The Evolution of Primary Health
Care in Canada
Brian Hutchison
McMaster University
Western Regional Training Centre Seminar
Regina, March 30, 2012
The Evolution of Primary
Health Care in Canada
 Why Primary Health Care Matters
 Where We’ve Been (pre-2000)
 How We’ve Changed (post-2000)
 Where Are We Now?
 Where Do We Need to Go?
 How Will We Get There?
Primary Health Care as a Public Good
“The protection of the people’s health should be recognized by
the Government as its primary obligation and duty to its
citizens”
“Health protection becomes public property, like the post
office, the army, the navy, the judiciary and the school…is
supported by public funds…[and] is available to all, not
according to income but according to need.”
Dr. Norman Bethune
The Case for Socialized Medicine
Speech to the Montreal Medico-Chirurgical Society, 1936
Definitions
Primary Care
“that level of the health service system that provides entry into
the system for all new needs and problems, provides personfocused (not disease-oriented) care over time, provides care
for all but very uncommon or unusual conditions, and coordinates or integrates care provided elsewhere by others.”
(Starfield, 1998)
Primary Health Care
extends beyond primary care to include health promotion,
community participation and intersectoral action to address
the determinants of health
Why Primary Health Care Matters
“National health care systems with strong primary care
infrastructures have healthier populations, fewer healthrelated disparities and lower overall costs for health
care.”
Starfield, CMAJ 2009;180(11):1091-2
“The strength of a country’s primary care system was
negatively associated with (a) all-cause mortality, (b) allcause premature mortality and (c) cause-specific
mortality from [pulmonary and cardiovascular diseases].”
(data from 18 wealthy OECD countries, 1970-98)
Macinko, Starfield & Shi, Health Serv Res 2003;38(3):831-65
Why Primary Health Care Matters
More specialists: higher costs, lower quality
More primary care physicians: lower costs, higher
quality
(data for Medicare beneficiaries from 50 US states)
Baicker & Chandra, Health Affairs, April 7 2004;W4:184-97
Where We’ve Been (pre-2000)
 1960s – introduction of universal public insurance for
physician services
 1970s – alternative organization and funding models
 mid-1980s through 1990s – broadening the range of
primary care providers
 mid-1990s – primary care reform pilot and demonstration
projects
Primary Care in Canada: So Much Innovation, So Little Change
(Hutchison, Abelson & Lavis, Health Affairs 2001)
How We’ve Changed (post-2000)
Policy Recommendations
 Standing Senate Committee on Social Affairs, Science and
Technology, 2002
“The federal government should provide ongoing financial
support for reform initiatives that lead to the creation of multidisciplinary primary health care groups”
 Commission on the Future of Health Care in Canada, 2002
“Four essential building blocks should define primary health
care across the country: continuity of care, early detection and
action, better information on needs and outcomes, and new
and stronger incentives for health care providers to participate
in primary health care approaches”
How We’ve Changed (post-2000)
Policy Commitments
 Increase access to primary health care organizations providing a
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defined set of services to a defined population
Increase the emphasis on health promotion, disease and injury
prevention, and chronic disease management
Expand 24/7 access to essential services
Establish interdisciplinary primary health care teams
Facilitate coordination and integration with other health services.
Goal of 50% of Canadians having access to multidisciplinary
primary health care teams 24 hours a day, 7 days a week by 2011.
Accelerate development and implementation of the electronic
health record and telehealth initiatives targeting remote and rural
communities
How We’ve Changed (post-2000)
Primary Care Reform Strategy
 Voluntary participation of providers and patients
 Incremental approach to system change
 Pluralism of physician payment and organizational models
 Engagement of provincial medical associations in policy
development and implementation
How We’ve Changed (post-2000)
Key Initiatives
 Expansion of health professional training programs
 Group practices and practice networks
 Interprofessional primary health care teams
 Quality improvement training and support
 Financial incentives and blended physician payment schemes
 Contracts and accountability agreements
 Patient registration/rostering/enrolment
 Investment in information management at the practice level
 eHealth investments – electronic health records and telehealth
 Investment in evaluation of innovations
Where Are We Now?
 Public payment for private practice
 Family physicians:
 comprise 50% of the physician workforce
 work predominantly in solo and small group practices
 90% of Canadians have a regular doctor
 Satisfaction with primary care quality is high
ACCESS
Regular Doctor
ER Visit in Past 2 Years
That Could Not Have
Been Treated by Regular
Doctor if Available
Online Appointment
Booking
Able to Communicate
with Doctor by Email
No ER Visit in Past 2 Years
Very or Somewhat Easy
to Get Needed After
Hours Care Without
Going to ER
Very Easy to Contact
Doctor by Phone During
Practice Hours
Time to Last
Appointment When Sick
(Same or Next Day)
BEST PERFORMER
CANADA
Commonwealth Fund International Health Policy Survey of sicker
adults in 8 countries: Australia, Canada, France, Germany, the
Netherlands, New Zealand, the U.K., the U.S.
