May 21, 2024

In her new book, former health minister Jane Philpott shares her dream for a primary care system that guarantees everyone has a place to go.

Fixing Canada’s Health Care System Starts With Family Doctors For All

(Photo: Liz Cooper, courtesy McClelland and Stewart)

Before becoming Canada’s minister of health in 2015, Jane Philpott worked in medicine, spending the first decade of her medical career in Niger and a subsequent 17 years as a family doctor in Markham and Stouffville, Ont. Now the Dean of Health Sciences and director of the School of Medicine at Queen’s University, Philpott is calling for change to Canada’s healthcare system. Below, an excerpt from her debut book, Health for All: A Doctor’s Prescription for a Healthier Canada.

We cannot fix all of the problems in health care overnight. We will have to prioritize, and we should start with a foundation based on primary care that has never been properly built in Canada. Simply put, we must make it a reality that every person living in Canada has a primary care home, just as every Canadian child has access to a public school.

The notion of a primary care “home” might not be familiar to everyone. It’s not a home where you live, like a long-term care or retirement home, but a health care setting where you feel at home—a place where you belong. The term is a variation of a concept called the patient-centred medical home that was introduced and made popular in the United States beginning in the mid-1990s. I prefer to use the term primary care home. This avoids the use of the word medical, and in doing so recognizes that what happens at your primary care home is more than medical. It also omits patient-centred; because primary care should always be person-centric, I believe that part of the phrase should go without saying.

I propose a system that guarantees everyone living in Canada has such a place to go. This may seem ambitious, but it is doable. It is smart. It is fair. The end state is more than universal coverage. It must be authentic access to care. Several provinces have done part of this work, but none of them have made it universal. And getting only part way is unacceptable. We would never tolerate a status quo in which only 80 percent of Canada’s children were able to attend school. 

Suggesting that the answer to our health system woes lies in primary care is nothing new. The best-known international consensus on the matter was achieved back in 1978 at a meeting in Alma-Ata—now known as Almaty, the largest city in Kazakhstan. At that time, representatives of 134 countries came together to declare that health is a fundamental human right and all governments should have a plan of action to launch and sustain primary health care as a part of their national health systems. In doing so, signatories to the Declaration of Alma-Ata agreed that “an acceptable level of health for all the people of the world by the year 2000 can be attained [italics added].”

There it was. Almost 50 years ago, Canada was among the nations who knew and understood that the path to a healthier country runs through primary health care, including the services of primary care.

Clearly, “an acceptable level of health for all people” was not achieved by the year 2000, not in Canada at least. A national health system rooted in primary health care is easier to describe than to achieve. Many countries cite challenges in acquiring the necessary funding, and there is no standard implementation protocol for universal access to primary health care. Nevertheless, it must still be our goal. Scientific literature, including a seminal paper by the late Dr. Barbara Starfield and her colleagues in 2005, offers an abundance of evidence that countries with strong systems of primary care get the best health outcomes for their population, at the most affordable costs, in a way that is both equitable and accessible. 

The World Health Organization defines primary care as “a model of care that supports first-contact, accessible, continuous, comprehensive, and coordinated person-focused care.” Every modifier in that definition matters. You might want to pause, reread them and think about each one. Unfortunately, Canada has never intentionally designed or delivered a universal system of primary care. Perhaps we thought our good intentions would allow us to stumble into such a system, but clearly that hasn’t happened. Thankfully, it is not too late. 

In order to make this plan work, we need to get three groups of people on board: the public, the community of health professionals and political leaders. The transition to universal primary care will happen faster if there is a shared vision with loud public demand for and expectation of such a system. We will not be successful unless clinicians are on board. Most of all, we will need the unrelenting determination of political leaders in all orders of government, of all stripes, who will fight for this vision on behalf of Canadians and not stop until it is accomplished.

