Universal primary care access by 2035

Former federal Health Minister Dr. Jane Philpott’s new book outlines a plan to get Canada there. A Q&A.

Dr. Jane Philpott is having a storied career: She dedicated the first 10 years of her medical career to serving in Niger, West Africa. Following this, she practised as a family doctor in Markham-Stouffville, Ont., for 17 years, and in 2008, she became the chief of family medicine at Markham Stouffville Hospital. From 2015 to 2019, she served as Canada’s Minister of Health.

Since then, she’s been dean of the faculty of health sciences and director of the school of medicine at Queen’s University but has indicated she will complete her term in June 2025.

Dr. Philpott recently published her first book, Health for All:? A doctor’s prescription for a healthier Canada. Much of the book? tells her story (all from the loss of her daughter to meningococcemia in Niger to her time in politics), and it discusses the spiritual and mental well-being aspects of health. But it also makes the case for universal primary care access by 2035 where, just like schools for children, patients would be in a catchment area for a primary care home and be guaranteed access.

Some wonder about patient choice, but in other countries there are systems where one can, once a year or so, switch medical homes. Or perhaps a patient goes on a waiting list if they don’t want to be with their local primary care providers—certainly that is no worse a situation than the current system we have in Canada for getting a primary care clinician.

Q: Let’s imagine it is 2035 and I’ve just moved to a new city and so I need a primary care provider. What would happen then under your proposal?

Presumably, when you move to your new community, if you had school-aged children, you would easily be able to find out which school they were attached to. So there would be a simple mechanism like that to determine where your primary care home would be.

Based on the way that it works in other countries, you might have a website that you can log onto and insert your postal code and you’ll be informed that your local neighbourhood primary care home is on the corner, a couple of blocks away.

Then you sign up and show that you’ve moved into the neighborhood, and you’re immediately included in their group, and that becomes the place that you go for your comprehensive primary care needs.

You would have a most-responsible provider who would be either a family doctor or a primary care nurse practitioner (NP) who you would see for your routine checkups or chronic disease management or maybe your mental health management if it was a long-term need. But if on a given day you needed to be seen and your person wasn’t available, you would see the most appropriate provider who could take care of your health needs on that day.

Q: In your book you talk about these primary care homes being open seven days a week and up to?12 hours a day and that they might also provide legal clinics and tax clinics. So these would be bigger than the primary care clinics we see today?

It obviously is the place for that frontline clinical primary care, but what a wonderful opportunity to make this more than just a health services hub because, of course, so many things other than health have an impact on health. So wouldn’t it be great if this was the place where your neighbourhood employment centre was, or housing supports, or other social supports?

The other clinical services like home care, palliative care, placement services for long-term care are there. This is your one-stop shop for health, and it really roots the system in a primary healthcare model.

Q: Right now, of course, many family doctors own their clinic but it seems like these primary care homes would need to be government run?

There are other models that you could look at. For example, in the U.K. where they have a model like this, they are still private corporations, so it doesn’t exclude the physician-owned model. But in most countries that do something similar to this, it would be a publicly funded model. Well, it’s always publicly funded, of course, but it would also be publicly administered.

Q: Say you are a physician-owner—there would be some level of concern about accountability as the neighbourhood population grows. You can’t just be told: “You’re responsible for everyone who moves to within 10 blocks of your clinic, and you have to deal with that.”

Right. Again, looking at the models where this works well, the accountability is held not by the physicians or the clinicians, but at a municipal level. Norway is the example I often like to use. It’s the municipality that actually is responsible. This is not dissimilar to the school model, to say, “Oh, my goodness. There’s a big subdivision going in with 20,000 new people. We’re going to need to organize ahead of time as those homes are getting built so that we also build a primary care clinic and hire the people.” That onus should not be on the clinicians.

Q: These clinics would be multidisciplinary. So do you have any thoughts about how to figure out, in an ideal world, how many NPs would you have, how many doctors, etc.?

I think business people would say that if you’re trying to develop a model that’s scalable, you should reduce variability to a certain extent. So there should be some standard features that you would have in every primary care home, and that would be the MDs, and the NPs, and the administrators and maybe some RPNs (registered practical nurses). All homes would have that.

But not every neighbourhood needs the same thing. In one neighbourhood you might need extra people who are providing addiction services and social workers to provide counseling if it’s an area that’s got higher rates of mental health issues. In some areas you might find the diabetes rates are much higher, so you’d have extra dieticians there.

Q: You mentioned that volunteers might help out in these primary care homes? There’s a crisis of loneliness in North America and that might help with that.

Can you imagine how well it could be if high school students, seniors, people who are looking to connect, (were) able to help out? (I) imagine being a volunteer at your local health home would be exciting for many people. There’s still a strong volunteer movement in the hospital sector, but we have never built that into the primary care sector.

Q: So how could we make universal primary care happen in Canada by 2035?

There are multiple paths. . . . Our history in Canada is that we often see single provinces that innovate and then the feds pick it up. That was the classic story for medicare in the first place with Saskatchewan innovating on doctor’s insurance or hospital insurance and then going federally. It’s quite foreseeable that that may be what happens here as well. In fact, I’ve already heard from some provinces who want to talk.

Q: Oh. You do mention in the book that no one’s actually done it but there’s nothing stopping a province from doing it. You’re getting some interest?

Yeah. There’s some interest—which would be great because then you can actually model it out in perhaps a smaller population and show that it works.

Having said that, ultimately, we are a country. Countries should have standards of what their citizens can expect. And one of the basic standards people should be able to expect is basic primary healthcare. That’s the commitment that Canada’s made going back at least to the Alma-Ata declaration that we believe in the right to primary healthcare, but we’ve never actually delivered fully on that.

