Right-sizing healthcare systems for kids: Primary care access

In this episode of SPARK: Conversations, we explore the role of primary care teams or healthcare professionals in right-sizing children’s healthcare systems. Dr. Tara Kiran discusses the revolutionary OurCare study, its findings, and implications for addressing the current primary care crisis and ensure that every child, youth, and family is assigned and has timely access to a primary care team or provider. Through this webinar we will also explore how other countries have ensured access to primary care for citizens; what this means for children, youth and their families and the healthcare systems that serve them; and how this could be reflected in Canada. 

Transcript

Connected by purpose. Driven by passion. This is Children's Healthcare Canada’s SPARK: Conversations podcast series.  

Dr. Katharine Smart: Welcome to SPARK: Conversations, Children's Healthcare Canada's monthly podcast series. SPARK: Conversations is one component of Children's Healthcare Canada’s SPARK Knowledge Mobilization Program. During the 2024-2025 fiscal year, SPARK: Conversations will be dedicated to right-sizing children's healthcare systems. Thanks to our SPARK: Conversations podcast right-sizing series sponsor, the IWK Health Center for their ongoing support. I'm Dr. Katharine Smart, and today I'm absolutely delighted to be speaking with Dr. Tara Kiran.  

Dr. Kiran is absolutely one of my heroes in primary care, and I think we are going to have the opportunity to learn a lot from her today. So, let me tell you a little bit about her. Dr. Kiran is a family doctor and a renowned primary care researcher. She investigates how changes in the healthcare system impact patients, particularly those most marginalized. In her research and practice, she develops and tests solutions to make healthcare more inclusive and more effective. Much of Dr. Kiran’s research has evaluated how primary care reforms have impacted quality of care. She also leads research to directly improve quality of care, including initiatives to measure and reduce care disparities, engage patients in health service improvement and support physicians to learn from data. In 2022, Tara launched Our Care, a national initiative to engage the public in co0creating the blueprint for a stronger, more equitable primary care system in Canada. 

Tara holds the Fidani Chair of Improvement and Innovation at the University of Toronto. She practices family medicine at St Michael's Hospital, Unity Health Toronto. She is the Cice-Chair for Quality and Innovation in the Department of Family and Community Medicine at the University of Toronto, a scientist at the MAP Center for Urban Health Solutions at St Michael's Hospital, a Senior Adjunct Scientist at ICES and an Associate Professor in the Faculty of Medicine and the Institute of Health Policy Management and Evaluation at U of T. You can learn more about her research at https://maphealth.ca/kiran/. 

So, as all of you listeners know, Children's Healthcare Canada is on a mission to right-size children's healthcare systems. Right-sized healthcare systems for children are accessible, equitable, connected healthcare systems designed for the needs of children, youth and their families. From coast to coast to coast and across the continuum of care, children, youth and their families are experiencing long and costly delays for essential and time sensitive healthcare services. We'll explore what this means in real world contexts, along with the collective action required to change the way systems work, interact and intersect. Through this episode, we will focus on the role of primary care in right-sizing healthcare systems for children, youth and their families. So welcome Tara, and thank you for joining us today.  

Dr. Tara Kiran: It's great to be here. 

Dr. Katharine Smart: So you know, I'm really excited to be talking to you because, you know, I think a lot of our listeners probably realize that primary care is really the door that people walk through when they want to access the healthcare system, and especially for children, youth and their families, most people would receive their care from a family doctor or another primary care provider, and that's where so much of that early education comes from when we're thinking about addressing people's health. So, I think what you're doing is really, really important. So, when we're thinking about, you know, team-based care and the work that you're doing, can you just give us your perspective as a family doctor and someone who's an expert in this area, like, why is primary care so important when we're thinking about children and their families? 

