Abstract
Objective
To present recommendations from 5 provincial reference panels conducted as part of the OurCare initiative, the largest-ever national effort to engage the public about the future of primary care in Canada.
Composition of the committee
Each provincial reference panel included 30 to 36 members of the public who were randomly selected to represent the demographic characteristics of that province. Panels were held in Nova Scotia, Quebec, Ontario, Manitoba, and British Columbia.
Methods
OurCare panelists spent up to 40 hours learning about primary care from experts in each province and deliberating to reach consensus on values, issues, and recommendations. Provincial advisory committees were composed of clinician leaders, policy-makers, and researchers. In each province, OurCare panelists collectively developed a report summarizing the results of their deliberations.
Report
Panels in all 5 provinces identified 3 major challenges affecting primary care: a growing health workforce crisis, inequitable access to care, and fragmented services. Participants emphasized that everyone in Canada should have timely, equitable access to primary care, and called for a system that is prevention-focused, inclusive, patient-centred, and accountable. In all provinces, panelists recommended expanding team-based care, improving health professional retention and recruitment, ensuring patient access to health records, addressing the social determinants of health, and educating and empowering patients.
Conclusion
Results from the reference panels provide actionable direction for health system leaders, policy-makers, family physicians, and others engaged in health system improvement.
Résumé
Objectif
Présenter les recommandations de 5 panels de référence provinciaux consultés dans le cadre de l’initiative NosSoins, l’effort national le plus considérable à ce jour pour mobiliser la population pour l’avenir des soins primaires au Canada.
Composition du comité
Chaque panel de référence provincial était formé de 30 à 36 membres du public qui étaient choisis aléatoirement pour représenter les caractéristiques démographiques de leur province. Les panels se sont rencontrés en Nouvelle-Écosse, au Québec, en Ontario, au Manitoba et en Colombie-Britannique.
Méthodes
Les panélistes de NosSoins ont passé jusqu’à 40 heures à être renseignés par des experts à propos des soins primaires dans chaque province, et à délibérer pour en arriver à un consensus sur les valeurs, les enjeux et les recommandations. Les comités consultatifs régionaux regroupaient des leaders cliniciens, des décideurs et des chercheurs. Dans chaque province, les panélistes de NosSoins ont collectivement élaboré un rapport résumant les résultats de leurs délibérations.
Rapport
Les panels des 5 provinces ont cerné 3 principaux problèmes affectant les soins primaires : une crise grandissante du personnel de santé, les iniquités dans l’accès aux soins et la fragmentation des services. Les participants ont insisté sur le fait que toutes les personnes au Canada devraient avoir un accès équitable et en temps opportun, et ont revendiqué un système axé sur la prévention, inclusif, centré sur le patient et imputable. Dans toutes les provinces, les panélistes ont recommandé l’élargissement des soins en équipe, l’amélioration de la rétention et du recrutement des professionnels de la santé, l’assurance d’un accès par les patients aux dossiers de santé, la prise en compte des déterminants sociaux de la santé, de même que l’éducation et la responsabilisation des patients.
Conclusion
Les résultats des panels de référence offrent des orientations réalisables aux dirigeants du système de santé, aux décideurs, aux médecins de famille et aux autres intervenants impliqués dans l’amélioration du système de santé.
Canadians value the principle of universal health care,1,2 yet more than 1 in 5 people in Canada do not have access to primary care, the front door to our publicly funded health care system.3 Currently, this system and the people working in it are under tremendous strain. There is need for the health care system to change to meet the demands of an aging, growing population4,5; rising medical and social complexity6-8; advances in medicine9; and an older, burned out workforce.10-12 These reforms should be shaped by the expressed values, needs, and priorities of patients and the public, but too often these voices are left out of critical discussions. In this report, we reflect on the values, policy priorities, and recommendations from provincial reference panels conducted as part of the OurCare initiative and discuss next steps to advance the public’s vision for better primary care.
Composition of committee
OurCare is the largest ever national effort to engage the public about the future of primary care in Canada.13 As part of OurCare, we hosted a series of 5 reference panels conducted in 2023 in Nova Scotia, Quebec, Ontario, Manitoba, and British Columbia. Each reference panel included 28 to 35 members of the public (panelists) who were randomly selected to represent the geography and demographic characteristics of their province, with overweighting of specific equity-deserving groups (Figure 1 and Table 1).14 Members volunteered their time but received funds to offset relevant costs such as child care, Internet, devices, and lost wages.
