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Avis Favaro
1 in 5 Canadians don’t have a family doctor or a nurse practitioner. No one they can go to when they’re sick. No one to order those preventive tests to head off diseases like diabetes or to find cancers for early treatment.

It is a crisis in primary care as family doctors retire or quit for other specialties because they’re burning out under administrative workloads, difficulties getting patient referrals and financial stress.

On today’s show, 2 women who say they know how to turn this around with the message that every Canadian, living urban or rural, should have the right to basic health care near their homes.

Dr. Jane Philpott is the former federal minister of health, a family doctor and Dean of Medicine at Queen’s University, who’s written a new book, Health for All.

Jane Philpott
We believe that every Canadian should be attached to a publicly funded primary care team in their neighbourhood. And it’s not something that’s just a pipe dream. This is what other countries actually do and have done for some time.

Avis Favaro
And we’ll hear from Dr. Tara Kiran, a family doctor and scientist with the MAP Centre for Urban Health Solutions at Toronto’s St. Michael’s Hospital. She spearheaded a program called OurCare with data showing what Canadians want from primary medicine, with a plan for making it happen quickly.

Tara Kiran
I’d like to think that in 1 to 2 years, we could actually see a really big difference, make funds available to support infrastructure and new team builds in communities where it’d be good.

Avis Favaro
Hello, and welcome to the Canadian Health Information Podcast. We call it the CHIP for short. I’m Avis Favaro, the host of this conversation.

A note, the opinions expressed here don’t necessarily reflect those of the Canadian Institute for Health Information, but it is an open discussion. And this one is about 2 doctors who are on a mission to get you a health clinic to call your own.

It’s a pleasure to welcome both of you to the show, Dr. Philpott, Dr. Kiran. Thank you for coming.

Jane Philpott
Thanks for having us.

Tara Kiran
Thanks for having us.

Avis Favaro
And I guess my first question is how often do you get asked by someone, can you help me find a family doctor?

Jane Philpott
I certainly hear it from members of the general public, people in grocery stores, people at the university. It’s a very common question, and I receive a lot of emails about it as well.

Avis Favaro
Wow. And, Dr. Kiran, how does that make you feel when you get approached that? Because every doctor friend I know is getting that question daily.

Tara Kiran
Yeah. It’s really hard because your instinct is wanting to try and help people. And I think there was also a time where, you know, it may have been easier for me to actually say, okay, yeah, I know there is a practice taking somebody or, you know, you can call my practice, and I know there’s some doctors accepting, or maybe even I may have room, depending on — but nowadays, it’s really hard.

Many governments have an official 811 type of numbers where you can call and get on a waiting list, but we know they’re not working. We know that many people, when they get on that kind of waiting list, they’re often waiting 5, 10 years, and they’re actually explicitly told that that’s going to be the wait time.

Avis Favaro
It’s quite interesting because as we were preparing for this podcast, of the four women on the call discussing it, 3 did not have a family doctor, 1 was in danger of losing theirs, and I live in constant fear that I will lose my doctor. I think the latest data is 6.5 or more million people without a doctor.

Dr. Philpott, you know, why is family medicine, frontline care important?

Jane Philpott
So family medicine is part of what we — a broader area that we call primary care, which is really the front door to the health care system. It’s the first place where people should go for continuous, comprehensive, coordinated, person-centred care.

And we know that countries in the world, or regions in the world, that have primary care for everyone are the countries or regions that get the best health outcomes and the most affordable costs because problems get dealt with before they arrive sometimes because someone’s promoting your health, someone’s championing your best outcomes in health, and following you if you have a chronic illness over time.

But when we’ve got 22% of the population that don’t have that, that’s a huge number of people in Canada that are not getting a front door to the health care system.

Avis Favaro
And what’s the research showing, Dr. Kiran, about the effect of not having that front door to get into the system?

