Abstract
Primary care reforms often proceed without a clear articulation of what patients and the public expect primary care to deliver. In Canada, nearly six million people lack access to a regular primary care clinician despite universal health insurance. Through the OurCare initiative, nearly 10,000 people across Canada participated in a structured, deliberative process to define what primary care should provide. The resulting OurCare Standard articulates six expectations for a publicly funded, relationship-based, timely, culturally safe, and accountable primary care system. Ontario has recently embedded these priorities in legislation through the Primary Care Act and committed to achieving universal access to primary care by 2029. Yet longstanding variation in team implementation, inequitable distribution of resources, limited evidence of expanded physician capacity, and increasing movement of family physicians toward focused practice complicate this goal. Experience from the Netherlands—where near-universal access to primary care has been achieved—highlights several design features that support timely access at scale, including stronger demand management in practices, substitutive team roles, an educated public and family physicians working at top of scope. Achieving primary care for all will require not only expanding teams but redesigning how care is organized, delivered, and kept accountable to meet the needs of the communities primary care is meant to serve.
- Family Physicians
- FMLC 2025
- Health Policy
- Health Services Accessibility
- Patient Participation
- Primary Health Care
Introduction
Across jurisdictions, primary care is widely recognized as the foundation of high-performing health systems. Yet in many countries, including Canada and the United States, reforms to primary care have often proceeded without a clear articulation of what patients and the public expect from the system—or how those expectations should shape policy design. As a result, reform efforts often prioritize professional, corporate, or political interests over the interests of patients and the public—the people the system should be designed to serve.
In Ontario, recent reforms represent a rare attempt to explicitly anchor primary care transformation in the views of patients and the public. Through the OurCare initiative, a large-scale national engagement, the public articulated a shared vision for primary care that has since been codified in legislation passed in Ontario, Canada’s largest province with a population of over 16 million people. The province plans to achieve the vision by building on existing primary care teams, but research suggests there are significant implementation and workforce challenges that need to be overcome.
Ontario, like every province and territory in Canada, insures all permanent residents for medically necessary physician and hospital services with no co-payment. Despite universal health insurance in Canada, recent estimates suggest 5.8 million people in Canada,1 including nearly 2 million people in Ontario,2 do not have a family doctor, nurse practitioner or primary care team. In this paper, we will explore: (1) how patients and the public set the vision for primary care reform in Ontario, (2) Ontario’s experience with team-based care and the challenges in executing on the public vision, and (3) what the Netherlands can teach us about the reforms needed to achieve a vision of primary care for all.
Grounding Reform in Patient and Public Priorities
Health system reform has traditionally relied on expert-driven processes, often with limited direct input from patients and the public. The OurCare initiative was designed to address this gap by creating a structured, deliberative process to elicit public priorities for primary care. Over 16 months, our team heard from nearly 10,000 people across Canada using a three-phase approach: a national survey; five provincial priority panels where 30 to 36 randomly selected residents of a province spent 30 to 40 hours learning and deliberating about primary care; and ten one-day community roundtables, organized in partnership with community organizations, designed to amplify the perspectives of underserved groups including Indigenous communities, African, Caribbean, and Black communities, and newcomer groups.3 The engagement process was guided by several advisory committees comprising clinicians, health system leaders, professional organizations, researchers, senior civil servants, and members of the public.
Patients and the public who participated in OurCare came from varied backgrounds and geographies, but despite their differences there was a strong consensus that every person in Canada deserves access to high-quality primary care. We distilled the core findings from our national engagements into the OurCare Standard, a six-element framework that describes what every person in Canada should expect from the primary care system: publicly-funded primary care for all delivered by a clinician working in a team; primary care that is timely and ongoing; primary care integrated with community services to support general well-being; access to one’s own health record online; culturally safe care delivered by a workforce that reflects the diversity of the community it serves; and a system that is accountable to the community it serves by being transparent, involving the public in design of services and empowering patients to care for themselves (Figure 1).3
The OurCare standard represents a patient and public-partnered vision of primary care that can guide and evaluate policy reforms. Several provinces have begun to use the OurCare Standard in this regard, but Ontario has moved further than most jurisdictions in translating these public priorities into policy.
In June 2025, the Ontario government passed the Primary Care Act, a first-of-its-kind legislation for Canada that affirms primary care as the foundation of the health system and specifies six objectives for the system.4 Those objectives reflect the six elements of the OurCare Standard, concept for concept (Figure 1). The legislation was passed seven months after the Ontario government launched a Primary Care Action Team and declared a goal of having every resident in Ontario have access to primary care by 2029.5 This policy announcement was driven by public dissatisfaction with the status quo, which was exemplified by numerous media stories of residents not being able to access primary care6 and by health system leaders, including hospital CEOs,7 calling for more investment in primary care. Ontario’s majority-Conservative government appointed Dr. Jane Philpott to lead the Primary Care Action Team. Dr. Philpott is a family physician and was the Federal Minister of Health between 2015 and 2019 under a majority-Liberal federal government; in 2024, she published a book articulating a vision for health-for-all and calling for a national primary care act.8
Opportunities and Lessons from Ontario
In February 2025, the Ontario government committed $2.1 billion dollars towards new primary care teams to support achieving the vision of primary care for all.9 Interprofessional teams are seen as a key solution to increasing access to primary care,10 given the relative shortage of family physicians in Canada.11 However, Ontario’s history with team-based primary care suggests that it will be challenging to optimize teams to truly deliver equitable primary care across the province.