Dr. Tara Kiran: Yeah, so, I mean, I think about primary care as the front door to the healthcare system. It's a place that you go when you have a new condition, but also a place that you do go to manage health conditions, and then, importantly, it's a place, actually, where you go to prevent things from happening in the future and being able to live a longer and healthier life. And I think when it comes to children, that last bit is particularly important. Now, of course, you know, children also have lots of acute things that happen. You know, they develop fevers. Many you know, children do have chronic conditions like asthma or other things that they're dealing with, but you know, all children from birth really need to have appropriate preventive care and well care really to support them to be able to live their fullest life. This includes, you know, a check 48 hours after being discharged from hospital about whether their weight is appropriate for, you know, their metrics and then making sure that, you know, parents are understanding how best to feed them and look after them in those early stages. And then, of course, there's a whole slew of immunizations that children need, and we need to make sure that their growth and development over those early two years in particular is really going on trajectory as needed and that's our time to pick things up as you know, Katharine, you know, there's an issue with a child.  

Sometimes it can be subtle, you know, whether it's their eyes, you know, appearing as they should, or whether it's, you know, growth falling off a growth chart and not keeping up, or whether it means that, you know, social developmentally, for example, they aren't, they're not able to, you know, jump up and down in the way that they should. Or they're not able to, they're not interacting with you and making eye contact in the way that they should. These are all the kind of subtle things sometimes that we pick up in these routine visits where we monitor the growth and development, and when we pick them up early, it means that we can manage them early and manage them in a way that really means that they aren't going to have ongoing consequences. But if we let things slide and we don't pick them up really, unfortunately, actually, it can have huge consequences, including for not just their growth, but their learning and their development as humans. And then, of course, they have the whole rest of their lives with those consequences at play. So for children in particular, it's so important for us to have a home for them where they can have access to someone or a team who are able to look after their preventive healthcare needs, their chronic condition needs, and any new thing that arises, and so what I'll say also with primary care is, you know, primary care, if something is going wrong, it's the way, it's the place then that coordinates care among the rest of the healthcare system.  

It's also the place, though, where you build a relationship with a healthcare clinician or a team over time, so that when challenges do arise, you've got that foundation of trust. And you know you feel confident as a parent and as a child, you know what it is that you need to do in order to help yourself to get better.  

Dr. Katharine Smart: Thank you for that really beautiful description about why primary care is so important, you know. And I think you've touched on a few things that we've been touching on through this podcast. And I think one of the most important things is that idea of, if we find challenges for children early and address them in a timely way, we have much better outcomes, and we can prevent complications, and I think that's what's one of the pieces that's so important for people to understand is when things are neglected or people don't have somewhere to go, or someone they trust to address their concerns, small problems can become big problems, and those can have lifelong implications, as you've touched on so it is so critical that people have those relationships to identify those challenges and make sure that we're getting children timely care so we don't turn something that could have been easily dealt with into a bigger problem, or make the implications of something that may be chronic worse than it needed to be because we didn't pick up on it.  

So, I think you're really touching there on many of the themes we've been talking about when we talk about how important right-sizing children's healthcare is, and the other thing I love that you said is about relationships, because I think so much of that you know, as clinicians, we understand that's a lot of the value we bring. But I also think you know, when you know your patients, when they come in and something's changed, they're not quite themselves, right? You might ask questions or probe or check into things that they maybe aren't bringing forward. And I think that's really important in our adolescent population, mental health and different challenges kids can have. If you know them, you may say you know what, you seem a bit different today. And I think again, that relationship based care really allows us to identify things before they get out of hand, so I really appreciate you highlighting those things.  

Dr. Tara Kiran: Maybe I'll just build on that Katharine, because I think the core, a core part of their relationship, building actually is building trust, right? And we've learned over and over that trust is such a foundational element for people to be able to accept and want to move forward with a lot of the medical interventions that we recommend, that we know actually there's a lot of evidence behind, but sometimes people can become skeptical about and I think about vaccinations as one example of that. We know that there's been kind of a decline in some vaccination rates for conditions that are, you know, now, unfortunately, becoming more prevalent. And these are conditions like measles, you know, which could actually be prevented if people are vaccinated. But, you know, some people are now more reluctant to get vaccinated. Sometimes it's just convenience, and they, they, you know, they, they, they've forgotten about it. But sometimes they're reluctant, and, well, there's a lot of studies and evidence to show that actually, people are much more likely to get a vaccine if they have a trusting relationship with a healthcare clinician, and people do trust their family doctors and their pediatricians. And so that's part of you know, I think a great example of how a long term relationship and trust can actually benefit health.  