Tara Kiran
We did this survey back in 2022 [indiscernible], where we heard from people across the country, and we found out that more than 1 in 5 people don’t have access to a family doctor or nurse practitioner they can see regularly.

And I want to emphasize that’s actually worse in some parts of the country. So, you know, it’s more than 1 in 5 overall, but in places like Quebec and the Arctic regions, it’s almost 1 in 3. And in B.C., it’s more than 1 in 4. So really awful to think about that many people not having access to the front door of the health care system.

And so what it means is that they’re going without preventive care, but also care related to their chronic conditions. It means that [they’re overlooked] in terms of trying to actually find other parts of the system that they know they probably need, you know, if they need to see a specialist or get a test.

I think in addition to that, I’d say, you know, it’s more costly. It’s pretty clear that if you have access to primary care, your costs as a society are going to be lower, but people are less healthy and not getting that care, the costs go up.

Avis Favaro
I see you nodding your head and shaking your head, Dr. Philpott. What’s going through your head? You know this. Right? You know this.

Jane Philpott
Well, absolutely. And, you know, you don’t have to be a health professional to understand that being preventative is the best way to go. So it makes a lot of sense that if you can screen people for cancer and detect it when it’s small, you can often treat it, and a person can someday be cancer-free. If you don’t detect that cancer until someone shows up in the emergency department with stage four cancer, because they didn’t have a family doctor looking out for them, then it becomes to the point that it’s untreatable, and people die prematurely, as Dr. Kiran said.

Tara Kiran
Well, I was going to also say it really is getting worse, Avis. I mean, you mentioned that, you know, we [have] more than 6.5 million adults, but we also know more people graduating from medical school aren’t picking family medicine. We know that people who’ve trained in family medicine are leaving their practice. And we know there’s a huge portion of the workforce that’s over age 65 and that are slated to retire soon.

Avis Favaro
And, Dr. Kiran, you’ve been trying to take the pulse of Canadians who are dealing with this dire situation. Your program is called OurCare, and it’s been providing a lot of data as Canadians answered key questions that you gave them. What is it that the people you spoke to want to see happen?

Tara Kiran
Yeah. It’s been a wonderful journey for the last 20 months, really trying to hear from people across the country because they wanted to make sure that everyone was able to have primary care, regardless of where they lived or what background they were, what language they spoke, what their abilities were. They wanted to make sure everybody had access to primary care. And they saw that our system wasn’t living up to that and made a number of recommendations on how we need to do better.

Avis Favaro
By the way, I was 1 of the people that responded to that survey. And that’s why I first heard of the idea that we’re going to discuss.
So for people who don’t know what it is you’re proposing, Dr. Philpott, what is it that you want to see in regards to care, that primary care should be a right? Explain what you want to see.

Jane Philpott
Well, we’ve been using this metaphor, which I think is a really easy one for people to grab hold of and helps you imagine that it’s possible, because sometimes the problem seems so big and people despair so much that they sort of can’t imagine that we could ever fix this.

And then we say to them, we have developed a system in this country that every child in our country should have access to a publicly funded school for elementary school and secondary school. And no matter where you move in the country, you don’t have to worry about whether you’re going to be able to register your child for school because we’ve built a universal system of access to public education.

That’s what we want for primary care. And Tara and her team have gone into much more detail as to, you know, what exactly that should look like, and what the standard should be. But we believe that every Canadian should be attached to a primary — a publicly funded primary care team in their neighborhood. And it’s not something that’s just a pipe dream. This is what other countries actually do and have done for some time.

Avis Favaro
So, Dr. Kiran, when you did your research with the 9,000-plus people, where did they say they wanted this care? And what it was supposed to look like?

Tara Kiran
They want everybody to be able to have a primary care clinician who is attached to a team, so a team of other health care professionals. Why did they recommend a team? Because they recognized that team-based care was a way, actually, to alleviate provider burden, but also provide more holistic care to them and actually grow the capacity for our primary care workforce to serve more people.