Figure 1.
Geographic distribution of members of the public who participated in the OurCare reference panels
Table 1.
Demographic characteristics of reference panel participants
| CHARACTERISTIC | BRITISH COLUMBIA, n=31 | MANITOBA, n=28 | ONTARIO, n=35 | QUEBEC, n=31 | NOVA SCOTIA, n=34 | TOTAL, N=159 |
|---|---|---|---|---|---|---|
| Gender, n (%) | ||||||
| • Woman | 18 (58) | 15 (54) | 17 (49) | 17 (55) | 17 (50) | 84 (53) |
| • Man | 12 (39) | 12 (43) | 16 (46) | 14 (45) | 17 (50) | 71 (45) |
| • Nonbinary or GNC | 1 (3) | 1 (4) | 2 (6) | 0 (0) | 0 (0) | 4 (3) |
| Age, n (%) | ||||||
| • 18-29 | 3 (10) | 2 (7) | 5 (14) | 3 (10) | 5 (15) | 18 (11) |
| • 30-44 | 9 (29) | 7 (25) | 9 (26) | 9 (29) | 7 (21) | 41 (26) |
| • 45-64 | 12 (39) | 12 (43) | 13 (37) | 10 (32) | 12 (35) | 59 (37) |
| • ≥65 | 7 (23) | 7 (25) | 8 (23) | 9 (29) | 10 (29) | 41 (26) |
| Have difficulty paying monthly bills, n (%) | 10 (32) | 10 (36) | 19 (54) | 12 (39) | 15 (44) | 66 (42) |
| Have been in Canada for <10 y, n (%) | 3 (10) | 5 (18) | 5 (14) | 6 (19) | 6 (18) | 25 (16) |
| Ethnicity, n (%) | ||||||
| • Indigenous | 1 (3) | 7 (25) | 3 (9) | 1 (3) | 1 (3) | 13 (8) |
| • Racialized | 12 (39) | 5 (18) | 15 (43) | 9 (29) | 9 (26) | 50 (31) |
| • White | 18 (58) | 16 (57) | 17 (49) | 21 (68) | 24 (71) | 96 (60) |
| Health status, n (%) | ||||||
| • Good, very good, or excellent | 24 (77) | NA | 29 (83) | 21 (68) | 26 (76) | 100 (76) |
| • Fair or poor | 7 (23) | NA | 6 (17) | 10 (32) | 8 (24) | 31 (24) |
| Does not have a primary care clinician, n (%) | 12 (39) | NA | 6 (17) | 12 (39) | 11 (32) | 41 (31) |
GNC—gender nonconforming, NA—not applicable.
Methods
OurCare panelists spent up to 40 hours learning about primary care from experts in each province and deliberating to reach consensus on values, issues, and recommendations. We provided simultaneous language interpretation as needed. Provincial advisory committees composed of clinician leaders, policy-makers, and researchers helped shape the process and curriculum (Figure 2). For example, based on input from Manitoba’s advisory committee, we over-represented the Indigenous population in that panel, with approximately one-quarter of Manitoba panelists self-identifying as First Nations, Métis, or Inuit. In each province, OurCare panelists collectively developed a report summarizing the results of their deliberations.14
Figure 2.
Sample structure and curriculum for the reference panels in British Columbia
Report
What do people in Canada feel are the pillars of primary care? Figure 3 summarizes the values identified by 5 panels as foundational to the primary care system. Accessibility was a consistently articulated value closely related to equity. Panelists felt that everyone in Canada should have equitable access to publicly funded primary care when, where, and how they need it. Care should be free of barriers and discrimination, inclusive by design, and responsive to the diverse needs of patients, regardless of their ability, background, location, or socioeconomic status. They defined equitable care as care that is destigmatized, anti-oppressive, and culturally responsive; care that acknowledges the role of power, privilege, and prejudice; and care that addresses the social determinants of health.
Figure 3.