Dr. Katharine Smart: Oh, absolutely. And in this era where misinformation is on the rise and more and more, we're seeing people peddle bad information over social media to people, I think, never has these have these trusted relationships been more important. Because the power of misinformation, the spread and scale, having an out, trusted person you can check in about is important. You know, we're really in an era where there is a backlash against science, and I think it's our job to bring to the forefront for the people we care, for the actual facts, so that they're making good decisions and not causing harm. And you know, as you touched on with measles, I think that's such a great example of a disease that was almost eliminated in North America and now is resurging. And we even saw a death of a child in Ontario this year. And those are tragedies, right? That I think often happen because people have not had the right information.  

So, speaking of people, you know, Tara, one of the things I really am excited about talking to you about today and learning more about is your OurCare study. I think that work that you did is really unique, to my knowledge, nothing like it's ever happened before. I think it's, I'm really excited about how you actually engaged with citizens to hear about what their views were, what they wanted for primary care. So, I just want to tell our listeners a little bit more about what that work was, and then I want you to tell us a bit about what your findings were.  

So, for people who haven't heard of the OurCare study, it was a three phase research project and public engagement initiative led by Dr. Kiran to help to try to give some answers to our struggling primary care system. So, in Fall of 2022, they undertook a national bilingual patient survey to inform the development of the blueprint of the future primary care services and how to make it possible for more Canadians to access high quality healthcare. Then they undertook provincial priority panels, five panels, 160 participants in BC, Manitoba, Ontario, Quebec and Nova Scotia. And these were deep dialogs where people talked about the challenges around primary care, and a report was generated from each panel, and then they went on to do 10 community round tables, two in each of the five provinces, with almost 200 participants from equity-deserving and under service marginalized communities and their participants shared their experiences and their challenges when attempting to access primary care, as well as their ideas for change. And the report of those findings is available too.  

So, Tara, I'd love to hear from you know, what did you find? What maybe surprised you, what didn't surprise you? And how did this work sort of pave a way forward for creating this, this, you know, blueprint for primary care reform in Canada.  

Dr. Tara Kiran: Yeah. Thanks, Katharine. I mean, it was an amazing journey. Over the 16 months, we heard from, you know, more than 10,000 people across the country who collectively spent more than 10,000 hours with us in those different kind of ways in which you described.  

I mean, to start out, I'd say, you know, the headline finding from our national survey was that 22% of adults who we heard from did not have a family doctor or nurse practitioner that they regularly could see for care. So, you know, translated to the adult population in Canada, that's more than six and a half million people without primary care. And of course, you know, we didn't survey children, but we assume that, you know, that there's, there's an additional, you know, hundreds of thousands on top of that, of children who don't have access. 

And you know what we what we additionally found out was that, you know, even for people who did have a family doctor or nurse practitioner, they were struggling often to get the timely care that they needed. So only, for example, 35% of people said that they were able to get an appointment the same or next day when they had an urgent concern. And for people who didn't have primary care, even when they had a non-urgent problem, they were turning to places like a walk-in clinic or an emergency department.  

We also heard from people in the survey that you know, that it was really important for you. We heard what was important to them, and we heard one of the things that was critically important was that they have a family doctor, a nurse practitioner who knows them as a person and considers all of the factors that affect their health. And to me, you know, that really shone a light on how the public values, not just timely access or any access, but actually that relationship. It was clear that that's what people wanted. And you know, it was also clear in our survey that people were open to different ways of doing things. Like we asked a whole bunch of questions about, you know, would you be willing for the, you know, if the healthcare system looked like this, or would you be willing to see a nurse practitioner or other members of the team? And in general, people were very willing to have that healthcare system be redesigned, especially if it meant that everybody in Canada could have access to primary care. So those were some of the, you know, key highlights from our survey, and I would say that they were echoed and really built upon in those dialogs that we had.  

