Heba Shahaed, Richard H. Glazier, Michael Anderson, Erica Barbazza, Véronique L.L.C. Bos, Ingrid S. Saunes, Juha Auvinen, Maryam Daneshvarfard and Tara Kiran
CMAJ December 04, 2023 195 (47) E1628-E1636; DOI: https://doi.org/10.1503/cmaj.221824
KEY POINTS
- Canada spends less of its total health budget on primary care than the average among Organisation for Economic Cooperation and Development (OECD) countries (5.3% v. 8.1%).
- Canada can learn lessons to inform policy on primary care from OECD countries like the United Kingdom, Norway, Netherlands and Finland where more than 95% of the population has a regular primary care clinician or place of care.
- An analysis of these countries shows that those with high rates of primary care attachment have stronger contractual agreements and accountability for family physicians, including where they practise, their scope of practice and who they accept as patients.
- Countries with high rates of primary care attachment have similar numbers of family physicians, but fewer work in walk-in clinics or specialized areas; family physicians are paid by capitation or salary, work in interprofessional teams and have excellent digital tools and information systems.
Health systems with strong primary care have better outcomes, lower costs and better equity.1 Yet, even at the outset of the COVID-19 pandemic, about 17% of people in Canada reported not having a regular primary care clinician.2 At the same time, Canada is seeing declining enrolment in family medicine as a specialty among medical students,3 and more graduating family physicians are choosing not to practise generalist office-based care.4 The pandemic added further strain, spurring some family physicians to retire early,5 a phenomenon not unique to Canada.6
To distill lessons for Canadian policy on primary care, we identified Organisation for Economic Co-operation and Development (OECD) countries with historically high rates of primary care attachment, compared related health system factors and identified strategies these countries use to achieve high attachment. These lessons range from how health systems are organized to specifics on how primary care is funded, supported and kept accountable. We define primary care attachment as a patient’s perception of whether they have a regular primary care clinician or primary care practice where they get care. In Canada, regular primary care clinicians are either family physicians or nurse practitioners; in other countries, they also include physician assistants. We use the term family physicians interchangeably with general practitioners (GPs), as the latter is more common in some other countries. Key data sources include the 2020 Commonwealth Fund survey, 2 the Health System in Transition reports provided by the European Health Observatory7 and the Commonwealth Fund Country Profiles.8
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Box 1: Lessons Canada can learn from OECD countries with high rates of primary care attachment
Accountability
- Having GPs largely work in office-based generalist practice (v. specialized or focused practices)
- Accountability of primary care clinician to health insurer
Funding
- Higher proportion of total health spending that is public
- Higher proportion of total health spending on primary care
- More physicians per capita
System organization
- Requiring and facilitating patient registration with a GP or practice
- Encouraging care close to home
Information systems
- Enhanced patient–clinician communication
- Integration between primary care and other parts of the system
Practice organization and physician payment
- Responsibilities of other health care professionals (e.g., nurses, physiotherapists)
- GPs paid by salary or capitation (or practices paid by capitation)
- Organized after-hours care
- Limited walk-in clinics
- Note: GP = general practitioner, OECD = Organisation for Economic Co-operation and Development.
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Conclusion
Primary care is the front door of the health care system, yet almost 1 in 5 people living in Canada did not have a primary care clinician at the outset of the pandemic, and the situation is poised to get worse if left unaddressed. Canada can learn from OECD countries such as the Netherlands, Norway, the UK and Finland, where more than 95% of people have a primary care clinician, near-universal insurance coverage exists, the proportion of health spending that is public and spent on primary care is larger than Canada’s and GPs are organized better in teams and are more accountable for the care they must provide. These international examples can inform bold policy reform in Canada to advance a vision of primary care for all.