Values to guide primary care renewal as identified by members of the public in each of the 5 provincial reference panels
Panelists in all provinces underscored the importance of a prevention-focused, wellness-promoting primary care system that aims to address health problems before they occur. Panelists highlighted the need for a holistic health care system, which they defined as care that focuses on a person’s overall well-being; addresses the physical, mental, spiritual, and social needs of patients; and provides care in the context of patients’ communities. Panelists believed the health care system should also be sustainable, equipped to handle changing and growing population needs, and support patients’ long-term well-being.
Accountability was also an important value described by 4 provincial panels: panelists emphasized the importance of trust and transparency at both the clinician and system levels. They described an accountable primary care system as one with clear standards of care co-designed with patients, and health system outcomes that are clearly defined, measured, and publicly reported.
Panelists also consistently articulated values of patient-centred care using the terms considerate, understandable, empathic, and respectful. They wanted patients to be empowered to be active partners in their care and informed of their rights and care options. They conveyed that clinicians should listen to patients and respect their unique knowledge, lived experience, values, and needs, and customize care accordingly.
What key challenges should be addressed? In all 5 provinces, panels identified 3 major challenges affecting primary care systems: a growing human health resource crisis, inequitable access to care, and fragmented care (where continuity of care is not prioritized). In addition, several panels spoke about the need to address outdated and fragmented health information systems, a lack of patient empowerment, and the lack of long-term planning and accountability. One panel (Quebec) also flagged that the quality of care in the publicly funded system was being undermined by the growing presence of for-profit care delivery and care options requiring out-of-pocket payment.
What recommendations were consistently voiced by members of the public? We identified 7 cross-cutting themes from the 5 reference panel reports (Table 2).
Table 2.
Recommendations to improve primary care in Canada as identified by members of the public in 5 provincial reference panels
| THEME | RECOMMENDATIONS (RELEVANT PROVINCIAL REFERENCE PANEL) | RELEVANT QUOTATIONS FROM PANEL REPORTS |
|---|---|---|
| Health professional retention and recruitment |
|
|
| Team-based care for all |
|
|
| Accessible patient-held health record |
|
|
| Virtual and mobile care |
|
|
| Diversity and inclusion |
|
|
| Patient empowerment and transparency |
|
|
| Upstream action |
|
|
BC—British Columbia, MB—Manitoba, NS—Nova Scotia, ON—Ontario, QC—Quebec.
Health professional retention and recruitment: All panels recognized the importance of improving working conditions for family physicians and other primary care professionals. Some panels specifically cited the importance of addressing administrative burdens that reduce 1-on-1 time with patients and contribute to burnout for clinicians. Three panels had creative suggestions for enhancing recruitment and retention of primary care professionals, from advertising campaigns to student incentives, and expansion of grassroots initiatives. Four panels recommended accelerating integration of internationally trained primary care professionals into the workforce.
Team-based care for all: All panels strongly recommended expanding team-based care, recognizing it as a way to address clinician burnout, improve access, and provide more comprehensive care. In British Columbia and Manitoba, panels specifically recommended expanding community health centres and access centres, which are community-governed team models. Three panels explicitly recommended starting the expansion of teams in areas of greatest need. Nova Scotia made specific suggestions to integrate specialists into primary care teams; Ontario and British Columbia recommended organizing care akin to the public school system; and Ontario suggested a move toward “automatic rostering” where health teams are mandated to accept any patient from their catchment, with provisions for patient choice.
Patient-held health record: All panels were clear that patients should have easy access to their own medical records with provisions in place to ensure the privacy and security of patient data. Some panels suggested a common data standard to enable interoperability, and that patient data should only be used for purposes related to health care provision and not for commercial purposes (eg, selling to third parties). Nova Scotia spoke about extending their hospital-based provincial “One Person One Record” initiative to include primary care and other health professionals such as pharmacists, physiotherapists, and dentists; and recommended supports and incentives to encourage professionals to use the platform.15
Virtual and mobile care: Four panels recommended expanding virtual and mobile care options to enhance access in rural and remote communities and for those with mobility challenges. Three panels were explicit that virtual care should only be provided as a part of a continuum of longitudinal care that includes in-person care and not as a stand-alone care modality. They wanted to see investment in infrastructure to make virtual care more accessible, including providing affordable and reliable Internet and using public places (eg, libraries) as access points. Panelists were clear that virtual care should not replace in-person care if in-person care is requested and feasible.