And what was incredible is, like the diversity we really heard from a really diverse group of people across the country, you know, different socio demographic backgrounds, age, gender, income levels, educational backgrounds, whether they were immigrants and then living in many different parts of Canada. And it was a really beautiful thing to see such diverse people come together and spend for Provincial priority panels. It was like 30 to 40 hours together strangers and they had to, you know, not just learn about the primary care system, but have that they had the hard job of coming to consensus in their kind of small groups and then their large group in terms of, you know, what are the values they wanted to see in the primary care system, what are the issues that were most important, and then what were recommendations they would put forward? And I will say that there was, it was incredible that even in this world of polarization, there was so much consensus around what it is that people wanted to see, and at the heart of that was this value that every person in Canada deserves access to primary care. They were very clear about that. Everybody should deserve access regardless of their background, and they recognized that probably the only way that would happen is if people were connected to a team, and they wanted all of that to actually be publicly funded. They recognized that, you know, more and more now, there was this role of like, being, having to pay out of pocket for services because people didn't have the publicly funded services that they deserve, and they didn't want to see that growth and paying out of pocket. They wanted to, you know, have a stronger public system. They wanted to ensure that care was timely, but also that, you know, it balanced with that relationship and getting to know people over time. They wanted to ensure that care was available after hours, and there was a mix of virtual and in person, and they wanted to see a wellness-oriented system, so not a system focused on sickness, but wellness, and one that really considered the social determinants of health as well. So, things like, how housing or employment might affect somebody's health. 

We heard over and over again how frustrated people were that they didn't have access to their own health records, and so it was very clear that they wanted to have access to their health records online. And then, I would say in our community roundtables in particular, but also in the provincial priority panels, we unfortunately heard a lot of stories about continued racism and discrimination within our healthcare system, were very hard to hear, sad to hear, and it was clear that people wanted to have a system that was culturally safe, where those experiences didn't happen, and they felt one way for that to be culturally safe is to ensure that the workforce that's caring for people actually reflects the diversity of the people that it's caring for. And that primary care really also should be delivering all of the healthcare needs that people need. So, you know, it shouldn't be that you have a family doctor and the family doctor says, well, actually, you know, mental health, addictions, gender affirming care, that's out of my scope. I don't know that. No, if you have primary care, it means that they deliver all the care that they need, and it should be accessible from a language, from a physical ability, perspective and other pieces. 

And then, you know, lastly, we also heard this concept of how primary care really needs to be accountable to the communities that it serves. And so, what does that mean? It means that patients in the public are involved in decision making, everything from you know, what measures should be reported to what services should be delivered. It also meant that they wanted to see transparency. So how much is being spent on the reforms, and what is that bringing us? What's the performance of our system? And they wanted to see a larger role for patients in terms of their own empowerment and education. So, they want patients to be able to better navigate the system and have the information to look after their own health better. So, I will just say that you know those things that I just mentioned to you, Katharine, we've summarized them in something called the Our Care Standard. And I would encourage people to go into our website, ourcare.ca to take a look at the Our Care Standard. And you know, if they if it's something that resonates for them, actually, take a moment to write to their elected representative. We make it really easy, to say, yeah, this is something that we want. But it was pretty clear through all our consultations that that was a consensus across the board. 

