Canada needs primary care manifesto to fix health system

Citizens must demand better, writes Steven Lewis.

A spectre is haunting medicare — the spectre of a broken primary care system. The evidence is everywhere: over six million Canadians without a regular source of care from a doctor, a nurse practitioner or a community health centre.

It's a fragmented model that cannot handle the complex needs of an aging and diverse population.

The Canada Health Act promises universality, comprehensiveness and accessibility. The system does not deliver. It is a catastrophic failure of design, adaptation, funding, accountability and organization.

Canada proudly signed the World Health Organization's Astana Declaration of 2018.

“We strongly affirm our commitment to the fundamental right of every human being to the enjoyment of the highest attainable standard of health without distinction of any kind . ... strengthening primary health care (PHC) is the most inclusive, effective and efficient approach to enhance people's physical and mental health, as well as social well-being ... PHC is a cornerstone of a sustainable health system for universal health coverage ...”

Fail to fix primary care and the system will collapse under the weight of avoidable harm, an overwhelmed hospital system and unsustainable cost.

Behold an anxious public, a demoralized workforce, and incremental reforms that take too long and accomplish too little: the centre cannot hold. Current measures — new medical schools, higher pay — are futile attempts at rescuing an obsolete model.

By international standards Canada's primary care performance is an embarrassment. It is a system designed to meet the episodic needs of a largely healthy, middle-class population. Tomorrow's must be built to serve people with complex needs for whom the stakes are highest.

Citizens of Canada, unite. Demand a primary care system fit for purpose in the 21st century. A system that meets the needs of marginalized populations, the frail elderly, the anxious and depressed, those with multiple chronic conditions, new arrivals, diverse cultures. That prevents or delays health breakdown and relieves pressure on hospitals and specialists. That energizes the workforce and makes the best use of everyone's talents.

Listen to what governments and health-care providers say and judge them by what they do. Their money and policies must walk the talk of their rhetoric. Aspirations are nothing without concrete plans and disciplined strategies.

Unmet needs need to be met and obsolete, ineffective and needlessly expensive care needs to be eliminated. Ask where new money will go, what defines success, and who will be accountable for achieving what.

Pilot projects are the opiates of the masses. Nothing will come of a minor tweak here, an election-year top-up there. Demand a real plan with quantified targets: some is not a number, soon is not a time. In one year, three years, five years, how many of the 6.5 million will have primary care homes?

Workers of the rest of the world, sit tight. Come if you must and we will welcome you. But Canada must wean itself from policies that rely on plundering developing nations for nurses and doctors.

Self-sufficiency demands a new approach to creating the collaborative and flexible primary-care workforce of the future. Training programs must ditch the baggage that makes them too long, too expensive and too slow to adapt to changing needs, science and technology.

There is a way forward. Declare a primary-care state of emergency and mobilize a credible response. Assemble the best and the brightest and give them a one-year mandate to design the way forward, from training to regulation to policy to governance.

Learn from successes around the world, including developing nations that have done much with little. Study and adapt innovations from other sectors.

If not this, then offer and pursue a plausible alternative. Redesign on this scale cannot be done off the side of a hundred desks. Solutions must unify and co-ordinate dozens of moving parts; the transition will require unprecedented creativity and management.

The battle for primary care is the battle for medicare. This time, fight it to win.