Cross-country project gives patients a say in solving primary-care crisis

As a family doctor, Tara Kiran has seen first-hand the reverberating effects of the primary-care physician shortage on Canada’s health-care system. And it is in her role as a scientist with MAP Centre for Urban Health Solutions that she plans to uncover what patients have to say about these gaps.

Kiran and a team of collaborators are launching OurCare, a three-phase research project that aims to provide much-needed answers to Canada’s primary care woes. “We’ve been having conversations within the profession and with governments about (improving primary care) for a while,” says Kiran. “But we generally don’t bring the public into those discussions in the way that we should. This project is about extending the conversation to include the public’s view about what that future should look like.”

The idea for the project was conceived in June 2021 as a collaboration between Kiran and Peter MacLeod, who runs MASS LBP, an organization that works to involve people in policymaking. Plans were finalized with buy-in from provincial and national health-care partners, stakeholders and the public through the Canadian Medical Association’s group, Patient Voice.

“Primary care is the foundation of the health-care system, yet we’re in a country where almost 5 million people report not having a family doctor or nurse practitioner,” Kiran says.

The ongoing COVID-19 pandemic has exacerbated existing issues in primary care. Burnout, retirement and change of professions have all contributed to dwindling numbers of family physicians.

Replacements are slow in coming: the number of medical students choosing to go into family medicine is declining. Specifically, fewer medical students are going into “comprehensive office-based care,” in which physicians look after patients of all ages throughout their lifetimes.

“This kind of family medicine has become increasingly challenging for a number of reasons,” Kiran says, explaining that comprehensive office-based care models have doctors dealing with the business aspect of medicine on their own. Instead, many family physicians are opting for hospital-based work or specializing in family medicine within emergency medicine or palliative care.

For Kiran, another driver of the shortage of comprehensive office-based family doctors is the payment model. “I’m very lucky to work in a practice where I get paid not by fee-for-service (FFS) or pay-per-visit, but by a payment called capitation.”

FFS is the predominant model in Canada, in which doctors are paid per patient visit. With capitation, the province pays doctors a fee for each person who enrols in their family practices. “(Capitation) gives me more flexibility to spend more time with patients.”

Kiran adds that she feels more supported in her work because she is in a team-based setting, another model preferred by younger family doctors. “There are ways of making practice more attractive, but our systems haven’t moved to that.”

“There are ways of making practice more attractive, but our systems haven’t moved to that.”

The first phase of the OurCare project will roll out a nation-wide survey aimed at understanding the experiences and priorities of patients across Canada. Kiran and her team will distribute the survey through social media and community organizations. Though there are some access limitations (the survey is web-based and will be available in English and French), Kiran says she hopes to capture a wide range of responses to better understand who is getting services and how.

The survey covers a lot of ground — ranging from if and how people access primary care, to preferences regarding virtual care and walk-in clinics, to what patients want prioritized in their care when all options are not possible.

“We know from other countries that there are ways to do better in primary care,” says Kiran. “We want to engage with Canadians to understand their values and what they would be willing to trade off for a future vision of care.”

After the nation-wide survey is complete, the second phase will take a deeper look into one province. OurCare organizers will select 35 people who are roughly representative of the demographics of Ontario to meet over two to three months to learn the ins-and-outs of the primary-care system and its major dilemmas.

At the end, the group will come up with recommendations on how to address issues in Ontario’s primary-care system.

“We know that health care is provincially delivered so the experience is different in different provinces,” says Kiran. “If we get funding, we’d love to do it in other provinces as well.”

The final phase of the OurCare project will involve something that Kiran calls “Healthy Equity Round Tables.” Taking the information gathered from the survey and the second-phase focus group, OurCare will work with marginalized communities in three provinces to understand how their experiences and priorities compare. Details about which groups and provinces will be included are still in the design phase.

“We know there are gaps in the system,” Kiran says. Marginalized groups like those who live in poverty, are new to Canada, are recently incarcerated or have a history of substance-use disorder, are all less likely to have access to primary care. “It’ll be important for us to understand whether the priorities that were identified in these first two phases resonate with marginalized groups. And if not, what are the priorities that are unique or different for them?”

Phases 1 and 2 have secured funding thanks to partnerships with MASS LBP and Staples’ Even the Odds Campaign. Kiran and her team are still looking to finance Phase 3 but hope to see the project completed in the spring of 2023. Organizers will produce a report summary following each phase, and once the entire project is completed, they’ll have a blueprint for what the future of Canada’s primary care should look like according to the public.

Kiran hopes the project will tease out whose primary care needs have been left behind and what those people value most. “This project isn’t just about building a stronger system overall, but also a more equitable system. It’s one that helps close the gap in health outcomes that we see and gets everyone the primary care they need.”

Take the survey here.