Dr. Katharine Smart: It's really amazing, isn't it, you know, just the wisdom of the citizens that you worked with. And I mean, not, not surprising. I don't think that, that people know what they need and want. But, you know, you've really just laid out there a blueprint for, really, what would in my mind be an ideal, patient centered, responsive system that could really deliver for Canadians and really help us get towards a healthier population and better management and support of people that do have chronic illness and chronic problems, but again, that balance between wellness and creating health and then also helping people that are dealing with healthcare problems. And I think it's just such a great lesson that you know, when we actually go to people and include people and have these conversations, people know what they need and want, and it is really our job, I think, to understand why our system isn't delivering on that vision. Because it's actually not super complicated, really, is it like it's really some basic values, basic relationships, and it's really calling on us to have a system that's purpose built, rather than sort of a hodgepodge of people trying to work in a, in a not integrated way. And I think that on for most people probably makes sense, you know.  

So that leads me to wonder, how it does Canada compare to other countries, you know? I think this is a common question I get from people like, what's going on elsewhere? Do other people have it figured out? What do you know about other primary care systems and how these countries compare with Canada and you know around access, experiences outcomes, both for families in general, but any information you have on children and youth would be interesting to our listeners too, I think.  

Dr. Tara Kiran: Yeah, thanks, Katharine. I think it is really important that we learn from countries where they are getting it right when it comes to primary care. So, our research team actually tried to do that. We compared Canada to nine pure countries that where 95% or more of the population have access to primary care. So, these are countries like Denmark, the Netherlands, Norway, the UK, France. So there's a number of countries, and we published a paper back, actually, back in December of 2023 that actually summarized our findings. But some of the key things we found, so we found that, you know, those countries, although their total health spending was about on par with ours, you know, maybe plus or minus some, actually, the proportion of health spending that was in the public system versus that was, you know, private pay was much higher in those countries. So, they had a better funded public system than we do per capita.  

And then they also actually, you know, they had similar numbers of general practitioners or family doctors per capita, but actually they had more overall doctors per capita. And I think that's an important piece as well. So, what's happened, I think, here in Canada, is that more and more, you know, we don't have enough physicians for the population we have, and part of the consequence has been then that family doctors, who are generally trained, actually start to work in other parts of the system, for example, supporting our hospitals. And that's part of the reason why, then we're seeing the shortage in our family physician workforce. You know, partly also because family doctors are relatively underpaid compared to some of these other options that are available to them. But all of it, a lot of it stems from the fact that we just didn't train enough physicians. And we can go into why that was, but and we're basically suffering the consequences of that, and we can see that very clearly in the data.  

And then, you know, we did a deep dive into some of those other countries, and we learned about some of the ways in which they worked that are different than the way we work. And I will also say that I personally also had an opportunity to actually go to Denmark about six months ago and visit to understand their primary care system, and I'm more in depth, and I'll share with you just a little bit about kind of what they do that's different, and I think it would highlight some potential kind of solutions on our end.  

So interestingly, in Denmark, Family Medicine is a very well respected profession. It actually has a similar length of training to other specialties, and it actually pays more than the average other specialists would make. Most of the family medicine is still delivered by, you know, general practitioners who have their own clinics. But interesting for interestingly, so for general practitioners to practice in Denmark, they kind of have to get, like, a license from their local region. And there are only a certain number of licenses that are available, and the license is specific to a geography. So, once you get that license, you kind of have to be in that geography, and the license kind of has some obligations with it. So as a, you know, you have to, you know, roster and look after 1600 patients. You have to be open eight to four Monday to Friday. You have to participate in afterhours rotation, and you have to commit to seeing same patients with urgent concerns, the same or next the same day and other concerns within five business days, so non-urgent concerns within five business days.  

And so that's sort of like the extent of the actually, the accountabilities and the contracts, but it's some very clear accountability about how many people you serve and timely care. And that's not to say that a single doctor has to, you know, work Monday to Friday to four. You could actually choose to hire a doctor to fill in for you on a regular basis, two or three days a week. But that license is responsible for kind of still those parameters of 1600. And then usually, you know, in Denmark, actually, they don't have a lot of different team members, but they do work very actively with their nurses and also their midwives and medical office assistance and a lot of the chronic condition management, as well as the well baby and well and prenatal and postnatal care is done in collaboration with the midwives. So, the chronic conditions often with the nurses, and then this prenatal and children and postnatal and children's care, together with the midwives. 

