By: Kate Tucker, General Member
It has been known for over two decades that in high-income countries, health systems most oriented toward primary care have better outcomes, lower costs, and greater patient satisfaction [1]. Despite overall high levels of satisfaction with the care received, Canadians rate their access to health services quite poorly and are generally not seeing improvements in this domain [2]. Primary health care services include routine care for urgent but minor health problems, chronic disease prevention and management, health promotion, and a series of other first-point-of-contact services such as mental health care, maternity, and childcare, psychosocial services, liaison with home care, nutrition counseling, and end-of-life care. A strong primary care system is recognized as the cornerstone of health systems and is essential to the success of the health system as a whole [3].
Primary care is delivered by primary care providers (PCPs), often family doctors and nurse practitioners. Other health professionals, such as pharmacists, midwives, physiotherapists, and emergency room physicians also play a role in delivering primary care services. Approximately 85.5% of the Canadian population has a designated primary care provider, however, among patients with PCPs, just 38.7% report the capacity to access same-day or next-day appointments with their regular provider [4]. Quebec reports the highest percentage of the population without a primary care provider at 21.5% and Ontario reports the lowest percentage at 9.4%. Young people aged 18-34 are the group who are least likely to have designated primary care providers. These numbers are set to increase as family doctors retire, fewer medical students choose to enter Family Medicine, and primary care providers keep smaller rosters to maintain work-life balance [5].
Increasingly, it is being proven that a change in the delivery of primary care is necessary to support the current population, and, as the population continues to age, a larger primary care provider workforce will be required to meet the demands of the population in Canada [6]. So, what could a change in primary care look like? In addition to increasing the number of family doctors, numerous novel models for primary care delivery are being explored and developed across the country. Various innovative models of primary care delivery have emerged in response to the increasing demand for primary care providers and services and the COVID-19 pandemic. Policies, best practices, and resource allocation have all been permitted to shift in response to varied access, circumstances, and demands. Notable among these innovative responses to the primary care crisis include the Patient’s Medical Home model from the College of Family Physicians of Canada, as well as a variety of team-based primary care practices, virtual care solutions, expansion of the scope of practice of various allied health professionals, and countless other community-specific approaches that are addressing the needs of the people who depend on their services. As these models of care are being tried and tested, their ability to go beyond band-aid solutions and maintain longevity will also be considered in this review. Creating accessible, efficient, family and community-centered practices that are as sustainable as they are usable is central to utilizing new solutions and expanding on existing services to support primary care service delivery in Canada.
Patients Medical Home
In 2011, in response to the demand for improved primary care services, the CFPC released the best practices and guidelines policy document for primary care, titled “Patients Medical Home” (PMH). The PMH framework is designed to support family physicians in implementing essential practices to improve the quality of primary care across Canada [7]. It provides clear expectations for governments, other health professionals, and patients on how a primary health care system could be structured to meet the needs of Canadians. More recently, a revised version of this policy was released in 2019. The 2019 PMH aims to better reflect current national circumstances and address current circumstances that primary care providers face in their practice. The 2019 model reframed the 2011 goals as pillars and outlined three central themes for the ten pillars.
The PMH model guides primary care practices toward reform with tangible and clinically applicable directives that allow providers to consider how to address systemically oppressive experiences is necessary to truly achieve the primary care system that Canada dreams of delivering. As a general national policy and best practice, the PMH model has the potential to contribute to reform for an improved system that would support Canadians in the management of their health, improve health outcomes, rebuild trust and confidence in the healthcare system, and re-establish Canada's reputation as a global leader in healthcare. The model of PMH is in alignment with family and community-centered primary care practice, and while it does not directly address the shortage of providers, it does provide a means of delivering the highest quality care within the current system.
Interdisciplinary Teams
A prominent leader in primary health innovation over the past decade has been interdisciplinary teams. This approach serves as the basis for the Patient’s Medical Home and has set the standard for accessible, person-centered, cost-effective care across the country. Interprofessional healthcare teams are not new to health services given the nature of health services and the wide range of skills and services required [8]. However, an increased focus on collaboration in primary care, because of the demand in this sector, is a newer concept. The addition of allied health professionals (such as nurses, nurse practitioners, pharmacists, therapists, etc.) to family care clinics was implemented to improve access to care and utilize primary care services to their full capacity. These models have been called a wide variety of names including Family Health Teams, Interprofessional Primary Care Teams, and Collaborative Care Teams. In this model, persons seeking care may receive care from their primary care provider, or another provider on the team depending on availability and reason for the visit. This allows allied health professionals to work to the full extent of their scope of practice and is thought to free up some of the physicians’ time, allowing them to see more patients within their full scope of practice and remove the need for persons seeking care to visit a walk-in clinic or emergency department for primary health care services.