Ontario introduced the Family Health Team in 2005, an interprofessional primary care model where family physicians are paid primarily through capitation and the government provides funding to hire non-physician health professionals including nurses, nurse practitioners, social workers, and pharmacists. By 2022, approximately one-quarter of Ontario’s population was receiving primary care in a team-based primary care setting, the vast majority in Family Health Teams.12 However, research demonstrated a ten-fold variation in access to primary care teams by region.13,14 The variation was not based on need but rather was indicative of the inverse care law: areas with higher population needs, including northern Ontario and major urban centers, had the lowest access to teams.14
Research suggests that Family Health Teams have been associated with improved patient outcomes in some areas but not others. Compared to patients in other models, patients in Family Health Teams were more likely to receive recommended care for diabetes and experience more improvements in diabetes care over time15; they also had lower increases in emergency department use.16 However, relational continuity of care and timely access have not been very different between team-based and non-team-based models, with continuity of care being relatively high17 and timely access relatively poor in all models.18 Most notably, physicians practicing in team-based models, on average, have not had larger patient panel sizes than those in non-team models (unpublished research).
Although interprofessional teams should theoretically enable physicians to increase their capacity to care for more patients19 by task shifting to other health professionals, the historical implementation in Ontario has not been done with that goal in mind. Team implementation in Ontario has been heterogenous and historically not in keeping with population need. These findings intersect with broader workforce challenges. Specifically, new research confirms that increasing numbers of family physicians are choosing focused practice or hospital-based roles that offer more flexibility, higher remuneration, and more infrastructure support compared with comprehensive community-based practice.20
Taken together, Ontario’s experience offers several lessons. First, in the Canadian context, implementation of primary care teams needs to clearly specify the objective of increasing capacity to serve more patients. This objective can be in tension with objectives related to improving the quality of care for existing patients and enhancing health-professional wellness. Second, teams need to be held accountable to achieve their stated objectives—including through transparent public reporting of key performance measures including number of patients served (and their medical and social complexity), timely access and relational continuity. There should be minimum standards for teams that align with patient values and expectations. Third, team implementation must be done in the context of broader population and health human resource planning. Patients and the public who participated in the Ontario OurCare priority panel recommended team expansion start in areas of highest population need and that teams be mandated to accept any person living in the surrounding community—a concept they termed “automatic rostering” and a way to ensure full population coverage of primary care.21
To date, Ontario is the only province in Canada that has passed a Primary Care Act that asserts every resident should have access to primary care. Notably, Ontario also has among the highest rates of primary care attachment in the country compared to Canada’s other provinces and territories, even after accounting for sociodemographic differences.22 While it is difficult to disentangle the factors contributing to Ontario’s relatively strong position, likely contributors include the relatively early investments in team-based care, physician payment reforms that transitioned a substantial proportion of comprehensive family physicians to blended capitation models, and higher physician remuneration relative to other jurisdictions. While realizing the vision of primary care for all will require substantial effort in Ontario, the challenges are likely to be greater in provinces and territories with lower baseline attachment rates and more limited experience with team-based care and payment reform.
Designing a Better Primary Care System: Insights from the Netherlands
As we think about designing for a future that includes primary care for all, we can learn from countries with near-universal primary care access—like the Netherlands, where 99% of the population has a family doctor or place of care.23 In December 2024, I conducted a nine-day learning visit to the Netherlands that helped me rethink how we could structure care in Canada—lessons that are also applicable to the US.
Before diving into lessons, it is important to acknowledge significant differences in our society and healthcare systems. The Netherlands is a geographically small country with a population of 18.4 million that is more culturally homogenous than Canada or the US. They have a unique social health insurance system that mandates and supports its residents to obtain health insurance from highly regulated, private, mostly non-profit insurance companies. Compared to Canada, they have 1.7 times more doctors per capita and a higher proportion of their health budget is spent in the public system.
In the Netherlands, primary care is delivered mainly through general practitioners (GPs) who are self-employed and run independent practices. GPs generally have large panels, 2300 on average, and are gatekeepers for other types of care including care in emergency departments. Anyone going to an emergency department needs to be assessed by a GP first, so it is imperative that GPs provide timely access to patients with urgent issues.