Avis Favaro
So this would include nurse practitioners?

Tara Kiran
So they were open to nurse practitioners be their most responsible clinician. They were also very open to their family doctor with other health professionals like social workers, pharmacists, or dieticians, or nurses, and having to see those other professionals instead of the doctor, if the doctor said it was appropriate.

It’s not enough to just have a doctor in name. You need to be able to see them in a timely way. You need to be able to see them, you know, after hours or on the weekend. And another key part that, you know, people have talked about is they want a system focused on wellness, not sickness. And so they actually wanted that primary care system to connect to community and social services.

And a really important frustration we heard again and again was just how people didn’t have access to their own health record. And it caused a huge problem with them navigating the system and being able to advocate for their own health and health care needs. So people were really clear, we need to fix that. Everybody needs access to their own records.

Avis Favaro
Right now, in most parts of the country, you have to go looking for a doctor or a nurse practitioner. This is kind of like the Hunger Game of trying to find someone who will take care of you. What you’re talking about is kind of blowing up the system that we have and starting fresh.

Tara Kiran
You could think of it that way. You could think of it that way, that it’s like blowing up the system. But I think you could also just start where the need is. So if you think about the fact that there are 6.5 million-plus people who don’t have a family doctor or nurse practitioner who can see them regularly, let’s start with that. Let’s create a system that is at least working for those people. And then I think, gradually, we can make our changes. But what we are saying is somebody has to take responsibility for these people who don’t have care.

Jane Philpott
I would be aligned with Tara in saying, you know, I don’t — I wouldn’t want to characterize this as blowing up because for some people, they have a system that’s working, but we have this massive gap of people who don’t have access to anything. So the first place to start is to say, for that gap, let’s start to fill the gap with the new model, which is a model that will allow these interdisciplinary, publicly funded primary care teams where people who aren’t currently attached to a primary care provider can start to go for care. And that actually also makes it feel a little bit more doable.

Over time, if these, as primary care providers, including family doctors, start to see this is actually a really attractive way to practice, that more and more of our new graduates will start to choose family medicine than they are now because they’ll say, oh, wouldn’t that be amazing? I’d love to work at one of those facilities. We train them in team-based care, and then they don’t have a way to go and get into team-based care.

So gradually, over time, then, these are the kinds of models that would fill the need. I think that it’s quite realistic for us to imagine that that could be the standard way that primary care is delivered in the country.

Avis Favaro
How would the staff get paid?

Tara Kiran
Well, maybe I would just jump in here to say, in other countries, thinking about Norway or the Netherlands, they still actually do have their general practitioners be small businesspeople and they are paid fee-for-service to a degree, but then also some form of capitation. So a paid-per-patient per year, not just a pay-per-visit. So there’s usually some kind of blended funding. But the difference partly is is that the governments really guarantee access to the residents of the country to primary care.

Avis Favaro
The reason we brought both of you on is that you both have a deep passion for fixing the system. You both want to make it better in your lifetime, I assume.

Did you come — did you get to know each other because of this mission? Or how is it that you’re both saying the same thing from different spots, one at Queen’s University, one at Unity Health in Toronto?

Jane Philpott
Well, I’ll maybe start with that first. And I’ve known Tara for a number of years. Before she started the OurCare study and before I was at Queen’s, you know, we were both part of the Department of Family and Community Medicine at University of Toronto. So we’ve known each other for quite a while.

But I think to be fair, the ideas that Tara and I have been advancing and have had the opportunity to really get into the public discourse have been ideas that many of our colleagues have talked about for some time.

In fact, this concept of using the metaphor of the public school as a way of explaining to Canadians what we envision for every Canadian having a primary care home is an idea that’s been discussed for quite some time. And in fact, some of our colleagues wrote a very important paper that came out about 10 years ago now, that actually described this concept.