Family Health Teams have proven to be incredibly successful in their uptake and implementation. A 2021 Ontario-based study found that receiving care from a clinic that worked in an interprofessional team model was associated with an increase in the odds of patients reporting same/next-day access to care by 12.0% [9]. The main barriers to this approach have proven to include a lack of clarity of roles and expectations (as per the shift from the traditional care model), fears relating to professional identity, lack of communication, and lack of training [10].
Expansion of Scope
As seen in Family Health Teams, expansion to the scope of practice for allied health professionals is another notable innovation in primary care. Scope of practice refers to what providers are trained and able to do as per their professional designation. In an ineffective health system, providers may not work in their full scope of practice or may spend extraordinary amounts of time doing things that another health professional could also do [11]. For example, family physicians can administer flu vaccines, but so are pharmacists and nurses. By having nurses or pharmacists host flu clinics, family doctors can focus their time on tasks that are not within the scope of another accessible health professional. Promoting the scope of varied health professionals demonstrates additional avenues of care for persons seeking care who may otherwise wait a long time for services that could be easily provided if they knew where to go. Recently, there have also been cases of expanding the scope of practice so that health professionals perform additional tasks that they have already been trained to do. In April 2023, for example, Newfoundland announced an expansion to the scope of practice for pharmacists and registered nurses in the province to include things such as ordering additional tests, referrals to specialists, and prescribing for minor ailments [12]. These amendments to their scope of care intend to increase public accessibility to primary care services, however, there was some expression of concern from the NL Medical Association, as per integration in team-based care and consideration for maintaining having accessible family physicians as the gold standard of primary care delivery [13].
Virtual Care
Virtual Care has been around for quite some time but become increasingly accessible during the COVID-19 pandemic as a means to access and deliver care from the comfort of our homes. Virtual care provides an additional option for primary care access and can be very effective for minor prescriptions, referrals, or follow-ups [14]. Increased focus on data protection also emerged as this innovative approach to health services surged. Due to the rapid expansion of the services, additional research is ongoing and required to understand perceptions, outcomes, and accessibility. Considerations for equitable usage, impact on healthcare spending, and sustainability of the tools are hot topics for policymakers and government.
Other Innovations
Despite fantastic innovations including forward-thinking policies, team-based practices, expansion of scope, and alternate care opportunities, there is still an ongoing shortage of primary care providers. Cuts to medical school enrollment in the 1990s have meant that a considerable amount of family doctors are over the age of 65 and preparing to retire [15]. Changes to practices and expectations for work-life balance have also meant that many family doctors have smaller rosters of patients than they have historically held, and fewer medical students are choosing family medicine [5], [16]. This comes at a time where we are seeing baby boomers settle into older age and thus place an increased demand on primary care to support them into old age [17]. As a result, part of innovation in primary care includes initiatives to retain and recruit more primary care providers, such as family doctors and nurse practitioners. Medical schools across the country are beginning to add seats to their undergraduate and residency programs and are expanding their programs to include more satellite campuses that allow students to stay close to home to study medicine. For example, in 2023 Queen’s University introduced 20 seats in a novel program geared towards medical school applicants who are committed to family medicine[18]. This program will train students through medical school and residency and is set to introduce its first cohort in September of 2023. Other initiatives to recruit and retain family doctors include bonuses for rural family physicians, promotion of opportunities for work-life balance and community integration, and additional efforts to offer positions close to their home communities [19]. Programs that allow internationally trained physicians to practice medicine in Canada are also under development [20].
Final Thoughts
The landscape for primary healthcare innovation in Canada is vast and rapidly expanding, so where do we go from here? Community-specific initiatives are needed to ensure that Canadians have access to the care they need in an ideal place, from an ideal person, at the ideal time. Rural communities and urban centers alike require solutions and models that fit the needs of the populations they serve given their current circumstances and anticipated needs. A continued focus on person-centered care in both clinical circumstances and in the development of new means of delivering health services is central to the success of these innovations. We urge decisions makers, healthcare providers, and community leaders to listen closely to their communities, explore how these varied innovations work for them, and continue to turn to the people who will use these services to best inform what works for them in their unique circumstances. In a time where primary care reform is more important than ever, we look forward to exploring additional innovations that serve communities in maintaining high-quality access to excellent health services.
For more information on innovations in Primary Care, check out the College of Family Physicians of Canada’s series on innovations in primary care! https://www.cfpc.ca/en/policy-innovation/innovation-in-family-medicine-and-primary-care/innovation-in-primary-care-series
References
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