What Scotland Can Teach Canada About Fixing Its Doctor Shortage

Scotland and Ontario have a lot to teach the rest of Canada about how to improve access to primary care, according to a new report from the Canadian Centre for Policy Alternatives, or CCPA.

Scotland provides a road map for transitioning family doctors from being contractors to being government employees, which reduces their administrative burden. And Ontario provides a good example of how to build team-based health care.

Canada needs to consider these alternative approaches because the current status quo means one in five Canadians — and one in four British Columbians — do not have a family doctor, Andrew Longhurst, report author and senior researcher and political economist for the CCPA, told The Tyee.

This gap is creating an opportunity for privatized health care to creep in, which further undermines public health care, he said.

In 2015 just over 82 per cent of British Columbians were attached to a family doctor. By 2024, that had dropped to 75 per cent, according to the report.

Health equity is also doing poorly.

In 2024, 80 per cent of the lowest-income Canadians were connected to a primary care provider, compared with 86 per cent of the highest-income Canadians, which is a trend that has persisted since 2015, the report said.

In B.C. that gap is wider, with only 74 per cent of people in the lowest income bracket connected with a doctor, compared with 84 per cent of the highest income bracket.

Compounding the problem, poorer people are also more likely to suffer worse health outcomes. In part because they’re less likely to have family doctors, they’re also more likely to rely on hospital care, which is the most expensive form of care, Longhurst said.

“We pay a price when we fail to address those equity concerns,” he added.

Frustrated with administrative workloads

Back when Canada was first setting up its public health system, doctors wanted to maintain their business autonomy and therefore became independent contractors who would bill the public insurance plan, Longhurst said.

But today, many doctors are frustrated by the administrative workload and financial risk that come with running their own clinic. They generally prefer to work in a collaborative clinic setting and have access to pensions, benefits and parental leaves, he said.

B.C. tried to fix the problem in 2023 when it introduced the longitudinal family physician payment model — which let doctors make more money by billing for administrative time and medical complexity of a patient — but that didn’t fundamentally shift how doctors were required to be independent contractors, Longhurst said.

Canada doesn’t expect teachers to build schools, but it expects family doctors to build clinics, he added.

Longhurst said if Canada doesn’t find a way to give doctors what they want, more of them will turn to employment with private, for-profit clinics.

These clinics offer salaries, administrative support and clinic infrastructure and don’t require clinicians to run their own business.

Currently there are 131 non-physician-owned clinics in B.C., making up about eight per cent of the province’s total clinics, according to the CCPA report.

Dr. Danyaal Raza, a family physician and primary care and health policy scholar with St. Michael’s Hospital in Toronto, said there are two main ways corporate-owned, for-profit health care negatively affects patients.

First, private health clinics allow the wealthy to pay to access care, which removes health-care providers from the public sector and makes the overall staffing shortage worse.

The Canada Health Act says patients cannot be charged for medically necessary hospital or physician care, but private clinics are trying to get around this by instead charging thousands of dollars in “annual membership fees,” Raza said.

This still violates the Canada Health Act, he said.

A local example is Telus Health’s LifePlus program, in which patients were required to pay $4,650 in annual membership fees to see a doctor, although Telus claimed the fees were for allied health services, according to CBC.

Selling patient data for profit

The second problem with private health clinics is how they use clinical care to acquire patient data, which can then be sold for profit, Raza said.

Data brokers are buying chains of for-profit primary care clinics so they can mine and sell patient data to researchers, government agencies or — their largest client — the pharmaceutical industry, Raza said.

Pharmaceutical companies use the data to develop “clinical decision support tools” that recommend specific products made by the company.

That’s problematic, because the pharmaceutical industry has a long history of “exercising undue influence on the prescribing habits of doctors in ways that are bad for patients,” Raza said, pointing to Purdue Pharma as an example.

Purdue Pharma downplayed the addictive properties of opioids and heavily encouraged doctors to prescribe its products. This helped create a population dependent on opioids, which continues today with the ongoing unregulated toxic drug overdose crisis.

“There should be a very hard line between the interactions of pharmaceutical sales reps, and other sales techniques, and the actual delivery of health care,” Raza said.

Lessons from Scotland

Canada could close its primary care provider gap, improve health equity and block privatized health care by learning from government policy introduced in Scotland, Longhurst said.

In 2018 the country introduced the National Code of Practice for GP Premises, which worked as a road map to transition clinic ownership to NHS Scotland, the country's national health service, either by having NHS take over leases or by buying out a partner at market value.

This shift was “groundbreaking” because it offered a path away from the dominant independent contractor model while addressing the key reasons for declining interest in general practice, such as financial costs, risks and the burden of running a business, the report said.

It’s “really one of the most significant reflections in the English-speaking world, at least of comparable high-income jurisdictions, where there is a recognition that there are changing preferences in how family doctors want to practise medicine,” Longhurst said.

The Scottish model will let doctors prioritize practising medicine over running a business and focus on subspecialties and academic research too, he added.

Lessons from Ontario

Ontario has focused on investing in and opening community health centres, or CHCs, which are non-profit, community-governed models of care that allow clinicians to work in a team with administrative support, the report said.

The Canadian Association of Community Health Centres says CHCs integrate team-based primary care with illness prevention programs, community health initiatives and social services focused on housing, food, security and socio-economic determinants of health.

Patients can access family doctors, social workers, nurse practitioners, dietitians, chiropodists, dental hygienists, therapists and other clinicians at CHCs, and the clinics tend to focus on the health of people in marginalized communities, such as low-income people, racialized Canadians, Indigenous people and seniors.

There are more than 300 community health centres in Canada, with a quarter of them operating in Ontario and serving more than 500,000 patients each year, thanks to funding from successive provincial governments totalling $596 million in 2024-25, the report said.

There hasn’t been a similar proliferation of CHCs in B.C. because the province is reluctant to focus on the capital investments and operational funding required, Longhurst said.

The province doesn’t have a defined way to fund non-profit primary care organizations, he added.

B.C. has provided core organizations funding for urgent and primary care centres. These centres can have multidisciplinary teams but are run by health authorities, which have a very top-down operational model, Longhurst said.

“Some of them really struggle to understand what community-based primary care is and the importance of longitudinal relationships,” he said.

Unlike urgent and primary care centres, CHCs are community governed and responsive to the patients they serve. They are set up as non-profit societies or co-operatives that provide open membership for their patients, who can serve on the board of directors, the CCPA report said.

It’s not clear why B.C. chose to focus on opening urgent and primary care centres, Longhurst added, rather than community health centres, which have a longer history of success.

The Tyee asked the B.C. Ministry of Health for comment for this article but did not hear back by press time.

A road map for change

Federal leadership is needed to increase the number of Canadians connected to primary care providers, Longhurst said.

Provincial governments tend to be reactive when the federal government provides leadership in health care, but across the country there’s popular support for having a more standardized framework and consistency for health-care standards, he said.

Longhurst’s report recommends that all federal transfer payments come with strings attached, requiring provinces and territories to close the primary care gap, report annual progress and implement lessons learned from Scotland and Ontario to increase access to primary care providers.

“For a number of provinces it won’t be palatable at all,” Longhurst said. But to fix the problem, the provinces will have to be more flexible and imaginative.