Family physicians can help transform primary care

Steve Slade, BA

By Steve Slade, BA, Eric J. Mang, MPA, Artem Safarov, BSc, PMP, and Lawrence C. Loh, MD, MPH, CCFP, FCFP, FRCPC, FACPM

The College of Family Physicians of Canada extends its gratitude to Healthcare Management Forum for the current journal issue focusing on primary care. To address the immediate crisis in family medicine, support and solutions must be taken that account for the foundational role family doctors play within primary care to support the healthcare system overall. We note this aim in the July 2023 article “Canada’s primary care crisis: Federal government response”[1] by Flood and McGibbon, which underscores the importance of, and the challenges faced by, Canada’s family doctors and the primary care system. The authors argue, quite rightly, that the federal government can and should act “strategically, in ways that complement provincial efforts” to guarantee access to primary care—an aim that the CFPC fully agrees with.

This commentary aims to build on points made by Flood and McGibbon by sharing the CFPC’s proposed actions to address the crisis in family medicine and optimize access to primary care for patients in Canada. In so doing, we hope to build out a more complete picture of what family physicians contribute to healthcare delivery and share our perspective on how collective effort can bolster Canada’s healthcare system by supporting transformation in primary care.

Data and evidence show that comprehensive family practice continues to be the bedrock of the healthcare system. Statistics Canada’s Canadian Community Health Survey shows that 86% of people have a regular care provider [2], and in-depth analysis of this data by the CFPC shows that 97% of those with a regular care provider say that their provider is a family physician. The CFPC’s Family Medicine Longitudinal Survey also shows that 80% of recently CFPC-certified family physicians continue to “provide comprehensive care to a current group of patients over the long term”[3]. Taken together, these statistics indicate that community-based family practices are key a solution to improve access for those who are unattached to a regular source of primary care.

That said, large scale, cross-Canada health system change is needed to sustain this system and increase access to family doctors and primary care for all Canadians. First among these changes is a seismic shift in how medical students see family practice as a career option.

There is a marked disconnect between medical students’ early experiences of family medicine and their subsequent specialty choices. Data from the Association of Faculties of Medicine of Canada show that medical students’ rate their experiences in family medicine and longitudinal integrated clerkships higher compared to other specialty areas[4]. However, trends published by the Canadian Residency Matching Service (CaRMS) show a decreasing number of medical graduates applying annually to family medicine training programs (down from 3,938 in 2019 to 3,390 in 2023, a 14% decline in four years)[5]. At the same time, the Canadian Institute for Health Information (CIHI) publishes data showing that average gross clinical payments per family physician was $288,029 in 2020-21, compared to $357,832 for medical specialists (24% more) and $467,646 for surgical specialists (62% more)[6]. This despite the fact that family physicians are Canada’s most prominent regular care providers and strong evidence shows decreased morbidity and mortality attributable to continuous care[7]^,[8]. The data and evidence speak volumes.

To ensure the sustainability of comprehensive family practice and primary care in Canada, we must address this state of affairs. Provinces like British Columbia, Manitoba, and Nova Scotia are starting to profoundly adjust the circumstances of family practice[9]^{, [10], [11]}, to better support current practitioners and draw interest from future learners. However, Canada is not yet seeing the seismic, cross-country shift in support that is critically needed.

Efforts to support and enable the family physician workforce could bolster the healthcare system more broadly. To realize this potential we need to consider the family physician’s role beyond primary care. For example, proportionately more than twice as many family physicians say the emergency room (ER) is their main practice setting compared to other specialists (7% versus 3% respectively in 2019)[12]. Also, there are almost two Family Medicine ER physicians for every one Royal College certified ER specialist (2,247 versus 1,233 in 2021, respectively)[13]. Looking beyond the ER, cross-country medical service billing data for 2020 shows that family physicians:

• Performed 49% of over 20 million hospital-based assessments[14].
• Provided 47% of over 1 million surgical assistance services¹⁴.
• Provided 21% of just under 726 thousand anesthesia services¹⁴.
• Attended 34% of over 207 thousand obstetrical deliveries (excluding c-sections)¹⁴.

Notably, during the COVID-19 pandemic, family doctors stepped in to support Canada’s healthcare system in many other ways. A CFPC survey of members during the pandemic found that:

• By May 2020, 22% of family physicians had started work in new settings due to COVID-19[15].
• 15% of family physicians were providing care in long-term care homes in May 2020¹⁵.
• In May 2020, 90% of family physicians were providing virtual care¹⁵.
• In May 2022, 62% of family physicians were caring for ambulatory COVID-19 patients, and 52% were caring for patients with long COVID[16].

