Canada’s primary care transformation slow, fragmented: Study

Canada’s primary care system is falling short of high-performance standards despite significant investments to transform the sector, according to a study led by Monica Aggarwal, assistant professor at the University of Toronto’s Dalla Lana School of Public Health.

In a 10-year review of Canada’s primary care performance published in The Milbank Quarterly, the researchers found that Canada lags behind when it comes to providing timely access to doctors and care, developing inter-professional teams and communication across health care settings.

These standards are crucial to improving health outcomes and health equity, lowering mortality rates, and reducing costs, say the researchers, who include Professor G. Ross Baker of Dalla Lana’s Institute of Health Policy, Management and Evaluation (IHPME), research assistant Reham Abdelhalim and Professor Brian Hutchison of McMaster University – with support and input from Professor Rick Glazier of Dalla Lana and the department of family and community medicine at the Temerty Faculty of Medicine.

“The study found that Canada’s primary care transformation has been slow, piecemeal and incremental, with limited changes to the overall organization and delivery of primary care,” says Aggarwal.  

The study, which examined policy changes from 2012 to 2021, is the first to compare and evaluate primary care transformation across all of Canada’s provinces and territories.

The researchers conducted qualitative interviews with experts in each jurisdiction and a literature review of each region’s policies and innovations. The data were then analyzed and assessed using the features of high-performing systems, originally identified by Aggarwal and Hutchison in 2012. 

Aggarwal says challenges to transformation include Canada’s “decentralized health systems, pre-existing policy legacies, inadequate accountable investments in primary care innovations, resistance to change among health-care providers, limited evidence on the impetus of change and insufficient performance measurement and accountability.”  

Based on the assessment of the key features, the authors noted 10 areas that require significant reflection and action. These include reforms in policy direction, which have varied across jurisdictions, and governance mechanisms, which have been slow to effect change.

Formal patient enrolment was found to be limited, despite initiatives to attach patients to primary care providers and teams. Researchers also noted that significant improvement is required regarding involvement of patients in decisions about their care and planning of health services.

Widespread change has also yet to occur when it comes to implementation of funding and provider payment arrangements to support health system goals.

Building research capacity and productivity in primary care also remains an area of underinvestment across Canada.

Other areas of concern include performance measurement, systematic evaluation of new approaches and innovations, leadership development, and coordination and partnerships between primary care and other health-care and social services.

While progress was slow in these areas, the researchers identified areas that showed improvements over the course of the decade.

The adoption of electronic medical records was noted as a significant change, even if the shift toward integrated health records remains slow. Significant progress was also observed in quality improvement training and support for primary care providers. A growing number of jurisdictions are also credited with launching inter-professional teams or networks, although the degree of spread is variable.

In order to accelerate transformation in Canada and abroad, the authors call for a national strategy and performance measurement framework based on meaningful engagement of patients and other stakeholders. This should be accompanied by targeted investments and the building of strong data infrastructure to measure performance and support research, they say.

The study’s findings show Canada has a long way to go to build high-performance primary care systems.

“Canada and the world have waited long enough for high-performing primary care,” says Aggarwal, calling for national and world leaders to “walk the talk.” 

She said the data will enable her and fellow researchers to continue monitoring progress over the years to come.

“I plan to identify best practices and lessons learned in Canada and internationally and hope to create forums by which this knowledge can be available to policymakers so that leaders across the country can learn from each other and work together to build high-performing primary care systems in Canada today and in the future.”