Abstract
Background and objectives: A key policy priority is the development of a seamless patient journeys through the continuum of health services through integrated care system reform. In this study, we learn from recent reforms in Australia, Canada, the United Kingdom) to strengthen primary care engagement in the implementation of integrated systems reforms, to gain insights from the implementation barriers and enablers at multiple levels of the system to develop implementation support programs.
Approach: We conducted a rapid jurisdictional review (Winter 2023) across five Canadian provinces (British Columbia, Alberta, Manitoba, Ontario, and Nova Scotia) and two international comparators (Australia and Scotland and England, United Kingdom). We drew from academic and grey literature about primary care delivery models and recent system reforms impacting primary care (e.g., integrated systems). We mapped our results against a conceptual framework about the sub-functions of primary care to draw out similarities, differences, innovative or promising reforms. We convened a policy dialogue (April 2024) with policymakers and local experts (n=18) from Australia (New South Wales, Victoria, and the National Aboriginal Community Controlled Health Organisation), Canada (Alberta, British Columbia, and Ontario), and England from to discuss our findings and to learn about enabling factors for the implementation of integrated systems across these jurisdictions.
Results: Primary care reform is ongoing across jurisdictions with a more recent focus on refining team-based interprofessional care and/or strengthening care pathways between physician practices and other providers/community clinics. Formal and informal studies of these reforms underscore the challenge in maintaining strong relationships between governments (payers) and primary care providers to achieve system objectives. There are notable trends related to financing and governance that may facilitate primary care reform. First, a shift away from fee-for-service (FFS) payment models toward alternative payment plans (e.g., blended capitation with some targeted incentives, a variant of pay for performance targeted at physician practice). Second, supporting collaborative approaches to primary care reform that emphasise GP buy-in and voluntary participation in new contractual models rather than a ‘command and control’ model. Third, we identify promising tools to improve accountability that governments and policy planners can use to improve how patients interact with primary care providers (e.g., family doctors, nurses) and other health providers along their care pathway. Lastly, connecting system managers and policy researchers across jurisdictions holds promise in supporting ongoing policy learning and supporting local implementation.
Conclusion: Primary care reform initiatives that shift financing away from FFS remuneration, pursue integrated care through voluntary collaboration/interprofessional teams, and promote accountability and cross-country learning are widely supported by GPs, clinician-leaders and policymakers. Our results demonstrate that further research is needed about improving partnerships and the interrelationship between primary care providers and other local community organizations responsible for implementing integrated care systems.