And they have really integrated information systems, so patients can see all their info data on an app the doctors can look at that same data. You know, if, as a doctor, you know if you when you go into your electronic medical record, you can see the medications for a patient, and that's those same medications you're seeing, is the same thing a patient would see, the same thing a pharmacist would see in the same thing a specialist would see. And if you made a change, that change would be reflected in real time for everybody. And I would say, you made that change, and you could actually see kind of even how the medication was dispensed by the pharmacy. So really integrated sophisticated information systems that enable efficiency.  

And then, I would say, really importantly, there's sort of this philosophy, I think, of customer-oriented care and that like patients really control a lot of things. So, for example, you know, if you want to go see a specialist in Denmark, it's the patients who basically are able to then book their own appointment. The family doctor makes a referral, but the patients would then take that referral and choose who to book it with. How do they do that? Well, there's a public directory of every single specialist in the country and what their wait times are, where they're located, whether it's accessible from a physical, physical accessibility perspective, etc. So that's just one example, but I will say they're, you know, at the very core of all of this Katharine, the it was a country that kind of has at its core this value that everybody is going to have care. And you know, when I was there, they said, you know, what the politicians kind of want to see is that every person has a choice of family doctors. So what does that mean? You go on to the website, and then you should have, based on what you live, at least two doctors who are accepting patients on that website that you could choose from. And that's how you choose. You go to the website, and then you choose.  

Other countries do it differently. In Finland, you're automatically registered to a community health center. In Norway, you're automatically connected to a general practitioner, and you have the ability to change that. And so again, it takes away the stress of having to find someone. In the UK, you have sort of kind of a guarantee that these clinics near you would actually take you on. So, in all of these countries, they really designed a system where patients basically have a guarantee to be able to see a family doctor, does it always hold up? Is it perfect? No, and we can talk about that, but it's a whole lot better than it is here in Canada.  

Dr. Katharine Smart: And I think, you know, one of the things you've touched on that really jumps out at me is different, is that government commitment to everybody having access, right, and a system that's purpose built to do its best to ensure that, you know, I'm sure, like you said it's not 100% but, you know, I think that's one of the fundamental problems we have as our system is not designed from that perspective, really, at all, right? And, and there's not a lot of accountabilities in the system that ensure that, and I think that's been part of our challenge, you know.  

So, I would love to hear from you, like, what do you think it's going to take to create a world class system like that for primary care in Canada. I know, you know, I think it's really exciting that Dr. Philpott has been hired in Ontario to really look at this, and I'm sure she's going to be wanting to work with you and leverage your learnings as well. That's the first time I've sort of seen a government really like focus down practically to say, okay, we're going to resource this. And a clear, some may say, audacious goal, but essential one.  

So, you know, what do we need to do? And then, you know, you touched on the fact that things aren't always perfect there. What are the lessons also that we should keep in mind, from what when, where their systems haven't totally worked, that we would want to maybe design for as well? And again, when we're sort of thinking about children and youth, are there specific things that we should be thinking about to make sure that we hit that population as well with these changes. 

Dr. Tara Kiran: Yeah. So, I mean, I think, I think in terms of how do we get there, I do agree with you, Katharine, that a key piece is us setting the goal of everybody in Canada having access to primary care. And I don't think we've been bold about it in that way to date. You know, as an example, we just had the federal government sign agreements with the provinces and territories around a new healthcare deal and new healthcare money, some of which was to go to family healthcare, as they called it, and they had some accountabilities tied to that. But when you look at the details, actually, I was disappointed to see that actually the level of goal setting was really modest. So, you know, it might mean a country was going, sorry, a province was setting a goal of going from like 80 to 82% or, you know, 85 to 86% there was only one province, PEI that set the goal of 100% and that's really what we need to be doing.  

