Funding cuts, fewer generalists and inefficient organisation are preventing more and more Canadians from accessing public primary healthcare, according to a new study published in the Canadian Medical Association Journal (CMAJ) which compares Canadian healthcare unfavourably with public systems in nine Organisation for Economic Cooperation and Development (OECD) countries. About 20% of Canadians have no family doctor at all, and many more have irregular access to clinicians – a reality likely to worsen if not properly addressed now, said Dr Tara Kiran, a family physician in Toronto and one of the authors of the study. “In Canada, what we have is a haves-and-have-nots situation,” said Kiran. “[There are] people who do have access to a family doctor and sometimes even a health team, and then those who have nothing.” The CMAJ study, led by family physicians and researchers at the University of Toronto and published on Monday, compares the Canadian healthcare system with those of Denmark, Finland, France, Germany, Italy, the Netherlands, New Zealand, Norway and the UK. Those countries were chosen because 95% or more citizens have access to a family physician. Among the study’s chief conclusions is that countries that design healthcare systems around the principle of guaranteed access have far different – and usually better – outcomes than those in Canada. Important comparative differences included higher rates of primary care funding, more doctors, better organisation and information systems support and greater physician accountability to the public insurer. But perhaps the biggest difference, said Kiran, is that “they set a goal that primary care is something that should be guaranteed to everyone in the population, and they design around that”. She pointed out that Norwegians and Finns are automatically registered to a doctor or health centre, and those in the UK have a right to register with care providers in their immediate communities. The study also noted that relationship-based care with a single clinician is associated with better patient outcomes. Many Canadians, however, wait for years on provincial family doctor waitlists. Others have to call around town in hopes of finding someone willing to accept them. In the interim, they cobble care together through urgent care clinics, hospital ERs and, in some cases, private out-of-pocket services. In Canada, each province or territory is responsible for running its own healthcare regime. Drawing from their tax bases, provinces splits healthcare costs with the federal government. However, the federal government now only covers about 22% – a significant decline from the 50% it promised in the 1970s to help incentivize the creation of public healthcare regimes. The CMAJ study also shows that at 5.3%, Canada spends less of its total health budget on primary care than other OECD countries. In those countries, primary care spending constitutes an average of 8.1% of total healthcare budgets, the authors wrote. Research on Canadian healthcare shows declining funding puts increasing pressure on healthcare services and resources across the country – a trend that has, in recent years, enabled increasing privatisation of care in some Canadian jurisdictions. By and large, primary care providers in Canada are autonomous small business owners that get reimbursed by the government for services provided to rostered patients. This structure is the result of a hard-fought battle waged by Canadian doctors at the advent of the public system. That model may be losing its lustre, however. Kiran said that more and more Canadian medical school graduates are losing their appetite for the self-employed, fee-for-service model on which Canada currently relies in favour of greater work-life balance. With shifts like these, the CMAJ study suggests Canada may be forced to chose between continuing to pour money into a broken system, and reimagining it entirely. Kiran said a chief lesson to learn from other countries with public systems is that universal healthcare can work when it is designed and funded with intention. She pointed to the disconnect between what Canadians want – access to a physician through the public regime – and what they are getting instead: more urgent care clinics, out-of-pocket private clinics and expanded pharmacist services. “They want things to change,” she said.