One fix to the family doctor crisis? Not every problem needs a doctor

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Dr. Alykhan Abdulla, an Ottawa-area family doctor, has an idea that could help address Canada’s doctor shortage: let others share the load.

Health-care professionals like pharmacists, nurse practitioners, physiotherapists and others capable of delivering care whose services aren’t covered by medicare — but could be.

Skilled professionals “who could drastically reduce wait times and improve outcomes if only we let them,” Abdulla, an Ottawa-area family doctor and board director of the College of Family Physicians of Canada, wrote in an opinion piece recently published by Healthy Debate.

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“But, no, we cling to a 40-year-old framework that’s as outdated as corded rotary phones. It’s absurd.”

Canada’s Health Act, which has gone largely untouched over its 40-years-and-counting lifespan, decrees that all Canadian residents must have reasonable access to medically necessary hospital and physician services, without paying out of pocket.

But Abdulla and others say licensed and regulated health professionals also provide what could reasonably be described as “medically necessary” care.

Expanding the range of personnel covered by public health insurers, and reconfiguring the primary care system, in particular, to include more disciplines, would lead to more care, and more effective care, they say.

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“Even the simplest reforms, like funding psychologists or physiotherapists under public health plans, are mired in political inertia,” Abdulla wrote. “If we really cared about access, what are we waiting for? A complete collapse of the system?”

“We will never catch up with the amount of disease burden we have,” Abdulla said in an interview with National Post. “And so, what I’m trying to propose is, let’s all get at this. Let’s elevate everybody’s scope.”

It’s a controversial proposal. Many doctors have resisted turf encroachment or “scope creep.”

“Organized medicine is at a fork in the road in this conversation,” said Steven Lewis, an adjunct professor of health policy at Simon Fraser University who spent 45 years as a health policy analyst and researcher in Saskatchewan, the first province to establish a universal public hospital insurance system in 1947. It was also the first province to pioneer universal access to physician services, in 1962.

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“Organized medicine can try to hold on to its exclusive domain and claim that only it can provide primary care, and a family doctor is the master of all disciplines,” Lewis said. “Or it can go with the evidence, which shows that all these other professions tend to be vastly underutilized.”

“It’s a bit of a myth that we have this publicly financed system,” Lewis said. It’s true for doctors and hospitals. “But the rest is a bit of a wasteland in terms of public funding and that, arguably, is one of the reasons why we keep spending more and more money and yet we’re still perpetually in crisis.”

There are “glimmers of progress,” Abdulla wrote.

Alberta was the first province, in 2006, to grant independent prescribing powers to pharmacists, allowing pharmacists to prescribe drugs from nicotine patches to emergency contraceptives (the “morning-after” pill) without requiring the approval or authorization of a doctor.

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Today, Saskatchewan is permitting pharmacists in select locations to test for strep throat or ear infections, and to prescribe medications if needed. Ontario, meanwhile, is sifting through feedback to a proposal to allow pharmacists to treat sore throats, calluses and corns, headaches (mild ones), shingles, sleep problems like insomnia, fungal nail infections, swimmers’ ear, head lice, ringworm, jock itch, warts and dry eye, in addition to 19 other “minor ailments” they can already prescribe for.

The plan is to “continue making pharmacies a one-stop-shop for more convenient care closer to home,” Hannah Jensen, a spokesperson for Ontario Health Minister Sylvia Jones said in a statement to National Post.

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In January, then federal health minister Mark Holland wrote to his provincial and territorial colleagues, outlining a new Canada Health Act Services Policy which states that if a service is considered medically necessary it should be covered by the person’s provincial or territorial health care plan, whether the service is provided by a physician or “physician-equivalent,” like a nurse practitioner. Changes are due to come into effect April 1, 2026.

“Any charges to Canadians for these services that occur on or after that date, will be considered extra-billing and user charges” under the Canada Health Act, Holland said in a statement at the time. Meaning that “every dollar wrongfully taken out of the pockets of Canadians” will be deducted from provincial/territorial health transfers, he said.

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The feds were irked by growing reports of people being charged for medically necessary services, including at private clinics led by nurse practitioners who can’t bill governments for their services.

“The intent was to say, ‘Look, we’re worried about what should be core medicare services leaking into the private, out-of-pocket system,’” contrary to the spirit of medicare, Lewis said.

“Now, of course, the provinces will say, ‘Fine, we agree in principle, but you need to increase transfer payments.’” It’s the pay-to-play principle, he said. “The only mechanism Ottawa has to direct the system what to do is to negotiate cost-sharing of some sort.”

It’s tensions like these that explain why provinces have stuck narrowly, in most cases, to the Canada Health Act’s core, and rigid, doctor-or-hospital requirements (which no one forced them to do) “because they’re already spending north of 40 per cent of their provincial budgets on health care in some provinces,” and they need to impose some sort of ceiling, Lewis said.

