What can publicly funded schools teach us about how to fix the family doctor shortage?

Abstract

Recent estimates suggest that up to 22% of Canadians over 18 do not have regular access to a family doctor or nurse practitioner. This lack of access is often characterized as a “family doctor shortage” and has been making headlines for decades. However, we have more family doctors than ever before, and in fact, the lack of primary care access is less about a shortage of physicians and more a need to develop a modern infrastructure and new way of funding and organizing care. Real change will require a paradigm shift from doctor- to clinic-organized care. The example of how schools are organized for public education may hold answers about how to make that paradigm shift and with investment in infrastructure see improvements in access to care across the country.

The problem

Lack of access to primary care is a complex problem that cannot be solved through simple calculations of how many more doctors we need. ¹ Recent estimates suggest that up to 22% of Canadians over the age of 18 do not have regular access to a family doctor or nurse practitioner. ² This lack of access is often characterized as a “family doctor shortage” and has been making headlines for decades.^3-8 Fixing the shortage may seem as simple as dividing the total population by the average number of patients a doctor can see, then hiring or training the number of doctors that are “missing” from the current workforce. However, this “go to” approach to workforce planning has not worked, and despite having more family doctors per capita than ever before,^9,10 we have worse access to primary care. ¹¹

Calculating the number of doctors needed

Let’s examine the case of British Columbia which has a population of ∼5,500,000 people and ∼6,800 licensed family doctors. ¹² If we divide the population by the number of doctors, we get a standard practice size, or panel, of 809 patients. This panel size is well within what published studies suggest is reasonable.^13,14 However, this calculation has two major flaws. First, it does not account for the approximately ∼3,400 BC-licensed family physicians who do not provide community-based primary care and who do alternative work, such as providing hospital-based care or outpatient substance use disorder treatment.^15,16 This changes the calculation to the remaining 3,400 doctors theoretically each caring for ∼1,618 patients each. This larger number poses a potential excessive work volume, which compounds the other major flaw of the calculation: the assumption that all actual needs of patients can be met by their family doctor,^17-19 that all family doctors will work the same hours and with the same set of skills,^16,20 and that practice infrastructure will work seamlessly without creating any extra work for physicians.^21,22 In fact, patients are not interchangeable units of work, neither are family physicians interchangeable workers.

Existing research tells us there is significant variation in patient needs^18,19,23-25 and physician practice patterns.^16,20,26 For example, some doctors may work in neighbourhoods or with sub-populations whose needs are more complex and therefore each patient visit needs more time and/or resources, meaning fewer patients can be seen. The majority of existing primary care access in Canada is not team-based but rather is delivered by a family doctor and an administrative staff. ²⁷ The doctor would rarely be expertly equipped to do the work that, for example, a social worker, nurse, or pharmacist could do, and even if they did have those skills, performing them would take time away from seeing more patients. In order to provide equitable access to primary care, we need to adopt solutions that centre on team-based care and comprehensive infrastructure rather than just increasing the number of physicians.

The future is team-based

The new gold standard of quality primary care is team-based. ²⁸ Team-based primary care provides a patient a “medical home” centred on an ongoing relationship with a primary care provider (Nurse Practitioner (NP) or Family Physician (FP)) and also has skilled supports from a collaborative team. ²⁹ Teams can provide better care to patients and offer more support to doctors, reducing the likelihood of burnout and increasing the likelihood of retention.^30,31 Teams allow the clinic, rather than the doctor, to become the unit of organization, planning, and funding, and staffing to ensure access to primary care. Many existing team-based models still require a patient to be first attached to a NP or FP, so if you don’t have an NP or FP, neither can you access the team. Most primary care practices are owned by physicians and practice funding is done almost entirely through existing pay-per-visit remuneration and all team member salaries must be paid from this income. ²⁷ These payment models have been tinkered with for several years, but there has been only limited development of alternatives to physician-owned/operated infrastructure. ¹¹ Importantly, the status quo—physician-owned and operated practices with fee for service funding—has been providing quality primary care access to millions of Canadians to date; however, the model has failed to recruit and retain the workforce required to meet the ever growing gap in access to primary care.^32,33

Modernizing the workplace

Like most other workers in Canada, family doctors’ preferences and choices about how they work have been changing over the last few decades.^20,32,34 The majority want to work in teams, have a stable income, and be able to take a vacation and go on parental leave. ²¹ Forty-seven percent would prefer to be an employee of a clinic, rather than a small business owner, an option that remains not readily available in most Canadian provinces and territories. ²¹ We don’t have a shortage of family physicians, we have a shortage of qualified people willing to work in an outdated model of care. That model used to work well, but no longer is a one-size-fits all solution.

Lessons from public schools

The organization and funding of public schools may hold some answers to a better way forward, though the analogy is imperfect. Both education and healthcare are publicly funded and have federal and provincial legislations assuring reasonable access to improve the common good.^35,36 Across Canada, families are able to enrol their children into publicly funded educational programs, no matter where they live. ³⁶ If they move, they move their educational access needs to a new school. If public education access relied on the type of calculations we make for primary care, that is, taking the number of children needing access divided by average class size equals number of teachers needed to be employed/hired, education access would also be in trouble.

