Transcript
Speaker: Hello and welcome to today's episode of Red Eye. I'm Jane Williams.
Speaker: Over the summer we're bringing you a series of weekly podcasts from our 2023 -24 season, which wrapped up in mid -May. We will be back with our brand new fall season in September. Our first live radio broadcast will be at 10 a .m. on September 21st on Vancouver Cooperative Radio, CFRO.
Speaker: 100 .5 FM and streaming live at co -opradio .org slash redeye and podcasts from that show will be posted the following day. On the podcast today I speak with family physician and scientist Dr. Tara Kieran about how Canada compares with other OECD countries in terms of primary care.
Speaker: More and more Canadians are unable to access public primary health care, according to a study published in the Canadian Medical Association Journal at the beginning of December. In fact, about 20 % of Canadians have no family doctor at all.
Speaker: and many more have irregular access to clinicians. The CMAJ study was led by family physicians and researchers at St. Michael's Hospital in the University of Toronto. It compares the Canadian primary care system with New Zealand and eight other countries in Europe, including France, Germany, Italy and the UK.
Speaker: Dr. Tara Kiran is the senior author of the study. She's a family physician and scientist at St. Michael's Hospital and the University of Toronto. Hello Tara. Hello. Why did you pick the nine countries that you picked for your study?
Speaker: We know that access to primary care is a huge problem in Canada, and we wanted to learn from countries where they do things differently and where they have better results. And so what we did in our study was look at countries, OECD countries, where 95 % or more of the population has a family doctor or a place of care that they can access regularly. So they have regular access to primary care.
Speaker: So when you look at Canada, Canada obviously has a certain population size, there's a certain degree of rural population, income inequality, all that kind of thing. Is it comparable in terms of the countries that you were looking at?
Speaker: That's a great point. Canada, of course, has some unique aspects. We have a vast geography, so our relatively smaller population is spread out over a large geographic area and at the same time
Speaker: We also have a lot of newcomers or people who have come from other countries and have been here for a while that comprise our population. Of course, we also have a history of building this country on indigenous lands. And so in those and in other ways, Canada is different from the countries that we compared ourselves to. But at the same time, I think there are commonalities and things that we can learn from them.
Speaker: We included countries like Norway and Finland that also have a vast geography and many rural and remote areas. When we're comparing ourselves to a country like the Netherlands, though, I think we do have to be mindful that they have a small geography compared to us and so don't have some of the challenges. But even so, I think there are things that we can learn from them.
Speaker: I quoted in my introduction that 20 % of Canadians don't have a family doctor, which I was quite shocked at, even though I know anecdotally many friends of mine are having a hard time finding a family doctor. And then I read in your study that when you look at specifically the UK, Norway, Netherlands, and Finland, more than 95 % of the population there
Speaker: have a primary care clinician or a place that they can go regularly. That's just a huge difference.
Speaker: It's a really big difference, especially if you think about the fact that primary care is the front door to the healthcare system. So, you know, it's the entry point in order to access other parts of care, but it's also the place that you go to first, you know, or should be going to first if you have a new problem that's not an emergency and where you should be going to get care that helps to prevent
Speaker: issues from happening in the first place, or that looks after chronic illnesses that you might have that are ongoing, like diabetes or high blood pressure. So primary care is this first point of contact, or should be the first point of contact in the entryway to the healthcare system. But for so many people, that entryway is closed. And so it is wonderful to see that that's not the case in other countries. I think we've actually kind of sunk into some complacency here in Canada, thinking that, oh, you know, we've got a pretty good system. Things are working okay.
Speaker: And it's important for us to challenge ourselves to say, well, actually, these other countries, they figured out some different things than we have and are able to have. And in many cases, close to 100 % of their population have access to that front door primary care. Well, let's look at some of those things that they figured out. What differences did you find in how things are organized?
Speaker: Yeah, so I think one fundamental issue is that they are spending more money on primary care. So when we look at the proportion of the total health budget that is spent on primary care, we can see that compared to actually 22 other OECD countries, Canada is near the bottom in the proportion of spending on primary care.
Speaker: with Canada spending about 5 % compared to the other countries spending about 8 % on primary care. So a lower portion of the total health budget is spent on primary care in Canada. Another interesting difference that we found related to financing was that
Speaker: When we look at how money is spent, whether it's spent from the public system or whether it's from private pay or private insurers, we see that a much smaller proportion of the total funding for health care in Canada is actually paid for publicly compared to all of the other countries we compared them to.
Speaker: So about 70 % of all the total health budget is public spending and that's the lowest in Canada and that's the lowest compared to all of these other countries that we looked at. Now there are many other differences as well but the funding I think is some of the you know the basic pieces that are different and then I think one other really big fundamental difference is that the other countries they
Speaker: design their systems to be able to cover the whole population. Examples of that are, for example, in
Speaker: In the UK, people have guaranteed access to a clinic when they move into a neighborhood. So you're in a neighborhood and you can choose between three or four different clinics in which to get your care and those clinics basically have to take you on.
Speaker: In Norway and in Finland, interestingly, you're actually automatically registered to primary care. So in Norway, you're automatically registered to a GP, and in Finland, you're automatically registered to a health center. So that just takes the work out of having to find someone. And just to clarify, people do have choice still, so they can choose up to once or two times a year to switch to a different clinic or family doctor.