I am glad that Ontario was taking the step with appointing Jane Philpott. And instead of setting that goal a five year goal, I will say there another province that I think is also on its way to doing that is in Alberta, where they're creating a new primary care organization. I believe it was, you know, just created in late November as we're having this conversation. And their goal is to attach everyone as well. I don't know if I've heard about a timeline, but certainly that is their goal, too. So, we see some provinces and territories kind of stepping up with that vision, but I think it needs to be across the board.  

And importantly, it can't just be a vision with no resources. So, we do need government to commit the funds. And so, when we look across, for example, the you know, peer countries. So countries that are part of the OECD, the Organization for Economic Cooperation and Development, the proportion of the total health budget spent on primary care among 22 OECD countries was about 8% and in Canada, it's about 5% so, you know, we're not spending enough of our pie,  a bigger need, a bigger slice of our of our full pie to go to primary care. And then, to be honest, we probably also need, as we talked about, a bigger pie altogether and fund public care further. So, it is going to take resources and money. I think we do need to be open to doing things differently, and specifically, we need that funding for team based care and all professionals to want to work together in a way to serve more people, and keep that in mind as the very clear goal. And I think any teams that are set up really need to be community accountable and community governed, so that we ensure that the teams are actually meeting the needs of the community. 

I worry that over the last, you know, decade or two, we've actually drifted from, you know, what I think was, was the orientation in medicine to really serving and to serving our communities. I think we, you know, a lot of us, because of some of the burnout and the stress in the system have lost that ethos, which I think actually can ground and center us. And I think, you know, if we think about primary care teams, they absolutely have to be centered in that community.  

I think we do need to move forward on a integrated record where patients have access to their information, and I do think we're making progress on that front, especially if the Connected Care Act gets passed federally, which I'm hoping it will. There's lots of groups who've worked hard to actually advance that agenda. And you know, that's something that, again, it shouldn't cost a lot more money from government. So that's actually one where, you know, it's more about the cooperation of the different players in the system.  

And then, you know, as we're moving forward to designing all these things, I do think we need to keep the needs of the most vulnerable in mind. And you know, at a very basic level, for example, ensure that the care we deliver is language accessible, and we're not even doing that for two official languages right now, let alone all the others. So, you know, we had a really interesting community roundtable in Ontario that was actually like among Francophone immigrants who are also black. And you know what they told us was that even though French is an official language, like they can't get services in French in Ontario, it's really hard. And so just even that, we need to think about these, you know, specifically, you know, groups that are left behind, and ensure that primary care is meeting, that it's barrier free, that we're able to welcome everybody from different backgrounds.  

You know, I think there are things we can learn from other countries. You know, when I think about what other countries have been has been doing right? I think countries where they have valued Primary Care and Family Medicine and pay Family Medicine accordingly and has the right stature. I think that's really important for us to learn from. I think it's important, you know, for us to learn from things like the contracts that are there with doctors that do specify, you know how many patients they should be taking on in the timeliness. In return, though, for some good compensation and resources, that they're able then to deliver on that. And, you know, I think one of the challenges as we do this work is to ensure that whatever reforms we put in place are balancing access and relational continuity. So, what does that mean? So, you know, in the UK, I think that's a system that's been underfunded over the last decade and a half, you know. And yes, it's still a system designed to try and serve everybody, but that's become really, really hard now. And so, what we're seeing is there are, you know, yes, everybody is able to be often attached to a clinic near them, but the doctors have way too many patients to be able to take care of. And so then, you know, timeliness is a problem, and then they introduced some kind of metric to say, we want you to focus on providing timely care of or urgent issues. Okay, so then they did that, but then what happened was the relationship fell off. And actually, people were seeing and bouncing around different doctors within the same clinic, and that wasn't good for patients, because they'd have to repeat their story. And, you know, they get lost in the different in this different storytelling and different management approaches and but then it's not good for the doctors either, because I can tell you as a doctor, like, it's terrible to see complex patients you've never seen before every time you have to spend a lot of time with them, whereas it's relatively easy, much easier to see a complex patient that you know really well.  

