Will Falk and Rosalie Wyonch – Conceptualizing Primary Care as a Public Education System

From: Will Falk and Rosalie Wyonch

To: Canadian Healthcare Observers

Date: January 8, 2025

Re: Conceptualizing Primary Care as a Public Education System

Jane Philpott’s recent health policy book outlines a vision for providing primary care access to everyone using the metaphor of the public primary education system.

The concept is seductive, but primary care and primary education have almost no practical similarities. Governance and funding structures, employment and compensation, competition and community involvement mechanisms all differ. Transforming primary care to look more like the education system would require rebuilding the healthcare system from the ground up.

Half of Canadians either don’t have a family doctor (19 percent) or struggle to see the one they have (29 percent). If everyone becomes registered with a family doctor, but nothing else changes, the resulting crush in waiting rooms would mean we have just shifted the pressure point. We need to go further to achieve the former health minister’s vision.

The public education system has a hierarchical structure with many different roles within a school. There are principals and vice-principals who manage day-to-day operations, enforce policies and ensure standards are met. Specialists include librarians, music and art instructors, physical education instructors and coaches (some volunteer). School boards are elected and govern educational policies, curriculum standards and resource allocation. Parents and community members participate in school councils and committees. Both provide avenues for direct community involvement in influencing decisions and holding schools accountable.

Healthcare lacks this layered supervisory structure. Primary care providers often work independently or in small groups without any of the oversight that guides educational institutions. There is no equivalent to school boards or ministries that provide direct, localized governance and accountability in primary care settings.

Compensation and labour relations are also very different. Public school teachers are paid on standardized salary grids determined by qualifications and years of experience. Unions negotiate salaries, benefits, and working conditions. Teachers have robust pension plans, healthcare benefits, and scheduled time off, including two months during the summer.

Physicians often operate under fee-for-service models, which can incentivize quantity over quality of care. Primary care physicians are independent and incomes can vary widely based on patient volumes and services rendered. They set their own hours but do not have paid time off, pensions nor robust health benefits. Physicians in high-needs areas face longer hours and burnout without the structured breaks associated with education. Conversely, if a physician chooses to provide only a few hours of care, there are no mechanisms to compel them to work more to serve a larger patient population. In most provinces there is no mechanism to assign physicians by geography and any attempts have historically been resisted by provincial medical associations. Only Quebec has implemented a regional staffing model (the PREM). This model has not been a success.

The public education system is not the only option for children’s education. Parents might opt for sending their children to a publicly-funded Catholic school (28 percent in Ontario), pay privately for education (7 percent in Ontario), or home school (0.4 percent in Ontario). Private schools provide alternative curricula and public systems also offer customized educational tracks.

So, what would primary care look like if it were structured similarly to the education system? Everyone would be assigned to a primary care clinic within their region. The primary care clinic would be overseen by a professional, responsible for ensuring clinical standards are met and managing day-to-day operations. Physicians would be one of many types of employees at these clinics, along with pharmacists, mental health professionals, and social service providers. All providers would have standard compensation structures. Likely at lower salaries but with health benefits, pensions, time off, and accountability as employees for standard hours and meeting clinical standards (curriculum). The clinics would feature wellness-improving services available to those who want to optimize their health such as dietary and fitness advice. If patients prefer, they could opt to register with a different publicly funded clinic more tailored to their preferences and needs and the public funding would follow them. There would be private options available for those whose particular preferences and needs are not addressed through the multiple public options, perhaps one focused on their religious and cultural context or based on holistic health concepts, which they could pay for out-of-pocket.

The idea does sound great. If the government commits to transforming the primary care system to mirror the public education system, it would be revolutionary change. If, however, the metaphor only extends to registration, and can’t be successfully extended to incorporate changing employment, remuneration, administration and oversight structure it will do little to improve access.

Will Falk is an Executive in Residence at Rotman School of Management and a Senior Fellow at the C.D. Howe Institute, where Rosalie Wyonch is Associate Director of Research.

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The views expressed here are those of the authors. The C.D. Howe Institute does not take corporate positions on policy matters.