Q: You make the case for federal authority and suggest passing a Canada Primary Care Act as a sister act to the Canada Health Act. But what do you do if a province like Alberta says “nope”?

As I discussed in the book, there are mechanisms through the use of federal spending power for the feds to be able to say, “If you want this portion of the transfer, then you’re expected to deliver what the standard suggests.” It may not look exactly the same in every place, and you may have a better way that you think you can do it, but this portion of the transfer is associated with making sure that every person in your province has interdisciplinary publicly funded primary care. If you want to do that in a different way, that’s fine, but you can’t do nothing and get the money.

Q: That’s not necessarily that the federal government has to put down new money but they could apply that to the transfer they’re already sending?

It’s possible. I mean, realistically, provinces will expect a bit of an increase. . . . We spend much less than most countries do on primary care. Only about 6% of our spending in the country goes to primary care. Other countries who have better outcomes than us see 8% to 12% of their overall health spending goes to primary care. Whether that’s accomplished by adding to the transfer or saying that future growth in the transfer is disproportionately going to benefit primary care, there would be some mechanisms to do that without actually growing our costs overall.

Q: You’ve decided you’re not going to do a second term as dean of Queen’s Health Sciences. Do you have thoughts about what you might want to do next?

I don’t have a definitive plan in mind, but I’ve always been interested in trying to improve access to primary care. As I wrote the book, I became more and more determined that this needs to happen, that Canada needs to do this work. Because I’ve had a chance to look at healthcare from a bunch of different perspectives, I feel like I can put some energy behind this that might be helpful, so I will be looking for opportunities. I’m not sure exactly what that will turn out to be, but once I’m finished at Queen’s, I’d like to spend the rest of my career focused on trying to deliver on 100% access to primary care.

Q: You wrote in the book that you really have not spoken about your faith much but decided that you would in this book and you use that to write about the social aspects for health that are so important like people having belonging, meaning and purpose. Maybe give a sense of why you felt like doing that now?

Health is such a big topic, right? As I think I suggest in the book, you could have other entire sections on digital health and planetary health. One could go on and on. I had decided I was going to do the clinical and the social determinants and the political, but there was a sense that something was missing, and it was about mental wellness. But then I thought about this mental wellness continuum framework that I had heard from indigenous peoples, and I thought, “You know what? We need to talk about mental health in the sense of the soul or the spirit and open up that discourse amongst ourselves,” partly because indigenous teachings are so strong in that area.

And, to your point earlier, a lot of what ails us both as individuals but also as a society is that we’ve kind of forgotten to talk about how much we need one another and how much we need to have belonging and purpose in our lives. I thought, “You know what? This is a great opportunity to introduce this whole sphere of health to make it not a scary, taboo topic, and to say, ‘Let’s talk about what really matters to each other. Let’s talk about where do you find your hope,’ and make it an OK thing for us to say, ‘that’s part of health, too.’”

Q: You wrote that you came to realize that you have a purpose, which you said is about improving systems—whether clinical, educational or political—to improve people’s health. And you found that if the work you were doing was aligned with that you can just pile more and more tasks on and be totally happy. Now lots of doctors are struggling with burnout and I wonder how you feel having a purpose helps around that?

Clearly, lots of your readers are struggling with burnout. Some of that comes in the form of what people now tend to refer to as moral distress. Part of moral distress really is this sense of: “Things are broken all around me and I can’t fix them.” People get quite despairing when you feel like you can’t control anything.

What I found over time was (the value of reflecting on): What is it that I really want to accomplish in the world? I might not be able to change the entire healthcare system, but there are little things around me that I can change that I can improve. So, what are those proximal system issues that I could actually make a difference in? I found that as I started to do that, as I started to teach medical students, as I volunteered to be the family health organization lead, that I actually found joy in doing more work but changing my circumstances.

Recognizing what your purpose is (thinking) what can you do to work toward that purpose in small ways is part of how we will combat burnout—not to take a helpless approach but to realize, especially for physicians, circumstances are never entirely beyond our control. We can often do more than we realized to improve them.

Q: How did you come to find your purpose?

It was something I discovered gradually and probably couldn’t have put into words until in retrospect I realized, “Oh, actually that’s. . . .” I started to get joy, I started to get over my burnout when I started to do more teaching and administrative work. I recognized that that was actually a healing for me to be able to exercise my purpose by taking on tasks that would allow me to advance that purpose.

Q: Your husband recognizes there is a “restlessness” in you, you write, so he isn’t surprised when you do new things professionally. Your time as a federal cabinet minister ended for the reasons it did. (Dr. Philpott stood with Jody Wilson-Raybould when she was attorney general over the SNC-Lavalin affair; they were both booted from caucus.) Do you think you would have stayed in politics long term if things hadn’t gone that way that they did?

Well, it’s always hard to think through all the what-ifs. I mean, I intended to stay in politics longer at that time, and circumstances didn’t work out that way. There’s part of me that thinks things happened for a reason. And this time in the after-politics period I feel like has been, first of all, great to learn about what the medical education sector is like in a much more deep way. Even just the work of reflecting on the book, I feel like a lot of pieces came together for me. I didn’t want to leave politics when I did, but maybe I needed to do that in order to understand things that will prepare me for the rest of my journey.

Q: Do you think about what retirement would be like for you?

I am at this point not picturing retiring anytime soon. It’s nice to get a little bit of time off periodically to be with my family, but I love the opportunities of trying to leave the world in a slightly better position than it might’ve been if I hadn’t tried to make it better. I will just keep working away at the opportunities that come my way. As long as my mind and body allow me to, I’m going to keep working.

This article is from the Medical Post magazine. Physicians can register at our online home: CanadianHealthcareNetwork.ca.