Diversity and inclusion: Three panels recommended clinicians be trained in cultural safety and humility, and in anti-discrimination behaviour. Two panels wanted to see more health professional recruitment of Indigenous, northern, and other historically excluded communities. Two panels made recommendations to integrate Indigenous perspectives in training and care, while another recommended community perspectives be integrated into resident curriculum development. Manitoba specifically included an entire section of recommendations dedicated to improving primary care for Indigenous peoples.
Patient empowerment and transparency: All panels included recommendations to strengthen community involvement in primary care policy, planning, and evaluation; education of the public on their rights and the value of primary care; and measurement and public reporting on the primary care system, including research on the impact of reforms. Panelists also had a range of recommendations to support education and empowerment, including creating a “train the trainer” campaign, collaborating with filmmakers, and developing a primary care charter that clarifies the rights and expectations of patients.
Upstream action: Panelists recognized that health and well-being require more than the physician and hospital visits currently covered through provincial insurance plans. Four panels recommended expanding public coverage to include mental health, vision, dental, physical therapy, and medications—or to remove related financial barriers. All panels recommended addressing the social determinants of health, with some calling for stronger links between primary care and community agencies to address issues like employment, housing, and poverty. Panelists in Nova Scotia recommended primary care clinics adopt social prescribing, while in Manitoba panelists wanted a social worker or community resource worker as a full-time member of the health care team.
What are some potential next steps? Members of the public from diverse backgrounds and life experiences across Canada strongly endorsed publicly funded, accessible primary care for all. Recommendations from the provincial reference panels, along with the results from the OurCare national survey and community round tables, have been distilled into the OurCare Standard, which are 6 statements summarizing what every person should expect from their primary care system (Figure 4).14 Our aim is for the OurCare Standard to be used by health system leaders to guide meaningful change in line with patient values and priorities.
Figure 4.
The OurCare Standard
Table 3 summarizes actions that can be taken by different actors in the system. Three areas of policy change are particularly actionable by governments. First is growing the primary care workforce. This includes increasing availability of primary care–specific training for a range of professionals and accelerating integration of internationally trained health care workers. It also means making primary care more attractive to those in practice; for example, through better remuneration relative to other specialties and decreasing administrative burdens.
Table 3.
Actions that can be taken by various individuals and organizations in the health care system to implement recommendations from members of the public
| TARGET GROUP | EXAMPLE ACTIONS |
|---|---|
| Government |
|
| Professional organizations and colleges |
|
| Education and training institutions |
|
| Family practices and primary care clinicians |
|
Second, Canada can do more to harness the potential of interprofessional teams to improve primary care capacity. The 2023-2024 bilateral agreements are a step in the right direction,16 but Canada needs more federal investment in team-based care together with clear metrics and accountability linking provincial funding to the goal of primary care access for every person in Canada. Provincial governments should support more community-governed teams oriented to serving whole populations and ensure team funding incentivizes collaboration both within teams and between primary care and other parts of the health system.
Third, action is needed to ensure both patients and clinicians have access to patients’ health records, no matter where they were cared for previously. Federal and provincial governments should implement recommendations from the Canada Health Infoway’s Shared Pan-Canadian Interoperability Roadmap.17 This includes strong federal legislation to enforce interoperability and prevent information blocking, and a tough stance on vendors who refuse to cooperate.
Family physicians also play an important role in advancing the public’s vision for better primary care. Many are doing so already and specific actions will vary based on provincial and local context, as well as available resources. For example, there may be opportunities for family physicians to collaborate with other practices and stakeholders in their community to consider how pooled resources could collectively serve more patients. Practices can also work together to provide more comprehensive and shared after-hours coverage. Clinic spaces should be accessible, virtual care should be an integrated offering, and clinicians should support patients who wish to access their own records (where feasible). Clinics can collaborate with community agencies to address the social determinants of health and educate patients to better care for themselves and navigate the health care system.
Building a primary care system aligned with public values will require additional investment. We need a robust public dialogue to understand how much more people in Canada are willing to pay for better publicly funded health care, where these funds could come from, and potential trade-offs, whether or not these investments are made. We need to sustain the type of public engagement modelled in the OurCare initiative to ensure the system we have meets the needs and priorities of those it is meant to serve.