These statistics and facts demonstrate how family physicians are critical to healthcare provision in primary care and beyond. They are the most common providers of ongoing primary care and are also major contributors to tertiary care in multiple contexts. Family medicine training is designed to produce highly adaptive, highly skilled health workers that respond to context-specific and emerging needs. As Canada grapples with a system wide healthcare crisis, including in primary care, a key consideration will be how best to enable, support and capitalize on the broad abilities of family physicians.

The CFPC has developed a multi-pronged, evidence-based set of family practice reform proposals that, taken together, would go far in restoring Canada’s primary healthcare system. Key actions are described in detail in the CFPC’s “Family Practice Reform Policy Proposal Package”[17].  In summary, the solution set prioritizes the following:

1. Fund interprofessional collaborative teams.  Funding should be directed toward establishing additional interprofessional teams that realize The Patient’s Medical Home vision[18].
2. Reduce administrative burden for family physicians. This will maximize family physicians’ time for direct patient care, improve work-life balance, enhance patient-centredness, and prevent burnout.
3. Minimize the burden associated with adopting new technologies in practice. This is a necessary step toward implementing a pan Canadian health data strategy and modernizing the healthcare system toward a One Patient, One Record electronic health record (EHR) approach. Approaches focusing on facilitating referrals, such as centralized referral systems, must be prioritized.
4. Support national licensure and improved locum availability. Many family physicians are unable to take a break from practice because they can’t find someone to cover their absence. Locum coverage enhances family physicians’ work-life balance, and helps avoid burnout and further staffing shortages.
5. Invest in fair physician remuneration that incentivizes team-based practice and complexity of care. Capitation and blended payment models compensate family physicians for their full range of tasks and are compatible with high quality, team based care. Fair and competitive compensation will make family practice an attractive career choice for future physicians.

Focused investment in these areas aligns with the points raised by Flood and McGibbon, particularly regarding targeted federal funding of primary care initiatives. Recently announced commitments in British Columbia, Manitoba and Nova Scotia already follow the suggestion to increase the financial appeal of comprehensive practice, in line with its foundational importance.

The CFPC is a proponent of evidence-based healthcare policy, action, and evaluation. As we support and rebuild primary care, it will be necessary to challenge our assumptions and critique our own thinking. In their strong argument for a federal response to Canada’s primary care crisis, Flood and McGibbon reference a 2002 physician supply study[19] and assert that “length and cost of training obviously has a significant impact on the supply of PCPs and the prices/income they seek once in practice”¹. In fact, the referenced study does not touch upon the correlation between length of training and the income physicians seek; it does not acknowledge the multifactorial nature of practice challenges that contribute to specialty choice; and it does not examine how training helps to enable comprehensive family practice. The referenced study also does not account for the health service contribution of family medicine residents. Residents are not included in databases such as the one used in the referenced study, but nevertheless they provide broad health services in many clinical settings as they prepare for independent practice. Simply put, residents are providers and contributors to primary care even during their training, independent of the length of their program.

The CFPC also notes that Flood and McGibbon suggest that primary care providers may be “increasingly drawn from the public to the private sector, for example, working for private virtual care clinics or practising in cosmetic clinics, as the demand for such services has grown exponentially”¹. The CFPC is not aware of compelling evidence that suggests primary care providers are moving into private clinics, yet the suggestion of such an unsupported trend can influence our thinking, and ultimately our actions, in ways that are counterproductive.

Recognizing that, overall, Flood and McGibbon argue in strong support of primary care, we reiterate that discourse and action be firmly rooted in sound data and evidence, and again highlight the clear evidence-based solutions being advanced by the CFPC. These solutions can and should be deployed, ultimately, to increase the sustainability of comprehensive family medicine now and in the future.

Steve Slade is the Director of Research at The College of Family Physicians of Canada.

Eric J. Mang, MPA, is the Executive Director of Member and External Relations at The College of Family Physicians of Canada.

Artem Safarov, BSc, PMP, is the Director of Health Policy and Government Relations at The College of Family Physicians of Canada.

Lawrence C. Loh, MD, MPH, CCFP, FCFP, FRCPC, FACPM, is the Chief Executive Officer and Executive Director of The College of Family Physicians of Canada.

You can read the article by Flood and McGibbon here, in the September 2023 edition of Healthcare Management Forum.

References

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[1] Flood CM, Thomas B, McGibbon E. Canada’s primary care crisis: Federal government response. Healthcare Management Forum. 2023;0(0). doi:10.1177/08404704231183863.  

[2] Statistics Canada. Table 13-10-0096-01  Health characteristics, annual estimates. DOI: https://doi.org/10.25318/1310009601-eng

[3] College of Family Physicians of Canada. Family Medicine Longitudinal Survey: In Practice Survey (T3) Results 2021. Aggregate findings across Canada’s family medicine residency programs. Mississauga, ON: CFPC. https://www.cfpc.ca/CFPC/media/Resources/Research/FM-Longitudinal-Survey-T3-in-practice-Survey-2021-Aggregate-Report.pdf. Accessed August 9, 2023.

