Primary care lessons for Canada from OECD countries

To improve primary care, Canada can learn from Organisation for Economic Co-operation and Development (OECD) countries with high rates of patients attached to primary care clinicians, write authors in an analysis in the Canadian Medical Association Journal.

It is well known in Canada that there is a crisis in primary care, with about 17% of people reporting that they were without a regular primary care clinician before the COVID-19 pandemic. The pandemic made the situation worse, with some family physicians retiring early, a situation common in other countries.

The authors looked at nine countries where more than 95% of people have a family doctor, primary care clinician, or place of care, including France, Germany, New Zealand, United Kingdom, Denmark, Netherlands, Finland, Italy and Norway, and consider lessons for Canada.

Canada's health spending was in the middle of the pack, although the percentage of health spending that was public was the lowest at 70%, a figure unchanged since the 1990s. Canada had similar numbers of family physicians per capita but the lowest number of total physicians per capita and spent less of the total health budget on primary care.

"Other countries have designed their system so that everyone has access to primary care. We need to do the same," says Dr. Tara Kiran, a family physician at St. Michael's Hospital, Unity Health Toronto, and the Fidani Chair of Improvement and Innovation at the University of Toronto. "At the core, we need to guarantee access to primary care and increase how much we spend on it."

Historical factors, such as physicians negotiating to remain autonomous at the introduction of Medicare, have also affected Canada's health system.

Key lessons for Canada:

• Accountability—In countries with high rates of primary care attachment, family doctors have stronger contractual agreements and accountability to the government, insurers or both, whereas in Canada, they are private contractors with little system accountability. These countries also have more family doctors, or general practitioners, working in office-based, generalist practices compared with Canada, where many family doctors work in other parts of the system (e.g., providing emergency or hospital care) or in focused practice (e.g., sports medicine).
• Funding—A higher proportion of the total health budget should be spent on primary care. Medicare coverage in Canada could be extended to prescription medications, dental care, and expanded mental health care to reduce the burden on physicians to provide care in these areas. Canada also needs more physicians per capita.
• System organization — Canada should move to a model where residents are guaranteed access to a primary care practice near their home and ensure that these practices are funded appropriately.
• Information systems — Practice efficiency can be improved, and patient communications can be streamlined with online booking, secure messaging, and a single patient health record accessible across Canada by patients and clinicians.
• Practice organization and physician payment — Governments and medical associations should shift primary care physicians to capitation or salary payments and away from fee for service, which is how most family physicians currently are paid in Canada. More organized after-hours care, fewer walk-in clinics, and expanded roles for other health professionals can enable our primary care resources to be used more efficiently.

"These international examples can inform bold policy reform in Canada to advance a vision of primary care for all," the authors conclude.