I think the advantage Tara and I have now had is that we’ve been able to channel that knowledge that has been well-known in these sort of academic circles in the past and trying to get it out into the public a bit more, Tara, through this fantastic process of citizen engagement and, for myself, being able to get a book out into the general public.

We’re thrilled, I think it’s fair to say. I think Tara shares my joy in the fact that Canadians across the country are talking about this idea more, the fact that everyone has a right to primary care as it becomes not just medical practitioners or health care academics that are discussing the fact that we should do a lot better.

Avis Favaro
Okay. So you have a prescription for how it should be done. Who’s supposed to do this? How do we get these started? Dr. Philpott?

Jane Philpott
Well, as you know, I have a background of having spent some time in politics, so I think about the political lens of this and what’s possible because, as I said, it’s not a new idea. What we haven’t seen is a strong political will to make this happen. And so I —

Avis Favaro
Why not? Why not?

Jane Philpott
Well, that’s a great question, and I’m not sure if you’ve gotten that far in the book, but I do propose some theories as to why I think governments haven’t taken this on. It’s a huge task. It’s not going to be — we’re not going to be able to fulfill the dream of every Canadian having a primary care home in a 4-year period. So politicians tend to be afraid to promise things that they don’t think they can deliver on in the period of an election cycle.

And to a certain extent, I would say that, you know, politicians tend to respond to the public will as well. And one of the things I’m excited about, as we start to talk about this more with the general public, is it’s giving people a vision for what’s possible. And as more and more people imagine that this is possible for us, they will speak up and ask politicians, which will hopefully drive that political will to make it happen.

I think there’s a fear that it might be — you know, people think immediately, well, if this is a better system, it’s going to cost more. And the reality is that these other countries that Tara has referred to, they actually spend less than we do per capita on health but have a better primary care system and, therefore, better health outcomes. So the reality is that it won’t, at the end of the day, mean spending more. It will mean shifting more of our health care spending into the primary care space, though, rather than waiting until people are sicker and need that sickness-based care.

Avis Favaro
One of the interesting things that is being discussed is the idea of a Canada primary health care act. So that is adding the fact that people have the right to primary care. Is starting with legislation or some kind of mission statement, federally and provincially, the first place? Whoever wants to answer that one?

Jane Philpott
Well, I’ll maybe jump in first because my — I hypothesize that that’s what we need to do because it’s not like no one’s thought about this before and people haven’t wanted to do this. But we have never had federal legislation that has said everyone has this right, it’s going to be funded, and there’s going to be a mechanism for what will happen if provinces and other jurisdictions don’t deliver on this right.

Avis Favaro
I like the idea of a federal mission statement that, yeah, gets passed on. Dr. Kiran, where do you want this to go? What do you want to see happen next?

Tara Kiran
So, yeah. As Jane was saying, that we need governments across the country to commit to 100% of the population having access to primary care. And I say that because I think it’s actually a big distinction between aiming from, let’s say, 80 to 85% or 75, 80% and going to say, actually, we’re going to design a system that covers 100%. I think it does mean more money being spent in the public system.

Actually, if you contrast Canada to any of the OECD countries where everyone has access to primary care, they all spend more in the public system as a proportion of their total health budget than we do. We’re at the bottom [30%]. So we need to spend — you know, we have to spend a higher proportion of our money on primary care. So we’re also near the bottom when it comes to the proportion of total health spending on primary care.

As we’ve talked about, we need to expand teams. That is the only way, I think, that we’re going to have a workforce that’s able to do this, or achieve the vision. And I think one of the biggest things we need to do is actually a complete paradigm shift to ensuring that our primary care system is accountable. That’s one of the strongest recommendations we heard from our members of the public.

And so what does that mean? We’re really transparent with people about how it is that we’re spending our money and what we’re getting in return. It means that people are involved in governance, everything from like the decisions at the top. So if we’re going to have a primary care act, they should be, you know, involved in setting that up. But a team might be governed so, you know, what services are being provided by a team? And then we need to empower and educate patients and the public so that they can feel really confident navigating this and caring for themselves.