HEALTH INFORMATION TECHNOLOGY
& OFFICE SYSTEMS
Use of EMR
Computerized List of
Patients by Lab
Result
Computerized Lilst of
Patients by Diagnosis
Computerized Patient
Reminders
Computerized
Physician Reminders
Electronic Test
Ordering
Electronic Prescribing
Electronic Drug Alerts
Computerized
Tracking of Test
Results
BEST
PERFORMER
CANADA
Commonwealth Fund 2009 International Health Policy Survey of
primary care physicians in 11 countries: Australia, Canada,
France, Germany, Italy, the Netherlands, New Zealand, Norway,
Sweden, the U.K., the U.S.
Practice uses nonphysician staff to
manage care
CARE MANAGEMENT
Financial support or
incentives for adding
non-physician
clinicians to the
practice team
Practice routinely
gives patients written
list of medications
BEST PERFORMER
Practice routinely
gives chronically ill
patients written
instructions on
managing care at
home
CANADA
Commonwealth Fund 2009 International Health Policy Survey of
primary care physicians in 11 countries: Australia, Canada,
France, Germany, Italy, the Netherlands, New Zealand, Norway,
Sweden, the U.K., the U.S.
Practice Routinely
Receives and Reviews
Data on Clinical
Outcomes
Practice Has a
Process for
Identifying and
Following Up On
Adverse Events That
Works Well
PERFORMANCE
MONITORING
Practice Receives and
Reviews Data on
Patient Satisfaction
and Experience
BEST PERFORMER
Practice's Clinical
Performance
Routinely Compared
With Other Practices
CANADA
Commonwealth Fund 2009 International Health Policy Survey of
primary care physicians in 11 countries: Australia, Canada,
France, Germany, Italy, the Netherlands, New Zealand, Norway,
Sweden, the U.K., the U.S.
Where Do We Need to Go?
Where Do We Need to Go?
Clinical Practice
Where Do We Need to Go? Health System
Family and
Informal
Supports
Adapted from Charles Kilo’s “Primary Care Oriented Health System” model by the Health Quality Ontario Primary Care Quality Improvement Team
Where Do We Need to Go?
Improvement Aims
IOM Improvement
Aims
IHI Triple Aim
Population
Health
Safety
Effectiveness
X
Person-centredness
Patient
Experience
Per Capita
Health Cost
X
X
X
X
X
Timeliness
X
X
Equity
X
X
Efficiency
X
X
How Will We Get There?
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Declared policy direction anchored in public values,
needs and preferences
Primary health care governance at the community,
regional and provincial/territorial levels
Patient enrolment
Interprofessional teams
Funding and provider payment arrangements aligned
with health system goals
Leadership development
How Will We Get There?
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Patient engagement
Health information technology that effectively supports
patients and providers
Continuous quality improvement linked with ongoing
performance measurement
Coordination/integration/partnerships with other
health and social services
Systematic evaluation of innovation
Research to inform policy and practice
Challenges and Shortcomings
 System complexity
 Physician engagement
 Teamwork
 Investment requirements
 Equity
 Evidence-informed decision making
Lessons Learned
 Policy legacies and entrenched professional and public
values limit the possibilities for radical reform
 There is no single “right” model for the funding,
organization and delivery of primary health care
 Changing physician payment methods and organizational
forms does not automatically lead to changes in the
delivery or outcomes of care
Lessons Learned
 Primary health care renewal requires major investments
in system transformation and infrastructure
 Broad-based primary health care transformation is
possible only with the support of organized medicine
 System-level change is achievable through a voluntary
process that is incremental, cumulative and allows for
multiple complementary and continually evolving
organizational, funding and payment models
What Now?
 Staying the course
 Building a strong coalition in support of
primary health care improvement
“Here is Edward Bear coming
downstairs now, bump, bump, bump,
on the back of his head, behind
Christopher Robin. It is, as far as
he knows, the only way of coming
downstairs, but sometimes he feels
that there really is another way, if only
he could stop bumping for a moment
and think of it”
A.A. Milne 1926
Illustration E.H.Shepard 192614
“The future is already here. It’s just very
unevenly distributed.”
William Gibson