term relationship with a dedicated family physician who knows their needs and manages their care over time. The lack of access to primary care practitioners is symptomatic of a broader health workforce shortage. The typical solution to shortages is to produce more, but the reality is we will never be able to train enough family physicians to meet the growing needs.2 If family physicians want to remain core to primary care, we must re-examine what we do, how we do it, and who we can work with to ensure that everyone gets the care and health outcomes they deserve.
The College of Family Physicians of Canada’s Patient’s Medical Home vision promotes team-based primary care as a solution to the crisis.3 But team-based primary care is still met with apprehension and relies on conventional individual services in clinical settings. When millions of Canadians have no one to manage their blood pressure or diabetes, no one to screen their toddler or give vaccines, no one to do cancer screening or offer smoking cessation, what is our response? Are there other ways to deliver these services?
The 4 principles of family medicine describe family physicians as skilled clinicians who uphold the importance of the doctor-patient relationship and serve a defined practice population through community-based work and service.4 Nowhere in those 4 principles does it state that family physicians must provide all primary care services on their own. It can be hard for family physicians not to feel threatened when primary care is thrust into larger and more complex teams, where sharing tasks, working in complementary ways, delegating care even beyond our direct reach, and sharing responsibility are the norm. It is hard not to feel threatened when we are losing some control.
What could the role of the family physician look like if we reduced that threat and enabled others to carry out some of the work? What might care look like if the fullness of primary care could be optimized for all Canadians?
Broadening our thinking of team-based care: the historical role of paraprofessionals
Nearly 60 years ago, Hill District in Pittsburgh, PA, solved a health care crisis by inventing a new kind of health worker.
In the late 1960s, ambulance care in North America was largely provided by police or local funeral homes. Paramedicine, as we know it today, did not exist. In Hill District, a predominantly Black, marginalized, and economically depressed community, locals were appropriately reluctant to call police when faced with a health care issue. That reluctance became even more severe when medical emergencies, such as gunshot injuries and drug poisonings, intersected with law enforcement. Inequities and avoidable deaths were the norm.5,6
The solution was to position locals who were deeply invested in the Hill District community as health care responders. Freedom House Ambulance Service recruited an all-Black team of local residents to train as paramedics, regardless of their background, employment history, or education. The program trained them to an unprecedented standard of care, effectively inventing what we now recognize as civilian paramedicine. Launched in 1967, Freedom House responded to nearly 5800 ambulance calls in its first year, and brought much-needed empathy, community engagement, and antiracism to every call, alongside essential emergency health care interventions.6
The solution in Hill District was not to train more doctors or nurses, nor to incentivize them to work in underserved communities, nor to create local ambassador programs to improve relationships with police. The key was to identify the specific health care needs and concerns of the community and consider who would be best positioned to deliver those services. They deliberately redistributed health care tasks to workers with less training, to people already embedded locally with community relationships and alternate skill sets. The solution was in task sharing.7
What lessons can the Freedom House Ambulance Service teach us amid Canada’s primary care crisis? Task sharing can address some aspects of the crisis by redistributing the delivery of some health care services to trained community members. It highlights the opportunity to look beyond conventional regulated health care professionals such as nurses, pharmacists, and doctors—all of whom are part of the health workforce shortage.
Across all regions and communities and income levels, task sharing strategies have been shown to improve outcomes for the most pressing health challenges of our time: treating diabetes and chronic disease, improving mental health, increasing immunization uptake, preventing communicable disease, providing sexual and reproductive health care, improving nutrition, and providing care to elderly patients.8-12 We have frameworks for task shifting implementation, evaluation, and policy analysis.13,14 Perhaps most importantly, we have evidence that task sharing can deliver better health equity and reduced costs15,16—2 of the most challenging and elusive goals in health service delivery.
Imagining community health workers as a primary care paraprofession
In Canada, community health workers are a marginal, scarce, and largely underdeveloped workforce. Real challenges stand in the way of durable and transformational Canadian community health worker programs, despite the evidence to support them and the occasional pilot project.17,18 If we as family physicians are already threatened by other regulated health care professionals working in primary care, how much more will we be threatened by laypeople who could be trained to provide specific health care services?
Perhaps we fear that task sharing can erode the doctor-patient relationship, or degrade quality of care or the value of having a family doctor. The Freedom House Ambulance Service and other programs like it show us that these approaches deepen caring relationships, forging new bonds especially where trust is lacking, and deliver high-quality accessible care.
Perhaps the problem is the education and perceptions of existing health care professionals. We sometimes believe that our role is to deliver service to individual patients, rather than to be part of a larger system engaging scores of workers who contribute to the delivery of holistic comprehensive care with a shared vision and shared accountability. Perhaps our fear lies in concerns that patients would receive uncoordinated care from a broader team. Perhaps the problem is related to remuneration, prestige, or concern that our work will be further undervalued if we enable others to share the work.
Then again, a model where family physicians serve their patients and community by working with others in primary care delivery, teaching and delegating to other practitioners, trusting our colleagues, and fostering team-based values will enable us to see a future where Canadians receive the primary health care services they expect. Such a model might also bring Canadians the health outcomes and health equity that all Canadians deserve.
No laws or regulations in Canada forbid family doctors, nurse practitioners, pharmacists, or others from collaborating, sharing tasks when scopes of practice overlap, or delegating tasks through protocols. We saw this task sharing happening during the pandemic when we rapidly needed to optimize and mobilize care providers to carry out essential duties. We have examples of community health workers, traditional healers, social prescribers, cultural health brokers, peer workers, community paramedics, and other paraprofessionals—yet they are seldom considered integral parts of primary care teams, and scarcely given space to scale up and flourish. In most cases, the processes and practices to enable this kind of collaboration, protocolization, and delegation are well developed and enabled through physicians’ professional standards and regulatory structures. Existing regulatory opportunities for delegation are underused, partly because most physicians lack familiarity and dexterity with the professional standards, procedures, and opportunities for delegation. Basic regulatory revisions could help these practices flourish, and usher in a cadre of community health workers within a system of family physician oversight and delegation. Decades of experience in emergency and community paramedicine, first aid, and public health show that protocolized and delegated acts can deliver accessible and consistent care without introducing undue liabilities or quality concerns.
Adhering to the principles of family medicine means that it is our professional duty to advocate for ways to ensure that all Canadians have equitable access to primary care services that meet unique patient and community needs. Team-based care provides the structure to enable us to work collaboratively, but the willingness to collaborate comes from providers themselves. In 1967, the Freedom House Ambulance Service was born because community members and health professionals imagined an innovative solution that defied existing norms and resource constraints, and dared to address health care needs in a way that challenged conventions and put the community—rather than the physician—at the centre of the strategy. That model should be the norm.
Of course, we need more family physicians, nurses, social workers, and others when building conventional primary care teams. Let us also imagine and build a future where family doctors also serve their community by leading, delegating, collaborating with, and championing all who can contribute to the delivery of primary care, including community health workers and paraprofessionals. All Canadians deserve the right to access comprehensive primary care. Community health workers and paraprofessionals could be a big part of that future.
Footnotes
Competing interests
None declared
The opinions expressed in this article are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article has been peer reviewed.
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