How to fix primary care? A simple plan for what will work (and what won't)

The family doctors shortage in Canada a layered problem: burned-out general practitioners are quitting, medical students continue to favour other specialties, and the shortage is exacerbating other system issues—like the emergency rooms getting clobbered across the country. “The entire primary care system is under unprecedented and incredible duress. It is a crisis like no other that has ever been seen before,” says Dr. Lawrence Loh, executive director and CEO of the College of Family Physicians of Canada (CFPC). The college recently released A Prescription for Primary Care, a three-page document that crisply outlines a big-picture, strategic approach to improvement. It’s intended to offer guidance related to the family health services priority portion of the $25-billion federal bilateral agreements, which are currently being negotiated. No jaws will drop upon reading the report. It advocates for tried-and-true solutions, such as moving to team-based care, scrapping fee-for-service, reducing paperwork and going digital. Philosophically, it suggests regions embrace family doctors as cornerstones of care and improve access for everyone. “These are solutions that are going to work, no matter where you are, in a northern Ontario town, in Saskatchewan, or out on the Rock,” says Dr. Loh. “We’re hoping that the Prescription for Primary Care can represent some real, lasting solutions that are, frankly, not that new, but will get Canadians the care they need.” Dr. Loh notes that many provinces are trying to remedy their crisis in primary care by “throwing everything at the wall and seeing what sticks.” What’s perhaps the most unique about the report is its list of what it calls “suboptimal solutions.” Relying on walk-in clinics, supporting family medicine substitutes and recruiting more international doctors get flagged. Of expanding the role of pharmacists and other healthcare professionals, Dr. Loh says, “They would be better placed in a team rather than this sort of piecemeal expansion.” For instance, when a pharmacist prescribes, they may end up calling the doctor to ask questions about the patient—that’s unpaid work for overburdened doctors, plus the patient might benefit from seeing professionals such as a dietitian or physiotherapist. “You’re creating teams haphazardly and adding burden to family doctors. You can organize it better by creating teams that can function more optimally.” The CFPC makes it clear it disapproves of many provincial colleges more easily allowing international doctors to practise. “Bringing more physicians into a dysfunctional system will only result in more dissatisfaction,” the report states. Importantly, Dr. Loh says removing barriers comes with risk. “This is a lowering of standards that protect patients for the sake of improving access.” Dr. Loh says adjusting the big picture for primary care will make better use of existing resources. “It’s about working together and working smarter, not harder.” A more efficient system that allows primary care doctors to focus on patients—especially patients that need them, while the other professionals on their teams can step in when appropriate—will naturally right itself. That would remedy issues around retention and recruitment. He gives a nod to initiatives in places such as P.E.I. to push for team-based care, and a new compensation model in B.C. However, even these improvements won’t be as effective on their own, says Dr. Loh, they need to be about a larger system shift that truly puts primary care first, with real funding behind it. “We're talking about bronze system reform,” he says. “We’re saying to policy makers that here are the big system changes that work. If you fund it, and you actually drive it, this will get us to where we need to go.”

How to fix primary care? A simple plan for what will work (and what won't)

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