[4] Association of Faculties of Medicine of Canada. Graduation Questionnaire National Report 2022; Table 4, p 11.  Ottawa, ON: AFMC. https://www.afmc.ca/wp-content/uploads/2022/11/GQ2022_national_complete_EN_25oct2022.pdf. Accessed August 9, 2023.

[5] Canadian Resident Matching Service (CaRMS). 2023 CaRMS Forum; p 37. Ottawa, ON: CaRMS.  https://www.carms.ca/pdfs/carms-forum-2023.pdf. Accessed August 9, 2023.

[6] Canadian Institute for Health Information. National Physician Database — Payments Data, 2020–2021. Ottawa, ON: CIHI. https://www.cihi.ca/sites/default/files/document/npdb-data-tables-2020-en.zip. Accessed August 15, 2023.

[7] Pereira Gray DJ, Sidaway-Lee K, White E, et al. Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018;8:e021161. doi:10.1136/bmjopen-2017-021161.

[8] Hogne Sandvik, Øystein Hetlevik, Jesper Blinkenberg and Steinar Hunskaar. Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway. British Journal of General Practice 2022; 72 (715): e84-e90. DOI: https://doi.org/10.3399/BJGP.2021.0340.  

[9] “B.C. launching new payment model for family doctors in 2023”.  CBC News. October 31, 2022. https://www.cbc.ca/news/canada/british-columbia/bc-doctor-supports-announcement-1.6635200. Accessed August 9, 2023.

[10] “Doctors approve deal with Manitoba”. Winnipeg Sun. August 14, 2023. https://winnipegsun.com/news/provincial/doctors-approve-deal-with-manitoba. Accessed August 15, 2023.

[11] “Province Partners with Federal Government to Improve Healthcare”. Premier’s Office, Government of Nova Scotia. February 23, 2023. https://novascotia.ca/news/release/?id=20230223003. Accessed August 15, 2023.

[12] Canadian Medical Association. CMA Physician Workforce Survey 2019. Ottawa, ON: CMA.  https://surveys.cma.ca/viewer?file=%2Fmedia%2FSurveyPDF%2FCMA_Survey_Workforce2019_Q15_Work_Setting-e.pdf#page=1. Accessed August 9, 2023.

[13] Canadian Institute for Health Information. Supply, Distribution and Migration of Physicians in Canada, 2021 — Data Tables. Ottawa, ON: CIHI. https://www.cihi.ca/sites/default/files/document/supply-distribution-migration-physicians-2021-data-tables-en.zip. Accessed August 15, 2023.

[14] Canadian Institute for Health Information. National Physician Database — Utilization Data, 2020–2021. Ottawa, ON: CIHI. https://www.cihi.ca/sites/default/files/document/npdb-data-tables-2020-en.zip. Accessed August 15, 2023.

[15] College of Family Physicians of Canada. Family Physicians’ Response to the COVID-19 Pandemic: Results of the May 2020 CFPC Members Survey on COVID-19. Mississauga, ON: CFPC. https://www.cfpc.ca/CFPC/media/Resources/Research/Covid-19-Member-Survey-ENG-Final.pdf. Accessed August 9, 2023.

[16] College of Family Physicians of Canada. Family Physicians’ Response to the COVID-19 Pandemic: Results of the May/June 2022 CFPC Members Survey on COVID-19. Mississauga, ON: CFPC. https://www.cfpc.ca/CFPC/media/Resources/Research/COVID-19-2022-Survey-Results-EN-Final.pdf. Accessed August 9, 2023.

[17] College of Family Physicians of Canada. Transforming the Foundation of Canada’s Health Care System – Solutions to bolster primary care. Mississauga, ON: CFPC. https://www.cfpc.ca/CFPC/media/Resources/Health-Policy/HPGR-FP-Reform-Policy-EN.pdf. Accessed August 10, 2023.

[18] College of Family Physicians of Canada. A new vision for Canada: Family Practice—The Patient’s Medical Home 2019. Mississauga, ON: College of Family Physicians of Canada; 2019. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf. Accessed August 10, 2023.

[19] Canadian Institute for Health Information. From perceived surplus to perceived shortage: what happened to Canada’s physician workforce in the 1990s? Ben Chan, 2002. Ottawa, ON: CIHI. https://secure.cihi.ca/free_products/chanjun02.pdf. Accessed August 15, 2023.

Ruth Lavergne wants you to think about advancing equity in primary care

By Ruth Lavergne, PhD, and Erin Christian, MHA

Access to quality primary healthcare is recognized as the cornerstone of a well-functioning healthcare system. Efforts to strengthen the funding, organization, and delivery of primary healthcare and to develop more robust systems of primary healthcare have been ongoing in Canada, and new announcements of federal funding bring renewed attention to transformation.

