Universal primary care access by 2035

Dr. Jane Philpott is having a storied career: She dedicated the first 10 years of her medical career to serving in Niger, West Africa. Following this, she practised as a family doctor in Markham-Stouffville, Ont., for 17 years, and in 2008, she became the chief of family medicine at Markham Stouffville Hospital. From 2015 to 2019, she served as Canada’s Minister of Health.Since then, she’s been dean of the faculty of health sciences and director of the school of medicine at Queen’s University but has indicated she will complete her term in June 2025.Dr. Philpott recently published her first book, Health for All: A doctor’s prescription for a healthier Canada. Much of the book tells her story (all from the loss of her daughter to meningococcemia in Niger to her time in politics), and it discusses the spiritual and mental well-being aspects of health. But it also makes the case for universal primary care access by 2035 where, just like schools for children, patients would be in a catchment area for a primary care home and be guaranteed access.Some wonder about patient choice, but in other countries there are systems where one can, once a year or so, switch medical homes. Or perhaps a patient goes on a waiting list if they don’t want to be with their local primary care providers—certainly that is no worse a situation than the current system we have in Canada for getting a primary care clinician.Q: Let’s imagine it is 2035 and I’ve just moved to a new city and so I need a primary care provider. What would happen then under your proposal?Presumably, when you move to your new community, if you had school-aged children, you would easily be able to find out which school they were attached to. So there would be a simple mechanism like that to determine where your primary care home would be.Based on the way that it works in other countries, you might have a website that you can log onto and insert your postal code and you’ll be informed that your local neighbourhood primary care home is on the corner, a couple of blocks away.Then you sign up and show that you’ve moved into the neighborhood, and you’re immediately included in their group, and that becomes the place that you go for your comprehensive primary care needs.You would have a most-responsible provider who would be either a family doctor or a primary care nurse practitioner (NP) who you would see for your routine checkups or chronic disease management or maybe your mental health management if it was a long-term need. But if on a given day you needed to be seen and your person wasn’t available, you would see the most appropriate provider who could take care of your health needs on that day.Q: In your book you talk about these primary care homes being open seven days a week and up to 12 hours a day and that they might also provide legal clinics and tax clinics. So these would be bigger than the primary care clinics we see today?It obviously is the place for that frontline clinical primary care, but what a wonderful opportunity to make this more than just a health services hub because, of course, so many things other than health have an impact on health. So wouldn’t it be great if this was the place where your neighbourhood employment centre was, or housing supports, or other social supports?The other clinical services like home care, palliative care, placement services for long-term care are there. This is your one-stop shop for health, and it really roots the system in a primary healthcare model.Q: Right now, of course, many family doctors own their clinic but it seems like these primary care homes would need to be government run?There are other models that you could look at. For example, in the U.K. where they have a model like this, they are still private corporations, so it doesn’t exclude the physician-owned model. But in most countries that do something similar to this, it would be a publicly funded model. Well, it’s always publicly funded, of course, but it would also be publicly administered.Q: Say you are a physician-owner—there would be some level of concern about accountability as the neighbourhood population grows. You can’t just be told: “You’re responsible for everyone who moves to within 10 blocks of your clinic, and you have to deal with that.”Right. Again, looking at the models where this works well, the accountability is held not by the physicians or the clinicians, but at a municipal level. Norway is the example I often like to use. It’s the municipality that actually is responsible. This is not dissimilar to the school model, to say, “Oh, my goodness. There’s a big subdivision going in with 20,000 new people. We’re going to need to organize ahead of time as those homes are getting built so that we also build a primary care clinic and hire the people.” That onus should not be on the clinicians.Q: These clinics would be multidisciplinary. So do you have any thoughts about how to figure out, in an ideal world, how many NPs would you have, how many doctors, etc.?I think business people would say that if you’re trying to develop a model that’s scalable, you should reduce variability to a certain extent. So there should be some standard features that you would have in every primary care home, and that would be the MDs, and the NPs, and the administrators and maybe some RPNs (registered practical nurses). All homes would have that.But not every neighbourhood needs the same thing. In one neighbourhood you might need extra people who are providing addiction services and social workers to provide counseling if it’s an area that’s got higher rates of mental health issues. In some areas you might find the diabetes rates are much higher, so you’d have extra dieticians there.Q: You mentioned that volunteers might help out in these primary care homes? There’s a crisis of loneliness in North America and that might help with that.Can you imagine how well it could be if high school students, seniors, people who are looking to connect, (were) able to help out? (I) imagine being a volunteer at your local health home would be exciting for many people. There’s still a strong volunteer movement in the hospital sector, but we have never built that into the primary care sector.Q: So how could we make universal primary care happen in Canada by 2035?There are multiple paths. . . . Our history in Canada is that we often see single provinces that innovate and then the feds pick it up. That was the classic story for medicare in the first place with Saskatchewan innovating on doctor’s insurance or hospital insurance and then going federally. It’s quite foreseeable that that may be what happens here as well. In fact, I’ve already heard from some provinces who want to talk.Q: Oh. You do mention in the book that no one’s actually done it but there’s nothing stopping a province from doing it. You’re getting some interest?Yeah. There’s some interest—which would be great because then you can actually model it out in perhaps a smaller population and show that it works.Having said that, ultimately, we are a country. Countries should have standards of what their citizens can expect. And one of the basic standards people should be able to expect is basic primary healthcare. That’s the commitment that Canada’s made going back at least to the Alma-Ata declaration that we believe in the right to primary healthcare, but we’ve never actually delivered fully on that.Q: You make the case for federal authority and suggest passing a Canada Primary Care Act as a sister act to the Canada Health Act. But what do you do if a province like Alberta says “nope”?As I discussed in the book, there are mechanisms through the use of federal spending power for the feds to be able to say, “If you want this portion of the transfer, then you’re expected to deliver what the standard suggests.” It may not look exactly the same in every place, and you may have a better way that you think you can do it, but this portion of the transfer is associated with making sure that every person in your province has interdisciplinary publicly funded primary care. If you want to do that in a different way, that’s fine, but you can’t do nothing and get the money.Q: That’s not necessarily that the federal government has to put down new money but they could apply that to the transfer they’re already sending?It’s possible. I mean, realistically, provinces will expect a bit of an increase. . . . We spend much less than most countries do on primary care. Only about 6% of our spending in the country goes to primary care. Other countries who have better outcomes than us see 8% to 12% of their overall health spending goes to primary care. Whether that’s accomplished by adding to the transfer or saying that future growth in the transfer is disproportionately going to benefit primary care, there would be some mechanisms to do that without actually growing our costs overall.

Universal primary care access by 2035

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