Speaker: but they're guaranteed that access in those countries. In a country like the Netherlands, they don't go so far as to guarantee it in that way, but what happens is if someone can't find a family doctor or primary care physician, then the insurer is basically obligated to help you find that place.
Speaker: that person and we don't have those kinds of systems. We specifically don't have a system where we automatically register or people have a right to care and I'd say that's also one of the fundamental differences.
Speaker: A thing that struck me as I was reading your study is that in other countries, primary care doctors have a lot more support in terms of, for example, they have access to digital tools and information systems. They can work in interprofessional teams. Is that something that's coming from a government level to help primary care physicians?
Speaker: That's a great observation. And it's true that in many of these other countries, we actually have both things. We have more accountability generally for the way that family doctors practice. So for example, more family doctors in these other countries are actually practicing family medicine versus other kinds of specialized care.
Speaker: And one of the reasons we think that is, is because partly the accountability of, you know, where and how you can practice as a family doctor and the kinds of services you provide, but also another difference being that in many of these other countries, actually, they have more doctors per capita.
Speaker: And so what we see in Canada is many of our family doctors are taking other roles in other parts of the healthcare system because we have fewer doctors overall than in these other countries. And so what we need to do in all countries, because all of the countries, even the ones we looked at, are currently struggling with health human resource challenges coming out of the pandemic. And in all of these cases,
Speaker: We do need to think about how we can grow the capacity of our current health human resource in primary care to actually be able to care for an aging, growing, more complex population. And one way to do that is to integrate other team members into the clinics. And so some of these countries have started to do that, I think in a bigger scale than Canada, although I think all of us have more ways to go there. So for example,
Speaker: let's say in Finland, they've integrated more nursing. Nursing is the first point of contact in many of the health centers. They also routinely integrate psychologists and physiotherapists because we know a lot of what we see, for example, in primary care are mental health issues and also issues related to musculoskeletal disorders like back pain or knee pain. And so these kinds of things make sense. We have, if you bring in other team members and integrate them in,
Speaker: They can sometimes be the first point of contact and then family gougers are able to support where more expertise or different expertise might be needed.
Speaker: You also point out that fewer medical students are actually choosing family practice as a specialty, and then even among those who graduate as family physicians, more are choosing not to go into the kind of generalist, office -based care that used to be much more common and easy to get. Why is that?
Speaker: Yeah, it's a complicated question to answer, and I think it relates to multiple factors. I think one relates to the amount that family doctors are paid in Canada relative to other types of doctors. So pay does drive decision making among medical students, especially medical students who face growing debt coming out of medical school.
Speaker: I think other factors, though, also relate to support and lifestyle. So, for example, in Canada right now, the way we traditionally organized family medicine is that people have to basically open up their own small business, and then they're responsible not just for the doctoring, but also the business part of running a family practice. And many of our graduates now, they just want to go out there and actually work as a family doctor and not have to worry about the business side.
Speaker: And so they're choosing areas of work where they can do that more easily and where they're more supported, for example, in a team -based environment like we just talked about. So if you choose to do hospitalist work, that means you're looking after patients within a hospital, you've got an automatic team built right in there. And you don't have to look after the small business aspect.
Speaker: It also means that if you do work in the hospital, you're doing the kind of work where you could take a parental leave, you could take a vacation without having to worry about someone covering for you, because often the way those jobs are structured is shift work by week or by day. And so, whereas in a family practice, we see many of our graduates being worried about the ability to take vacation or a parental leave,
Speaker: because they are responsible for their practice and right now many practices aren't kind of set up in a team -based way that would allow people to have that flexibility to take vacation without having the guilt and then I think another aspect and this is an aspect that's different in Canada compared to other countries is you know more of our family doctors are paid fee for service which is really an outmoded
Speaker: payment model compared to where it is that we really need to go and what the evidence suggests is better. And in many of these other countries, family doctors are actually paid by salary or what's called capitation, where instead of a fee per visit, it's a fee per patient per year. And this again allows more flexibility to deal with complex problems and many problems in one visit.
Speaker: It sounds like you're advocating for some pretty bold policy moves coming out of this study. Do you think there's an appetite among doctors for a total rethink about how the system is run? That's a really great question. I think that there has been always some tension between doctors wanting to maintain their autonomy versus integrating doctors within the healthcare system.
Speaker: I think we've reached a point though in Canada now where there is actually a lot of unhappiness among my family doctor colleagues and as we've talked about the profession is less attractive to new graduates and so I actually do think the time is right for change that there are many family doctors who are open to it because they want their day -to -day lives to be better
Speaker: And I think it's about figuring out how we can support family doctors to have a joyful practice at the same time designing a system where everyone is guaranteed access to care.
Speaker: And so I think there's a unique opportunity right now where we can try and twin those two things together and thread that needle of both improving joy and work for clinicians while trying to improve access for patients. Thanks so much for talking with me today, Tara.
Speaker: Thank you. I've been speaking with Dr. Tara Kiran, a family physician and scientist at St. Michael's Hospital and the University of Toronto. She is the senior author of the study, Primary Care for All, which appeared in the Canadian Medical Association Journal at the beginning of December.
Speaker: The Red Eye Collective is based in Vancouver. You can check us out at coopradio .org slash redeye.