The roots of Canadian medicare, our national health insurance plan, go back to 1947, when then Saskatchewan premier Tommy Douglas introduced North America’s first universal hospital insurance plan—later adapted into a national program with the Hospital Insurance and Diagnostic Services Act of 1957. Later, doctors’ services were added to the coverage, first in Saskatchewan and then nationwide with the Medical Care Act in 1966. Through those decades and later, when the original laws were amalgamated under the Canada Health Act (CHA) in 1984, there was plenty of opposition, especially from medical organizations. But medicare’s champions persevered, including the Honourable Monique Bégin, who was federal minister of health and welfare when the CHA was passed with unanimous consent in the House of Commons. The result hasn’t been perfect, but the CHA is the reason that, for the most part, Canadians receive the services defined as medically necessary care, within Canada, based on that need and not on your ability to pay. 

While the CHA has largely withstood the test of time, it has not evolved with the changing health care ecosystem. It guarantees insurance coverage only for care provided either (1) in hospitals and/or (2) by doctors. Now, almost eight decades after medicare was just a dream in the mind of Tommy Douglas, most health care can or should happen outside hospitals, and we would be smart to insure the services of other health professionals who offer services in the community, in addition to doctors. 

We have arrived at a critical point for a new generation of politicians willing to collaborate and do the hard work of implementing a national health service fit for our needs—a publicly funded system of primary care. It will save money and save lives. It could be called Medicare 2.0, the 21st-century transformation.

It is a reality in the Netherlands, where more than 95 percent of citizens are registered with a family doctor. If a patient moves, they can change, anytime. Visits and tests are captured in the patient’s electronic record, which is accessible by other providers. The family doctor’s office is the centre of the Dutch health system. Every family doctor offers care in their office or in the patient’s home, and most teams include a manager, nurses, psychologists and practice assistants who do both administrative and clinical tasks. Most palliative care is delivered by family doctors in the patient’s home, in partnership with specialized nurses. After-hours care is provided at a “GP Medical Post” staffed by the family doctors from the surrounding practices and located in the neighbourhood hospital, making it easy to access specialists if needed.  

Canadians can afford publicly funded universal access to primary care. In fact, it would be less expensive than what we are doing now, and it offers better value for the money spent. Those who say such a system is prohibitive financially have not done the math that includes the downstream savings. Based on work done with my colleagues in Kingston, Ont., we have calculated that team-based primary care could be delivered for about $500 worth of government funding per person per year. That price tag includes physician remuneration. If people don’t have this care, the only alternatives are (1) to delay care, which means that the problem could get worse, causing it to be harder and more expensive to treat, or (2) to go to the emergency department. That trip, even before you add in the physician fees, will cost more than $300. It’s easy to see that every time the availability of a primary care home translates into someone being able to avoid a visit to the emergency department, we’re saving money for the whole system.

Beyond better value for money in acute care, there are immense downstream savings with universal access to primary care. For example, you can avoid cancers or detect them early. It will also slow or prevent the onset of cardiovascular diseases such as heart attacks or strokes. Similar prevention of both costs and suffering could be described for every system of the mind and body.

So why does the scenario I’ve described above—or something like it—not exist? There was never a national plan for universal access to primary care—and not a clearly articulated provincial one either. 

We are a long way from access to team-based care for the entire country. To achieve that, we need a national standard for primary health care that doesn’t currently exist. Individual family doctors (or even groups) cannot take on the health of the entire population as their professional responsibility any more than an individual schoolteacher should be expected to keep adding students to their classroom lists as the population of a community grows.

That said, primary care in Canada should function like public schools. Access to public school is one of the most universal social services standards that Canadians can count on. No one is left out. Children are assigned to a school based on their home address. If the population grows, a new school is built, and personnel are hired. The distance required to get to your local school may differ, but our Canadian experience and social contract makes it very clear that no child should be denied access to publicly funded education, until the end of secondary school.

When you move to a new community, you never need to question if your child will have access to a school. You may choose to send them elsewhere, but you don’t have to worry about whether they will be on a school roster in a specific geographic area. And when you move to another town, you don’t hang on to the link to your previous public school board out of fear that you’ll never get connected to another one. Imagine if we had allowed public schools to be run the way we’ve allowed primary care to evolve. Imagine if we thought it was acceptable for millions of children to simply be on a waiting list to get access to education. Yet that’s what we allowed to happen to primary care.

If we can design and implement universal access to public education, we can do the same for primary care. This should be our rallying cry. 

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