Family Physicians and the Future of Primary Health Care
Make no mistake about it, family doctors are the glue that holds the health care system together and they are key to providing all Ontarians with primary care, team or no team. Understanding the interconnectedness of the various sectors of the health care system and the positioning of family doctors within them would go a long way towards creating greater resilience within the health care system, and the innovation necessary for patients to receive the care they need.
More than twenty years after the Romanow Report, “Building on Values-The Future of Health Care in Canada”, was released with the intention to invigorate health care by emphasizing team-based primary care, access is in decline and costs are rising. The health care bureaucracy has grown along with vast amounts of data, but the health workforce including family physicians is burnt-out and frustrated. Dollars have not been sufficiently spent on patient-facing care and the public is at risk of losing the foundation of primary health care, family physicians.
How did we get to this crisis?
A Globe and Mail article from 2002, “Reliable 24/7 health care: possible, or pipe dream?”, outlines how primary care was the buzz phrase on everyone’s lips at that time and how teams were going to transform the delivery of health care in Canada: “Welcome to the brave new world of primary health care, trumpeted in Roy Romanow’s report last week as an essential ingredient to bring 40 years of publicly funded medicare into the 21st century.”
From the same 2002 article comes the infamous “80%” nurse practitioner/family doctor statistic. It was derived from studying static billing records that could not reflect the dynamic nature of care: ”A recent study of billing records in Ontario determined that nearly 80 per cent of what family doctors do could be performed by nurse practitioners or other health professionals, while more than 25 percent of what specialists do could be done by GPs”.
This is an important concept to be made clear. Family physicians create continuity between various parts of the health care system including community care, and the acute care system, as well as having the science-based medical background to assist in other roles within the health care system. This is especially the case as primary care evolves from comprehensive longitudinal “womb to tomb” care to additional roles particularly as pressure builds on existing specialists and acute care settings. It is imperative to retain family physicians.
The primary care team-based transformation envisioned in 2002 never materialized fully, mostly due to the unwillingness of provincial governments to fully fund it and despite Recommendation 19 from the Romanow Report for a proposed Primary Health Care Transfer to fast track primary care implementation. The “80%” statistic gave no context of speed or efficiency of the provider to create access. These two issues of sustainability of funding for team-based care and the impression that primary care teams led by nurse practitioners will function as productively and as effectively as family physician-led teams need to be fully understood.
First, following the 2002 Romanow Report, the 2004 federal-provincial Health Accord and its $41 billion “fix for a generation” did not sufficiently address team-based primary care that was expected to be transformative. Another bolus of federal funding was committed by the Trudeau government in 2023, $46 billion in new funding over ten years with strings attached to improve primary care over ten years. The question is always, what happens to the funding for primary care teams after the federal funding runs its course, and will there be a repeat of the Ontario experience of restricting family physicians from joining teams for years in attempts to control budgets?
Secondly, understanding the productivity of providers whether working in teams or not will be increasingly important for patient access, especially over the next ten years as the health workforce is grown, not necessarily as a determinant for funding of teams but to determine health workforce needs. It is essential that working conditions that allow for increased productivity also be conducive to retention. Financial incentives are likely to help. Family doctors have been working longer hours with little meaningful support from government and now it appears that both federal and provincial governments are setting the stage to backfill gaps in family doctor supply with nurse practitioners, suggesting they are equivalent. They are not. It is crucial to retain family physicians to provide much needed access to primary care or access will decline further.
The shortage of family physicians has a knock-on effect as primary care teams are expanded to millions of patients pulling providers, including nurses and nurse practitioners, away from other sectors. This is surely the case for long-term care. And this is especially important when the necessary health workforce does not currently exist in sufficient numbers. The Old Age Dependency Ratio, the number of working age people relative to the number of people over 65 years, is changing so that more productivity will be needed. Productivity should not be seen as “turnstile medicine” but as a necessary component to creating access to care and to triaging patients with acute-on-chronic disease.
A McMaster University study, “Benchmarking for Nurse Practitioner Patient Panel Size and Comparative Analysis of Nurse Practitioner Pay Scales: Update of a Scoping Review”, states “the range in the average number of patients seen by NPs per day varies considerably within and between countries; an average of 9-15 patients per day is common”. Given this expected level of productivity per nurse practitioner, it will take two to three nurse practitioners to provide the same level of access as one family physician despite having associated team members. This will lead to significant growth in primary care costs, and costs of overhead and benefits not to mention other utilization costs.
Governments should be prepared that funding needed for proposed primary care homes may far surpass what has been envisioned. The recent $1.8 billion promised in Ontario is likely to fall short.
It is also worth noting that once millions of patients finally have access to primary care that the use of diagnostics and specialist care will rise and wait times will increase. Improved primary care access is important for patients and a plan for the long-term sustainability of family medicine is needed beyond waiting for generational envelopes of funding from the federal government.
