A Patient's Prescription for Our Sick Primary Health-Care System

A panel of patients in British Columbia recommended more support for team-based care in community health centres and improved electronic medical records among ways to improve primary health care in the province.

“This is a unique opportunity we’ve had to hear from patients,” said Goldis Mitra, the B.C. lead for the OurCare project.

“I was heartened to see how thoughtful, passionate and brave all of these citizens were,” added Mitra, who is also a North Vancouver family physician, teaches at the University of British Columbia and is on the executive of the group BC Family Doctors that represents the profession. “As someone who does work in primary care policy I think it’s really helped me orient my focus to the key issues we really need to be tackling in the province.”

There were 31 randomly selected British Columbians, roughly matching the province’s demographics, who participated on the OurCare B.C. Priorities Panel. They spent some 30 hours together last spring hearing from speakers and discussing ways to make the system better.

The panel was part of a national process to engage Canadians on the future of primary care. Similar panels have been or will be convened in Ontario, Quebec, Nova Scotia and Manitoba. An earlier phase in the project surveyed some 9,000 people across the country.

Funders of the project, led by Toronto family physician and academic Tara Kiran, include Health Canada, the Max Bell Foundation and Even the Odds, a partnership between retailer Staples and the MAP Centre for Urban Health Solutions.

The B.C. panel’s 25 recommendations are included in a 75-page report released this week.

They recommended the province “foster, set up and fund Community Health Centres in every community to support timely access to primary care, including physicians and team-based care” and make sure that there are more of them in rural, remote, Indigenous and low-income communities.

Community Health Centres are created by not-for-profit organizations or co-operatives to deliver integrated services and programs that reflect their communities’ needs and priorities. They use a collaborative team approach to provide comprehensive, accessible, affordable and culturally appropriate services.

B.C. has around 30 CHCs and the government has promised to create many more, though it has been slow to deliver on the promise.

“We have a long way to go,” said Mitra, who acknowledged that over the past year B.C. has taken important steps to introduce a new payment model and a new system to attach patients to primary care.

“Other provinces are much further along I think in their journey to develop and sustain primary care teams, which are where doctors, nurses and other providers work in efficient and co-ordinated ways to provide care to patients.”

Another recommendation from the B.C. panel focused on establishing a central medical data platform that would allow both care providers and patients to access electronic medical records.

Canada currently has a patchwork of systems with many providers and no agreed upon data-sharing standard that would allow them to work better together. In many cases it is impossible to transfer information from one system to another.

Other recommendations included offering local access to primary care through a catchment area similar to the approach to public education; expanding coverage to include pharmaceuticals, dentistry, physical therapy and mental health services; offering flexible virtual care to complement in-person care; and using the World Health Organization’s “Health in all Policies” principle to shape policies.

The patients’ panel wanted more independent assessment of the system; policies to grow the number of primary care providers; and the establishment of a patient advocacy organization to consult on provincial legislation, champion transparency and ensure accountability.

Difficulties accessing primary care have grown over decades and the panel’s recommendations are in many cases similar to ones that have been made through other processes in the past. Some of the solutions have long been promised by governments and political parties.

“I think patients share this frustration that progress hasn’t come quickly enough,” Mitra said. “In the meantime we’ve had a worsening primary care crisis as a result of physician retirements, as a result of changes in practice patterns among family physicians more broadly, and supports for family doctors doing office space practice not keeping pace with supports for family doctors in other parts of the system.”

There are about 6,400 doctors in the province who identify as family physicians, but as of last October only about 3,400 of them were working in a full-service family practice. Many have chosen to work as hospitalists or in other positions where the pay and working conditions have been more attractive.

There are roughly one million British Columbians who are unattached to a family doctor or other primary care providers, a number that has grown steadily since at least 2003.

Fixing primary care will require sufficient funding, Mitra said, along with leadership not simply from the top, but at every level within the system.