Conclusion
The consensus recommendations from the OurCare provincial reference panels offer a roadmap for enhancing primary care access across Canada. Full reports written by panel members in each province are available at https://www.ourcare.ca. Policy-makers, health system leaders, clinicians, educators, and others all have a role to play in effecting these recommendations. Key areas of focus include setting a goal of universal access to primary care; increasing primary care funding; stabilizing the primary care workforce; expanding teams; ensuring data accessibility; removing barriers to care, especially for underserved groups; and empowering patients and the public to be partners in their care and in system design. As the health care system continues to evolve, the active engagement and leadership of family physicians will be essential to ensure reforms meet the diverse and growing needs of people in Canada.
Acknowledgment
We are grateful for the members of the public who volunteered their time to participate in the Provincial Priority Panels and write the related reports summarized in this manuscript. We also thank our collaborators on our National Health Policy and Health System Governance Group and Primary Care Leaders Circle, members of the Canadian Medical Association’s Patient Voice Advisory Group, and the Improving Primary Care Public Advisors Council at Unity Health Toronto for their help informing the initiative and interpreting the results. Reports from all 5 OurCare provincial priority panels are available for download at https://www.ourcare.ca/reports. The OurCare initiative has been made possible through financial contributions from the Staples Canada Even the Odds campaign, the Max Bell Foundation, and Health Canada. The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. Dr Tara Kiran is the Fidani Chair in Improvement and Innovation at the University of Toronto and is also supported as Clinician Scientist by the Department of Family and Community Medicine at the University of Toronto and at St Michael’s Hospital.
Editor’s key points
▸ In all 5 provinces, panels identified 3 major challenges plaguing primary care systems: a growing human health resource crisis, inequitable access to care, and fragmented care.
▸ Key areas of focus in the report include setting a goal of universal access to primary care; increasing primary care funding; stabilizing the primary care workforce; expanding teams; ensuring data accessibility; removing barriers to care, especially for underserved groups; and empowering patients and the public to be partners in their care and in system design.
▸ The government, professional organizations and colleges, education and training institutions, and family practices and primary care clinicians can take action to implement recommendations from members of the public.
Points de repère du rédacteur
▸ Dans les 5 provinces, les panels ont cerné 3 principaux problèmes affectant les systèmes de soins primaires : une crise grandissante dans les ressources humaines en santé, l’iniquité dans l’accès aux soins et la fragmentation des soins.
▸ Le rapport insiste sur les domaines clés suivants : l’établissement d’un objectif d’accès universel aux soins primaires; l’augmentation du financement des soins primaires; la stabilisation des effectifs en soins primaires; l’expansion des équipes; l’assurance de l’accessibilité aux données; l’élimination des obstacles aux soins, surtout chez les groupes mal desservis; et la responsabilisation des patients et du public comme partenaires dans leurs soins et dans la conception du système.
▸ Le gouvernement, les organismes et les collèges professionnels, les établissements d’éducation et de formation, les pratiques familiales et les cliniciens des soins primaires peuvent prendre des mesures pour mettre en œuvre les recommandations des membres du public.
Footnotes
Contributors
Dr Tara Kiran conceived of the manuscript and is the national lead for OurCare. Jasmin Kay, Peter MacLeod, and MASS LBP led the execution of the priority panels. Drs Alan Katz, Amanda Condon, M. Ruth Lavergne, Katherine Stringer, Mylaine Breton, Neb Kovacina, Mandy Buss, and Goldis Mitra co-designed the curriculum and supported the execution of the provincial priority panels. Jeanette Lim, Mirna Garabet, Lucie Mayer, Steven Black, and Jordan D. Waterbury were members of the priority panels in British Columbia, Ontario, Quebec, Manitoba, and Nova Scotia, respectively. Rachel Thelen, Kirsten Szymanski, Maryam Daneshvarfard, and Kanya L. Rajendra conducted a detailed cross-comparison of themes from the 5 priority panel reports. Dr Kiran drafted the manuscript and all co-authors critically reviewed it. All authors approved the final manuscript.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
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