Choices for Change: The Path for Restructuring Primary Healthcare Services in Canada

Main Messages

Many Canadians are currently rethinking the way we organize and deliver primary healthcare in this country. Many different models are being proposed, and there is a need to know why, how, and under what circumstances one model may be preferable to another or a combination of models may be the best solution. This policy synthesis will prove useful to the many groups seeking these answers — including healthcare managers and policy makers, practitioners, elected officials, and the public.

Based on solid methodology and exhaustive research, this document boils down what we know about the benefits and drawbacks of these different primary healthcare models. Decision makers will find the report’s recommendations particularly useful, as they provide a guide for making these services as effective, relevant, and viable as possible in the current Canadian context. The key implications that emerge from the research are:

  • No single organizational model for delivering primary healthcare among those identified can meet all the anticipated effects of primary healthcare: effectiveness, quality, access, continuity, productivity, and responsiveness.
  • Two models stand out since they meet, to varying degrees, most of the desired effects — the integrated community model and the professional co-ordination model.
  • If the attainment of all these desired effects is pursued, it is the combination of the integrated community model and the professional contact model which should be favoured, as long as ways are found to fill some remaining gaps in access to care. This combination of models maximizes all desired effects while minimizing duplication of effects and capitalizing on the organization that is currently in place.
  • Various measures should be taken in order to ensure the efficient integration of one or more of these models in the Canadian context:
    1. allow primary healthcare to be funded by a per capita formula and to include components such as specialized medical and hospital services, drugs, diagnostic and therapeutic services, homecare and palliative services;
    2. encourage compensation of physicians by sessional payment, per capita formula, or a mix of payment methods;
    3. favour a multidisciplinary approach, and award sufficient funding of interdisciplinary training and internship projects in order to enhance long-term sustainability; and
    4. dedicate funds to develop integrated information systems for various care groups to help manage and plan the system, and develop diagnostic and therapeutic technologies that fit the needs of organizations offering primary healthcare services.

Executive Summary

Primary healthcare has long been a concern of healthcare managers and policy makers. However, in recent years the organization, management, and delivery of care have also become a preoccupation of politicians, the general public, and other interest groups. In fact, the organization of primary healthcare is viewed by many as one of the major challenges facing the healthcare system in the 21st century.

The term “primary healthcare” has been interpreted in different ways. At its core, however, primary healthcare is defined as a set of universally accessible first-level services that promote health, prevent disease, and provide diagnostic, curative, rehabilitative, supportive, and palliative services. There are six broad effects primary healthcare should produce:

  • effectiveness — the ability to maintain or improve health;
  • productivity — the cost of services and the quantity, type, and nature of intake services for a health problem or care episode;
  • accessibility — promptness and ability to visit a primary healthcare physician, and ease of accessing specialized and diagnostic services;
  • continuity — the extent to which services are offered as a coherent succession of events in keeping with the health needs and personal context of patients;
  • quality — the total appropriateness of care as perceived by patients or professionals, including compliance with guidelines, as well as the suitability of services; and
  • responsiveness — consideration of and respect for the expectations and preferences of service users and providers.

This policy synthesis identifies four major models for organizing primary healthcare that are relevant to the Canadian context. Two models fall into what can be broadly called a communityoriented approach, while the other two fall into what can be called a professional approach.

The vision of community primary healthcare is to improve the health of specific geographically defined populations and to contribute to community development by providing a set of required medical, health, social, and community services. Within this vision, there are two types of models: the integrated community model and the nonintegrated community model. These models differ by their degree of integration into other parts of the healthcare system. Several characteristics of their resources, organizational structure, and practices reflect their varying degree of integration.

The vision of professional primary healthcare is to deliver medical services to patients who seek these services, or to people who choose to register with one of the primary healthcare organizations (subscribers). Professional models are subdivided based on delivery objectives into a professional contact model and a professional co-ordination model. The professional contact model is by far the most common in Canada, and classically involves physicians operating their own practices, being paid on a fee-for-service basis.

Although no single model best meets all the desired effects of primary healthcare at all times, two models appear superior. The integrated community model and, to a lesser extent, the professional co-ordination model, appear to best approach the ideal, although both have some notable shortcomings.

The integrated community model appears to be most effective (in terms of health and service), provides services of the highest quality (technical and relevant), and shows the best possibility of controlling costs and use, especially due to the capability of shifting use of services from a specialty to a primary health care level. It also has better continuity and equity of access. It suffers shortcomings, however, due to less accessibility (especially for primary healthcare) and responsiveness to patients. Nonetheless, the integrated community model appears to meet the goals of primary healthcare to the greatest degree.

On the other hand, the professional co-ordination model provides certain important benefits. It provides good access to primary healthcare, is responsive to patients, and shifts services from the specialty to the primary level. However, there appear to be drawbacks in health efficiency, continuity, equity, costs, and quality.

Of course, for these primary healthcare models to be truly effective, it must be possible to implement them in Canada. Neither of the preferable models is currently dominant in Canada — that distinction belongs to the professional contact model, evidenced by the number of physicians operating their own practices and working in walk-in clinics. Many of the characteristics of this dominant model are very different from the characteristics of the models that have been shown to be the best. In particular, there are differences in the method used for funding services, compensating physicians, multidisciplinary teamwork, and information, diagnostic, and therapeutic technology.

Regardless of the chosen vision — community or professional — major effort is required to make effective changes to primary healthcare organization. To increase the possibility of success, strategies for change must set a clear, firm direction for the change to be introduced. At the same time, there must be flexibility and room for movement in the implementation plan, to allow the emergence of a primary healthcare model suited to local conditions while accommodating professional and clinical autonomy.