Teachers do not run schools as their own private businesses where they lease a school building and pay other team members out of their own publicly funded remuneration. Instead, there is provincially led geographic distribution of funding for educational infrastructure that includes school buildings and operating budgets, salaries for leaders (e.g. principals), administrative support, and specialized professionals such as librarians, counsellors, and remedial supports. Additional funding covers curriculum development and updates, as well as information technology systems and assessment tools. A student is “attached” to a teacher, who expertly manages each student’s learning needs, and connects them to additional resources needed. Teachers are essential to education, and key to shaping the best possible publicly funded system, but they could not provide guaranteed access without the accompanying educational infrastructure that allows them to do their work. The idea that a responsive, effective, and equitable, province-wide system can rely on self-employed, individual doctors to make a community-level decision to practice in the most-needed location and care only for the patients whose health needs are unmet is far-fetched.^37,38

Community Health Centres could lead the way

We already have a time-tested “school-like” organization alternative for primary care; Community Health Centres (CHCs) provide high quality team-based care that is responsive to a specific community’s needs. ³⁹ CHCs have been in operation for almost 100 years in Canada, despite a lack of consistent provincial or federal funding models or supports. ⁴⁰ Each CHC designs a community-specific primary care program and adheres to a shared vision and governance model.^41,42 CHCs have primary care teams that work collaboratively to provide comprehensive care to patients and model an attractive and sustainable work environment for family doctors and other team members.^30,43,44 Family physicians are essential CHC team members, but they do not own and operate the business; instead, the clinic is a community-led, non-profit organization that is connected to other CHCs provincially ⁴² and nationally. ⁴¹ Investment and supports for new and existing CHCs could help develop a new primary care system^8,45 that is as accessible as our school system.

Recommendations for policy-makers and health leaders

Have the right people at the solutions tables

Primary care like public education is a common good. Stakeholders are diverse and include patients, communities, policy-makers and care providers. When public education needs to address a system problem, it is expected to engage students, parents, community members as well as teachers and administrators. Too often, discussion of solutions to improve access to primary care has occurred with just physician organizations and government representatives—often, behind closed doors. ⁴⁶ New ventures such as the 2022 “Our Care” pan-Canadian consultation with patients and members of the public, about the future of primary care (ourcare.ca), will add a missing perspective that can help understand both the effects of the access issues as well as the most desirable solutions to be prioritized. ⁴⁷ Failure to include these other voices has facilitated a recycling of partial fixes centred around a doctor-driven primary care system. If we truly want a primary care system that will improve health equity, as well as guarantee universal access, we need to create new approaches with diverse perspectives.

Separate infrastructure funding from physician remuneration

A modern primary care system needs infrastructure organization and funding that does not entirely rely on self-employed physicians deciding to start their own business in the highest needs location. Like a functioning education system, there are predictable, reasonable costs for operations, facilities, and staffing that should be planned in addition to attractive and appropriate physician remuneration. This funding should be based on community need and geographically distributed. This requires provincial and regional mechanisms to (a) assess regional need and (b) proactively fund operating costs of community-based, patient-centred clinics. Direct funding of, for example, Community Health Centres would focus service to areas most in need, ⁴⁸ improve physician recruitment—both those newer to practice and physicians whose current practice patterns avoid running their own business ³⁷ —and potentially improve patient care outcomes.^39,40,49 An attractive physician remuneration package is important, but only a part of a complete investment package for primary care. Provincial and federal governments must finance and build the primary care infrastructure people living in Canada deserve, and CHCs are a great model to base that on.

Invest in teams

Team-based primary care is the future, but there is varied implementation ⁵⁰ and exactly how to make it happen is still being sorted.^51,52,53 A clinic-based team that shares space, resources, and a vision for collaborative, patient-centred care is shown to be associated with improved care. ⁵⁴ In British Columbia, there is increasing recognition of the value of team-based care, but implementation has focused on “primary care network” supports outside the clinic structure that vary region to region. ⁵⁵ These resources, such as counselling and dietitian services, are not directly available to patients, but only those who are referred via an NP or FP that they have been able to see. A clear definition of what team-based primary care looks like and a robust and transparent evaluation plan to evaluate how it is meeting patient, provider, and system needs is a key element of a transition from a doctor-organized system to a clinic-organized system. ⁵⁶ No one would suggest that we return to a one-room school house for delivery of public education; similarly, we should move on from physician-only primary care practices.

Conclusion

The family doctor shortage in Canada is less about a shortage of physicians and more a need to develop a modern infrastructure and new way of funding and organizing care. This will require a paradigm shift in thinking from doctor- to clinic-organized care, like how public education is planned for at a school level, rather than teacher-by-teacher. We need more primary care teams and a provincial-level commitment to community-centred primary care access with long-term dedicated infrastructure funding, just like we have for public education.

ORCID iD

Rita K. McCracken https://orcid.org/0000-0002-2962-0364