And so, I think one of our big challenges will be to balance timely access and relationships in any system reform moving forward, what I also want us to be careful about is not just moving forward with band aid solutions. So, I see the band aid solutions across Canada, you know, let's have more urgent care centers. Let's have like a newborn clinic. You know, these are not what people actually want. You know, people don't want a virtual only clinic. They want a place where they can get virtual and in person care. People don't want to just have a walk in clinic. People want to be able to have an ongoing relationship. People don't just want a newborn care or people want care with a continuous like clinician who they know over time. I mean, it's not like the child doesn't have needs after they finish the newborn stage. So, we have to be really careful about these pieces.  

The other piece, I'll say is I think we can learn from the kind of team-based creativity that other countries have. And so, I'd love to see more integrations of professionals like psychologists and physiotherapists and our teams like they do in some other countries. So, I think we just, we've got, haven't gotten teams right, and we need to learn more from what other countries are doing in teams.  

Yeah, when it comes to children and youth. You know, as I mentioned, I worry that there's some band aid solutions out there, and I think we need to avoid the band aids and set the really big vision and design for that part of the reason why I say that too, is because I think what I've observed is that sometimes when governments put in the band aid solutions, there's actually a lot of energy from government officials, clinicians, other healthcare leaders, that goes into the design of the band aid, and that's energy that's then not being used, energy and resources that are not being used for the thing that people actually want.  

I think the other thing we can learn when it comes to children and youth is, you know, meeting people where they're at, and I think this is where, you know, if you design a system that's community driven and accountable, I think we're more likely to get there. So I think, for example, about some of my colleagues who do work in schools, so they've brought clinics to schools, and in particular, in communities where there are a lot of people who are living in poverty or a lot of newcomers to actually, you know, bring a clinic to school means that you're more likely to be able to reach the people who really need to be reached. You have, it's more much more convenient for those parents and those children, and it allows us also to understand people in the context in which they live. So, there's just, like, so many benefits to that, and I think as a medical profession, we need to do more of like going beyond our walls into the community, to remove barriers and be more accessible and understand what will work for those communities. 

Dr. Katharine Smart: Yeah, absolutely. Thank you. You know, I think you've done such a beautiful job of highlighting where our challenges are, why they exist, the gold standard that we could be aiming for that was also articulated by the many, many people that you and your team spoke to, examples of places that are doing it and why it's working there, which I think is important, right? Those practical aspects matter. The danger of being sidetracked by that quick solution, that band aid approach, which I think sort of is one of the defining features of how we've approached the healthcare crisis in Canada over the last years, and why we're not solving for these big problems, right? So we need to reorientate that energy and why this is so important for the future of our country. And I think what's really interesting is so much of what you've spoken about is also what Children's Healthcare Canada has found in their roundtable works as they're designing their vision for children and youth, is that community enabled, family, patient centered care, accessible, equitable, where people are and that brings out awareness of what people's needs are. And, you know, it's, it's wonderful, I think, to have these conversations and see folks like yourself that that have the vision of where we need to be. And I just hope that our leaders are listening and that there's a willingness in Canada to kind of dig in and do the hard work to get to the right solution and sort of pivot away from these short term fixes that, as you eloquently described, aren't really getting us where we need to be.  

So, thank you so much for sharing your wisdom, your knowledge, your experience, and thank you for your leadership in this critical area. And I really look forward to seeing what you and your team can achieve as you move forward with this goal of reimagining and redesigning primary care for Canada. 

Dr. Tara Kiran: Thanks, Katharine, that's been a great conversation. 

Dr. Katharine Smart: So thanks again to our spark conversations podcast sponsor, the IWK Health Center, for their ongoing support. That's it for today. Thanks for listening to SPARK: Conversations. To stay up to date on all our SPARK offerings, including upcoming podcast episodes, visit our website at childrenshealthcarecanada.ca and subscribe to our SPARK News bi-weekly e-bulletin, if you haven't already. If you like this podcast, show us some love by leaving us a review and telling your colleagues about us. We'll see you again next month.