It is very interesting to see that some institutions are taking matters into their own hands. Take for example a job posting at The Ottawa Hospital Wellness Clinic for Staff and Medical Staff for a Family Physician. The posting states, “With 1 in 6 people in Ottawa without a Family Physician, there are thousands of TOH Staff, Physicians and their families who lack access to primary care needed to help them to work to their full potential caring for acute care patients”. This opportunity at the clinic provides “NO OVERHEAD COST” for the family physician. Yet, consider what is happening here. As family physicians are absorbed into acute care settings providing primary care services or as hospitalists, the lines between community and hospital become blurred. This may be bad or good depending on whether you have lost your physician in the community or gained one in your place of work.
There are innovative programs to improve access to primary care and community care that involve the private sector and that the Ontario government appears to allow in principle including from Shoppers Drug Mart, Telus, and recent non-profit initiatives from Greenshield. But when family physicians themselves take the effort and risk to expand access to care or create the working conditions to attract and retain other family doctors and providers they frequently find themselves fighting to be heard or even shut down completely. This dichotomy, a obvious double standard, is demoralizing for family physicians wanting to serve patients without the construct of large corporations.
McMaster University’s Boris Kralj, PhD, specializing in health economics and labor economics writes in “Ontario: the biggest loser in primary care”, that Ontario experienced a net loss of family physicians in 2023, with approximately 240 leaving the profession in a single year. Other provinces have had minor reductions, but Ontario stands out as the biggest loser according to Kralj: Ontario’s primary care system is in free fall, and without decisive action, it and its population will remain the biggest loser for years to come.” He describes that twenty years ago, the government took decisive action that led to real improvements, but no such action is being taken today. Kralj observes, “Instead of concrete solutions, the government continues to offer endless plans with little follow-through. Empty promises have replaced meaningful reform-nothing more than a “bag of magic beans” that supposedly holds the key to solving Ontario’s primary care crisis at some distant point in the future.”
All the major parties campaign platforms intended to address the family doctor crisis in Ontario have provided nothing more than knee-jerk reactions to a crisis that governments of all stripes have allowed to fester for a generation. There had been plenty of time to plan. The demographic shift with the aging Boomers has been clear for years, both in the population and in the workforce. The problem is that government after government, from Bob Rae’s NDPs to McGuinty/Wynne Liberals and more recently Doug Ford’s PCs have not funded the primary care physician services necessary to create the access required -- nor will they allow the freedom to innovate. Politicians still don’t appear to grasp the magnitude of the challenge ahead as evidenced by campaigning on a promise of billions of dollars in funding rather than sustained and structural changes.
Without structural reforms to the health care system the shortages of family physicians will continue, and this is primarily because governments are unable or unwilling to fund the growing number of services required. Attempts to address the family practice freefall with nurse practitioners is likely to result in worsened access despite greater costs long-term. It is ironic and painful that government efforts at holding down primary care health care costs will have resulted in even higher costs while stifling the innovation that could have saved it.
Family doctors create the resiliency, productivity, and leadership needed in primary health care. They have the ability to keep our cracking health care system from breaking apart. The failure of government to understand the central role of family physicians and fund them sufficiently to attract and retain them will lead to further erosion of access to care for patients despite efforts to create primary care homes. Family physicians need to be at the centre of the plans being pursued if primary care is to be saved.
View related short video:
Physicians need to be heard on health care reform
Dr. Merrilee Fullerton’s book “A Physician in the Political Arena” can be read here.
References
“Reliable 24/7 health care: possible, or pipe dream”, Globe and Mail, December 3, 2002
“Federal government offers premiers $46-billion over 10 years, far short of demand for $28-billion per year”, Globe and Mail, February 7, 2023
“Benchmarking for Nurse Practitioner Patient Panel Size and Comparative Analysis of Nurse Practitioner Pay Scales: Update of a Scoping Review”, March 2015
https://fhs.mcmaster.ca/ccapnr/documents/np_panel_size_study_updated_scoping_review_report.pdf
“TELUS Health expands access to public primary care in Ontario: New Toronto clinic opens doors to thousands without a family doctor”, Canada Newswire, November 12, 2024
“The University of Ottawa and Shoppers Drug Mart announce multi-year partnership, new Pharmacy Care Clinic on Campus”, uOttawa newsroom/health and wellness, December 2, 2024
“Two Leading Canadian Social Enterprises Are Partnering to Improve the Health of Canadian Workers and Their Dependent Parents and Grandparents”, Greenshield via Canada Newswire, Feb 13, 2025
“Ontario: the biggest loser in primary care”, Canadian Healthcare Network, February 14, 2025
https://canadianhealthcarenetwork.ca/ontario-biggest-loser-primary-care
“Family Physician Opportunity, The Ottawa Hospital Wellness Clinic for Staff and Medical Staff”, The College of Family Physicians Canada/Careers, February 4, 2025
https://classified.cfpc.ca/employment/family-physician-listing-8006.aspx
“Ontario Health Senior Leadership Team”
https://www.ontariohealth.ca/about-us/our-people/senior-leadership-team