Demand Management
To enable timely access in the context of large panels, GPs in the Netherlands have developed sophisticated systems for demand management. Specifically, they have developed the role of “doktersassistent,” or practice assistant, an expert in primary care triage and communication. Practice assistants have three years of training out of high school and are trained on triage algorithms that have been co-developed by the Dutch College of GPs, an organization that creates guidelines for GPs by GPs. Practice assistants are the first point of contact for patients in the office. They can resolve straightforward concerns on the phone, address some minor issues in the office themselves and otherwise decide which health professional the patient needs to see and how long they can wait.
This kind of active demand management is critical for any health system designed for primary care for all; it helps balance timely access and relational continuity even in practices caring for large numbers of patients. Artificial intelligence can potentially support this type of work in the near future.
Family Physicians Working to Top of Scope
Many of the concerns patients bring to GP offices in the Netherlands are the same as those brought by patients in Canada or the US—but the role of the GP is different. In my observation, GPs in the Netherlands spend much of their time assessing acute issues, managing people with complex chronic issues, and supporting home-bound patients including those requiring end-of-life care. In contrast, GPs in the Netherlands spend very little time doing preventive care. Colorectal and breast cancer screening is managed by a central national agency. Pap tests are done by practice assistants. GPs do not generally do preventive health exams, which they generally consider to be low-yield and not supported by evidence.
Patients with stable chronic conditions or milder mental health concerns are managed by nurses. Nurses provide substitutive rather than additive care. For example, a patient with stable diabetes will see the nurse for three of four quarterly visits. Guidelines from the Dutch College of GPs are embedded in the electronic medical record and guide the nursing care, including escalation of medical treatment. GPs are consulted when needed, often asynchronously.
This type of task redistribution—and shifting of preventive care to outside the GP office—enables GPs to provide timely, high quality care to large panels of patients without burning out.
Collective and Regional GP Leadership
Dutch GPs also exercise leadership at a regional level, most notably through after-hours GP cooperatives. Rather than each physician being individually responsible for on-call coverage, groups of GPs collectively provide urgent care after-hours for large regions of several hundred thousand people.24 The cooperatives are owned and run by GPs and serve all residents in the region who access care through a central phone number. GPs rotate working in the after-hours center, typically in one of three roles: overseeing several practice assistants who triage incoming phone calls; providing in-person assessment at the after-hours clinic; or doing home visits (supported by a car, driver, and portable electronic record).
This type of regional leadership provides an organized, efficient health service to the whole population. It also enhances GP’s collective professional autonomy to organize services efficiently and in a way that aligns with preferences about workload and styles of working.
Public Empowerment as a Demand Management Strategy
In the Netherlands, patients are empowered as capable partners in managing demand. Clinical guidelines developed by the Dutch College of General Practitioners have been translated into accessible, patient-facing resources that provide practical advice on managing common conditions.25 These tools support self-care, reduce unnecessary visits, and reinforce the legitimacy of triage and gatekeeping. Anecdotally, GPs report that these guidelines have reduced office visits for minor ailments like allergic rhinitis.
Conclusion
Ontario’s new Primary Care Act is a unique attempt to align policy with public priorities. Achieving universal attachment by 2029 will require the government to expand and improve on current interprofessional delivery models—teams that have historically improved some aspects of quality of care but have not increased physician capacity to serve more patients and have not been located in areas of highest need. Universal attachment will also require reversing a growing shift of family physicians into focused practice. To be successful, reforms in Ontario will need to go further than ensuring every person has a primary care clinician to ensuring that care aligns with all six objectives of the Primary Care Act, which includes primary care that is timely and patient empowering. The Netherlands has achieved near-universal access to primary care, and their care delivery model suggest strategies that can be adopted in the North American context, including strengthening demand management in practice and ensuring family doctors work at top of scope. Transforming our primary care systems into ones that are centered on the needs of patients and the public will require embracing a new way of working that leverages family doctor leadership and empowers patients and other members of the primary care workforce to take on more roles and responsibilities.
Conflicts of Interest
Tara Kiran has received consulting fees from Ontario Health, honoraria from the Ontario Medical Association, and a grant and speaking fees from the Ontario College of Family Physicians.
Corresponding Author
Tara Kiran, MD, MSc, CCFP, FCFP, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, tara.kiran{at}utoronto.ca
Acknowledgements
Thank you to the many team members and collaborators who made OurCare a success (a full list is available at OurCare.ca), and to the many Dutch people who contributed to Tara Kiran’s learning tour, including Tim Olde Hartman, Suzanne Ligthart, Jettie Bonte, Eric Moll Van Charante, and Ralf Harskamp. This paper includes observations by Tara Kiran on the Dutch system and her views may not reflect those of her Dutch hosts.
- Received for publication January 23, 2026.
- Accepted for publication April 20, 2026.
References
Jump to section
Related Articles
Cited By...
- No citing articles found.