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He gets the fiscal problem. But the reality is Canada doesn’t have enough family doctors. Roughly 6.5 million Canadians don’t have access to one. “There is no way we can recruit or train our way out of this problem,” Lewis said. Not only should Canada greatly expand the nurse practitioner supply, “if you believe the comprehensiveness principle of the Canada Health Act, if you believe it means anything, we are failing miserably.”

Take mental health and addiction services: they are covered only if they’re delivered by doctors or in hospitals. Meaning people without private or employer-based insurance plans receive “inadequate care, delayed care or no care at all,” the Canadian Mental Health Association wrote in a letter to Holland last year. (Nova Scotia recently announced it will cover therapy for people with mood and anxiety disorders in coming months, by publicly funding private-sector professionals, as part of the first phase of its pledge to become the first province to offer universal mental health care. GreenShield this week began offering every Canadian over 18 two free sessions with a licensed therapist plus unlimited subscription to digital cognitive behavioural therapy, “no strings attached,” following a survey showing a spike in our collective anxiety.)

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Rehabilitation is also absent in the Canada Health Act, as well as occupational therapy and a “whole lot of other services that are ‘medically necessary’ that you don’t get from a physician only these days,” Lewis said.

Supplemental insurance is spotty, he added. Ironically, the people who routinely benefit the most from private insurance work for governments. “So, the irony is that governments provide insurance for these other services that governments deny to large swaths of the population,” Lewis said.

In addition to nurse practitioners, Holland nodded to pharmacists and midwives as among those capable, due to their expanded scope of practices, of providing some of the same services that would normally be insured if provided by a doctor.

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Ontario Medical Association president Dr. Dominik Nowak, however, said the term “physician-equivalent” could be problematic for governments.

“When I think of physician-equivalent, it’s someone who has gone to medical school, has done the years of training, the thousands of hours of expertise and experience that it takes to tell a sore throat from a peritonsillar abscess (a pus-filled pocket that forms in the tissues of the throat near the tonsils) or a regular headache from a serious health emergency like temporal arteritis (inflammation and damage to the vessels supplying blood to the head and brain),” said Nowak, a family doctor at Women’s College Hospital in Toronto.

“All of these different things that are life-threatening — differential diagnoses, as we call them in medical training — take years and thousands of hours of expertise to tell apart. And what’s where people deserve access to a doctor.

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“The way we scale access to a doctor is by building out (multi-disciplinary) teams in family practice,” Nowak said. “Not by siloing out health professionals and expanding the scope of health professionals by themselves.”

“It’s about building out teams rather than focusing on these Band-Aid solutions,” he said.

Lewis wholeheartedly supports the team model. He also thinks they are entirely incompatible with the fee-for-service system and should instead be funded by global, or fixed budgets, the way hospitals are funded, or a capitation system. “You have a big clinic with 15,000 patients. We’ll give you X dollars per patient, which is adjusted mainly for age and sex but in some cases for very high needs.”

“You can set up the model anyway you want,” said Abdulla, who works in a team himself. “You just want to make sure that people get oversight, and they get comprehensive care, and they end up with the right person at the right time.”

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Lewis doesn’t want to encourage “fragmentation,” with people hanging out their own shingles and practicing independently, “not least because it’s inconvenient for the public. Why should I go to three places to get primary care? It’s absurd.”

But it’s also unnecessary to use more expensive labour than necessary to look after relatively uncomplicated needs, he said, “and that’s what happens now.”

At the other end are people who aren’t getting the comprehensive care they need.

There are many more older people today than there were in the “early glory days” of medicare when the country’s population was a lot younger, Lewis said. Then, 65-and-overs accounted for perhaps seven per cent of the population. Today, they account for nearly one in five. The proportion is expected to increase to 24 per cent by the end of the 2030s.

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“A whole lot of people don’t actually benefit a lot if they only see a doctor,” Lewis said. An 82-year-old with mild cognitive impairment, cardiac disease and type 2 diabetes could benefit “from much more rehabilitation and an occupational therapist to make sure their home isn’t a danger to them because of limited mobility.”

The system should be designed around the complex elderly person, he said. “Because if it works for them, it’s going to work for the rest of us.”

Some worry expanding the scope of more providers would bankrupt the system. The public financing part could get a lot more expensive if more disciplines were covered under medicare, Lewis acknowledged. “But it would be, A, more effective and, B, it might not be that much more expensive if you did some labour substitution.”

“We assume this is just add-on, add-on, add-on. But if you have nurse practitioners and occupational therapists and physiotherapists and pharmacists doing more things, it doesn’t necessarily mean you’re getting more care. It means you’re going to get different care.”

National Post

This is the latest in a National Post series on How Canada Wins. Read earlier instalments here.

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