There aren’t enough family doctors to go around.
Cuts to medical school enrolment in the 1990s have meant that a sizable proportion of family doctors today are over age 65 and nearing retirement. The pandemic seems to have spurred many family doctors to stop working; one in five Toronto-area doctors are thinking of closing their practice in the next five years. At the same time, fewer medical students are choosing family medicine and among those who do, fewer are choosing to practice longitudinal office-based care. Our population is growing, people are living longer, and family doctors seem to be caring for smaller panels of patients.
So, how can we ensure that everyone in Canada has access to high-quality primary care when there is a growing shortage of family doctors?
Part of the answer lies in team-based primary care – family doctors and nurse practitioners (NP) working together with nurses, social workers, pharmacists, dietitians, physiotherapists and/or other health professionals to care for patients collaboratively, sharing one health record and ideally working under one roof.
Done right, team-based care can expand the capacity of family doctors to care for more patients.
Results from the OurCare national research survey of more than 9,000 people in Canada demonstrate strong support for team-based primary care – but the results also highlight how few people have access to it right now.
Only 5 per cent of people in Canada reported having an NP as their primary-care clinician and only 31 per cent said their primary-care practice included an NP. Yet, NPs are highly skilled and can be the most responsible primary-care clinician for many individuals. They can work independently or alongside family doctors, often in collaborative models of team-based care.
Respondents were overwhelmingly supportive of team-based care. Ninety per cent said they would be comfortable (39 per cent) or very comfortable (51 per cent) getting support from another member of a primary-care team if it was recommended by their family doctor or NP.
How can other team members help? Nurses can provide routine child care, counsel for preventive care and help manage stable chronic conditions. Social workers can provide counselling for mental health and addictions, support system navigation and connect people to community resources that address social needs. Pharmacists can optimize medications, dietitians can provide nutritional advice, and physiotherapists can assess and manage musculoskeletal problems. These are just a few examples of how we can leverage expertise to ensure high-quality care while growing the capacity of family physicians and NPs.
In addition to providing patients with access to health professionals with complementary expertise, teams can enhance care coordination and patient experience. They provide family doctors and NPs with valuable peer support and the ability to share responsibilities for patient care. Not surprisingly, research has demonstrated that team-based primary care can improve health outcomes as well as clinicians’ joy in work. Equitable access to these services is key to ensuring society’s most vulnerable groups reap the benefits of improved health outcomes.
However, the OurCare survey indicated that few people in Canada have access to a robust primary-care team. A minority said they had other health professionals as part of their practice. Thirty-six per cent of respondents who had a family doctor or NP said a nurse was part of the practice, but fewer than 15 per cent said that pharmacists, dieticians or social workers were.
In addition, too few respondents seemed to have a family doctor or NP that belonged to a group that provided cross-coverage when their care providers were away. Only half of those surveyed said they could access another family doctor or NP always (25 per cent) or usually (26 per cent) if their own provider was unavailable – a critical set-up for ensuring timely access for patients while preventing burnout for clinicians.
Group practice seems to also have other benefits for patients. Data from a recent survey of Canadian family physicians found that more physicians in group practice offer weekend appointments, use other personnel to manage chronic conditions, use electronic medical records and offer on-line booking.
When asked who should be part of a primary-care team in addition to a family doctor, survey respondents most commonly identified the following professions:
- 75 per cent – Nurse Practitioner
- 51 per cent – Nurse
- 51 per cent – Pharmacist
- 50 per cent – Psychologist
- 48 per cent – Physiotherapist
Interprofessional teams are considered a foundational building block of primary care and are endorsed as part of the vision for the Patient’s Medical Home model put forth by the College of Family Physicians Canada. Likewise, the Canadian Nurses Association views interprofessional collaboration as critical to improving access to patient-centered health-care delivery.
Yet, despite this recognition, expansion of team-based care across Canada has been heterogenous, staggered and slow. Ontario is one province that made early progress but even so, less than 30 per cent of Ontarians have access to a primary-care team. Ontario introduced the Family Health Team model in 2005 but paused expansion in 2012, ostensibly due to cost. Ontario’s Community Health Centres have been around for decades but provide family medicine services to less than 2 per cent of the population.
Unfortunately, the population potential of team-based care has not been fully realized in Ontario. The average number of patients cared for per doctor is currently lower in these models than in non-team models. Teams were not initially implemented with the goal of increasing the capacity of family doctors to take on more patients – they need to be re-oriented toward this objective in ways that we know work. And sadly, research has demonstrated that areas with the highest primary care need have the lowest access to team-based care – we need to reverse that.
In the next phase of OurCare, we are conducting in-depth dialogues with everyday people in five provinces across Canada about their priorities and recommendations for primary care. This week, we released the recommendations from the Ontario Priorities Panel. A key recommendation is to move away from solo providers and expand team-based care for all residents of the province.
The three of us, at some point in our careers, have each experienced the joy of practicing primary care as part of a dynamic, supportive team. We’ve reaped the benefits professionally of learning from our colleagues and tackling complex issues with the help of many minds put together. We’ve seen patients reap the benefits of diverse expertise and wrap-around care.
It’s time for all clinicians and patients to reap the same rewards; the OurCare survey tells us people are ready to embrace change. Let’s expand team-based care with the objectives of closing equity gaps and improving clinician capacity to ensure every person in Canada has access to primary care.
Explore the data yourself at data.ourcare.ca. For more information about OurCare, visit OurCare.ca.