Access to care: 5 principles for action on primary health-care teams

Primary care is in crisis. Recent estimates indicate 6.5 million Canadians, including 2.5 million Ontarians, do not have a primary care provider.

Interprofessional primary care teams include a range of health professionals in addition to a family doctor or nurse practitioner, and are a key solution to improve access to primary care.

As of Dec. 1, 2024 family physician and former federal cabinet minister Jane Philpott is leading Ontario’s new Primary Care Action Team. Philpott states, “Our goal will be for 100 percent of Ontarians to be attached to a family doctor or nurse practitioner working in a publicly funded team, where they receive ongoing, comprehensive care.”

Her book Health for All articulates a vision of primary care, or what is being described as a “health home,” which would guarantee every person access to a primary care team close to where they live. The Primary Care Action Team has announced its plans to achieve this goal within five years.

A health home is the front door to the health system and includes a team of primary care providers that supports an individual’s health and wellness; co-ordinating care across the system and through every stage of their lives. Each health home would ensure you could receive primary care services based on where you live; ensuring that if you move to a new city you would have access to your local health home, just as you would have access to your local school.

Principles are needed to achieve these goals. These principles should build on successes and address historical challenges. Our team, comprised of primary care researchers and a community partner, has focused our work on understanding how primary care teams can support access and better outcomes.

Collectively we propose the following five principles for the Primary Care Action Team to consider, which emerged from our panel discussion at the 2024 Trillium Primary Care Research Day on Oct. 25, 2024.

1. Primary care teams with minimum standard team members

All Ontarians should have access to a primary care team with a minimum composition of a family physician and/or nurse practitioner (NP), dietitian, nurse, occupational therapist, pharmacist, physiotherapist and social worker.

There are currently no evidence-based guidelines, minimum standard complement or ratio of patients to team members to ensure primary care teams are resourced to meet their local needs. The health professionals listed above are the most frequently included in Ontario’s primary care teams, according to findings of a website review conducted by one of the authors of this story (Catherine Donnelly) and occupational therapy students Maryjune Duggan and Thea Babalis. This review included 187 Family Health Teams (FHTs), the largest model of team-based primary care in Ontario, and identified over 60 different types of providers who offered almost 1,500 different programs.

2. Direct patient access to team members

People must have direct access to all primary care team members. Direct access means people can directly book an appointment with any team member. Currently, for the 25 per cent of Ontarians who belong to a Family Health Team, how people access team members beyond doctors and NPs is highly variable. Our review of Family Health Team websites found that some people can book directly, others require a referral; some can book online, others must call.

Direct access to the broader team empowers patients, allows providers to work to full scope, and increases primary care capacity by reducing physician or NP visits associated with appointments booked to get a referral to another team member.

First-contact physiotherapy roles in the National Health Service in the United Kingdom provide an example of how direct access can improve access to primary care and reduce health system costs. People in the U.K. with a musculoskeletal condition such as back pain or osteoarthritis are able to book directly with a physiotherapist. Recent evidence indicates that physiotherapy-led musculoskeletal care and physician-led musculoskeletal care in the U.K. resulted in similar health outcomes, but the physician-led care costs about 2.5 times more.

This is just one example of how direct access to team members can improve the quality, patient-centredness, and efficiency of primary care.

3. Infrastructure to support health neighbourhoods

People and teams must have the infrastructure to communicate across their health neighbourhood. The health neighbourhood includes care providers and services within and beyond a person’s primary care team. Currently, teams are ill-equipped to communicate and collaborate across organizations. For example, patients may access community pharmacists, physiotherapists, occupational therapists or mental health counsellors who don’t share an electronic health record (EHR) with the primary care team.

As a starting point, providing people with access to their own EHR would allow them to connect their primary care home with their “health neighbourhood”. Evidence indicates that patient access to their EHR can increase engagement in one’s health care and improve safety and effectiveness.

4. Data collection on care by all team members

Data must be collected on care provided by all primary care team members. After almost 20 years of existence, FHTs do not have consistent processes for collecting data related to visits, care provided, experiences and outcomes of care provided by non-physician team members. Further, data from visits with non-physician team members isn’t found in health administrative databases because it is not billed to the Ontario Health Insurance Plan (OHIP).

Our health system must systematically collect the data necessary to implement accountability structures for the investment in team-based primary care and to facilitate continuous quality improvement. This data must include visits, care provided, experiences and health outcomes for care provided by all primary care team members, not just services billed to OHIP.

Community Health Centres — an interprofessional primary care model that has a specific focus on populations that face additional barriers to accessing services such as geographic isolation or cultural or language barriers — track this information through their EHR and have linked this data to other health administrative data to assess the impact of their teams on the health system, demonstrating this is feasible.

5. Shared team leadership structures

Primary care teams must have shared leadership structures. Currently, only 24 FHT governance boards are community led, compared to 100 per cent of Community Health Centre boards.

Primary care teams are expected to be accountable to the communities they serve. Governance must reflect this. Further, inclusion of patients and families within decision-making is critical to achieving the primary care principle of person and family centeredness.

Additionally, primary care leadership structures and decision-making processes will benefit from diverse health professional perspectives and expertise, including representation from the core professions that currently work on teams.

The Canadian Interprofessional Health Collaborative identifies shared leadership as a core competency for all health professionals. We need governance and leadership structures that involve team members sharing accountability for decision-making. The Primary Care Action Team is an excellent opportunity to demonstrate the value of interprofessional decision-making to move from goal to action.

Achieving the Primary Care Action Team’s mandate will take new ways of thinking and working together to ensure broader access to teams for Ontarians — and these five principles provide clear actions to avoid the status quo. More than ever we need to create strong teams with community leadership, data access for decision-making and accountability to broader communities.

This story was co-authored by Clare Cruickshank, Patient Advisor, Ontario Health INSPIRE-PHC, Patient Expertise in Research Collaboration.

Catherine Donnelly receives funding from Canadian Institutes of Health Research, Social Sciences and Humanities Research Council, Federal Government, Ontario Ministry of Health, Ontario Health, Walton’s Trust, Baycrest, Ontario Ministry of Seniors and Accessibility

Jennifer Lake receives funding from New Initiative and Innovation Award – Network for Improving Health Systems administered through University of Toronto.

Jordan Miller receives funding from the Canadian Institutes of Health Research, Arthritis Society Canada, Foundation for Advancing Family Medicine, Chronic Pain Center of Excellence for Canadian Veterans, and Government of Australia National Health and Medical Research Council.

Rachelle Ashcroft receives funding from Canadian Institutes of Health Research, Social Sciences and Humanities Research Council, Ontario Ministry of Health, and the University of Toronto.