Health systems with strong primary healthcare systems tend to be more equitable, and primary care also contributes to better experiences of patients and providers and system efficiency. Since primary care is the first and main point of access to healthcare in Canada, more equitable access to primary care has the potential to improve equity in access throughout the system, and ultimately contribute to more equitable health outcomes.

However, data reported in this issue of HPM suggest that gaps in access to primary care have persisted or increased across Canada. There is some related evidence to show that previous primary care investments, such as new models and incentives haven’t, on average, gone to people with greatest need. It’s therefore possible that if new investments in primary care do not directly address inequities, they may continue to entrench them. With this in mind, we suggest some recommendations for more equitable primary care transformation, as well as some examples that illustrate these recommendations from across Canada.

Include equity as an integral objective in primary care transformation

As a starting point, more equitable access to primary care must be an integral objective in primary care transformation. For example, primary care transformation efforts that don’t first seek to ensure all populations have access to care may further entrench inequities. For this reason, we believe it’s important to explicitly recognize and prioritize the reduction of disparities alongside other policy directions. For example, the Health Accord for Newfoundland & Labrador released last year includes calls to action that seek to embed the social determinants of health throughout all decisions that influence health and to ensure new investments align with community needs. This is accompanied by actions to measure and track social determinants and accountability for health outcomes. At the level of service delivery, there is a need for adequate resourcing of primary healthcare that is designed to meet the needs of equity-deserving groups, such as the Nova Scotia Brotherhood Initiative and Nova Scotia Sisterhood, or Newcomer Health Clinic.

Expand training and capacity for trauma- and violence-informed care, contextually tailored care, and culturally safe care

To provide more equitable care, healthcare providers should receive training and support in trauma- and violence-informed care, contextually tailored care, and culturally safe care. Recognizing the diverse needs and experiences of patients is essential in delivering inclusive and responsive primary care services that address the unique challenges faced by marginalized populations. The First Nations Health Authority in British Columbia has developed an Anti-Racism, Cultural Safety and Humility Action Plan that could inform similar initiatives in other contexts. 

Support models of team-based care with equity mandates and accountability to communities

By embracing interdisciplinary approaches and involving various healthcare professionals, team-based models can better address the complex and diverse needs of patients, particularly those from underserved communities. However, the presence of team-based models on their own may not improve equity, especially if these models are less available to more marginalized populations. There is a need for community-governed models, such as Community Health Centres and First Nations governed health centres alongside other models of team-based care where resources are  allocated with consideration of equity-seeking groups and service delivery is accountable to community needs. Accountability to communities requires deliberate engagement and partnership. A working group co-chaired by the British Columbia Ministry of Health and the First Nations Health Authority developed an Indigenous Engagement and Cultural Safety Guidebook as a resource for Primary Care Networks, that offers concrete recommendations and additional resources around partnership and engagement. 

Ensure equity mandates are captured in accountability and performance frameworks

To ensure that equity is an explicit mandate of primary care transformation, and to ensure policies don’t have unintended consequences that undermine equity, it is crucial to consider equity in accountability and performance frameworks. Last year Ontario Health released an Equity, Inclusion, Diversity and Anti-Racism Framework that emphasizes collecting, reporting and using equity data, identification of clear accountability, and reporting and evaluation to drive improvement. This year Nova Scotia released a Health Equity Framework which lists both actions and measures. However, it is imperative that policies focused on primary care similarly include equity in accountability, reporting, and evaluation.

Ensure patterns of funding and resource allocation are tailored to needs and responsive as needs change

Patterns of funding and resource allocation should be flexible and responsive to changing needs. By tailoring financial investments based on the unique needs of communities, healthcare organizations can focus on meeting community needs, and not navigating insecure funding. Up-to-date population and health system data and ongoing engagement with communities is required to inform changing needs. Health system infrastructure needs to be in place to support this type of data-driven decision making. An equity–informed approach to data collection is also imperative, in particular with Indigenous communities keeping in mind principles of OCAP(R). 

Concluding thoughts

Policies implemented with the intention of strengthening primary care broadly can still have the effect of entrenching inequities. For example, innovative models implemented in communities that are most prepared, or incentives that go to high-performing providers or organizations can concentrate resources where there is less need, even when this is not the intention. It is essential to recognize that primary care transformation must explicitly consider existing inequities to avoid further entrenching them and build in accountability measures to ensure equity is a system-wide responsibility. 

Ruth Lavergne is an Associate Professor in the Department of Family Medicine at Dalhousie University.

Erin Christian is the Director of Clinical Networks at the IWK Health Centre in Halifax.

Read their article here in the September 2023 edition of Healthcare Management Forum.