Avis Favaro
I feel — I think many people feel powerless. I just hope my doctor — I say, thank you, please don’t retire. But what — you know, what are people supposed to do? We have 1 vote and that’s it. Do you have any advice for people listening in about what they can do, if they like your idea, how they can take it forward?

Jane Philpott
I do have some thoughts on that. So, you know, we have 1 vote roughly every 4 years, but that doesn’t mean we can’t have conversations with our elected officials at any time. And I think, sometimes, Canadians are shy and don’t recognize the fact that they can call their Member of Parliament or Member of Provincial Parliament or MLA at any time and ask for an appointment to talk about what’s important to them. They could write them a letter or send them an email and say that this is important to them, to say we want to have 100% access to primary care in this country. We believe that it’s doable. Other countries have done this. Would you please commit your potential future government to make this happen?

Tara Kiran
Just to build on Jane’s comment, I would encourage your listeners to go to ourcare.ca. They can actually just enter their email and their name, and it will automatically send something to their MP. And then we have a whole page, actually, to support people to advocate, including lots of handouts on kind of the things we’ve been talking about — why is it important, how much does Canada spend compared to other countries — to help them to actually have these really important conversations with their politicians but also, I think, actually, friends, neighbours, relatives.

All too often, I think we can kind of just fall into complacency, like, oh, this is the way it is. We don’t have any power. But ultimately, actually, we are the ones with power, and the only way the system is going to change is if we reach that together.

Avis Favaro
If there was some sort of pressure, a commitment, how long would it take to see this start up in parts of Canada? Dr. Kiran, how fast can you get this going?

Tara Kiran
Great question. So I’d like to think that in 1 to 2 years, we could actually see a really big difference and make funds available to support infrastructure and new team builds in communities where it’s needed. I actually think there are a lot of frontline folks on the ground who are eager to kind of help to make this vision happen.

I think we’d actually see some really creative proposals from across the country. And we’ll act quickly. If government says, okay, you got to do this within the next 1 to 2 years and you get this much money, I actually think that does put a fire under people.

Avis Favaro
Well, we’ve just seen in Manitoba, there’s been a change in the government because people wanted their emergency rooms not to close, and they wanted better access to health care.

Jane Philpott
I don’t think there’s any doubt that people want change. There is a growing public discontent with the state that health care is in and, you know, we’re heading in an unhealthy direction.

And so I’m thrilled that places like Manitoba and Nova Scotia have elected governments who have said they would do better on health care. I think that anybody who is running to form government in the next few years better have a good plan together for health care because it really does matter to Canadians.

Avis Favaro
Well, I just want to say a big thank-you. I really have enjoyed talking to you both because I have a little bit more of a sense of hope and a bit of a sense of direction. I believe in mission statements. So the idea of a Canada primary health care act sets the stage, I think, for action. So thank you, both. And I hope we can have a follow-up conversation in a year where some of these ideas actually take root somewhere.

Jane Philpott
Hear, hear. I hope that happens.

Tara Kiran
Thanks so much.

Avis Favaro
A reminder. You can read a lot more about Dr. Philpott’s prescription for the Canadian primary health care act in her book, Health for All which, not surprisingly, has become a bestseller.

And you can take a deep dive into the data collected by Dr. Kiran and her team at OurCare.ca, where you can take a quiz on your health care and see all of the recommendations that Canadians, like you, want to see to make our health care better. That’s OurCare.ca.

And you can also check out the website at AVÐÇÇò.ca, that’s C-I-H-I.ca, for data on health care across Canada.

Thank you for taking time to listen. Our executive producer is Jonathan Kuehlein, production assistant, Heather Balmain, and a shout-out to Alya Niang, the host of our French show.

And please subscribe to the CHIP wherever you get your podcasts.

I’m Avis Favaro. Talk to you next time.