International Health Perspectives: Comparing Primary Care in Canada, Germany, and the Netherlands

Research Paper proposing reforms to expand patient choice, increase health provider flexibility, and allow for improved access to primary care services for Canadians

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This Research Paper was prepared by Krystle Wittevrongel, Director of Research at the MEI, and Conrad Eder, Public Policy Analyst at the MEI, in collaboration with Emmanuelle B. Faubert, Economist at the MEI.

Highlights

A well-functioning healthcare system is one that is available when called upon, that is responsive to patients’ needs, and that improves the health of individuals. Yet, Canada’s primary healthcare system is not living up to its potential. In 2023, 14% of Canadian adults did not have regular access to a primary care provider or place to get care, compared with only 1% of the Dutch and 4% of the German population. For Canadians who did have access, almost 3/4 were unable to secure a timely appointment. To increase access to primary care, it is imperative to learn from better-performing systems such as those of Germany and the Netherlands.

Chapter 1 – The Importance of a Well-Functioning Primary Care System

• Primary care is a critical piece of the overall healthcare “puzzle,” and evidence confirms that accessible primary care can help us live longer and avoid disability and disease.
• In addition, since primary care serves as a substitute for other forms of health care and is comparatively less expensive, timely access to it can also contribute to lower overall health system costs.
• 46% of Canadians with access to a primary care provider or place to get care waited six days or more for an appointment, compared with only 26% of German patients and 13% of Dutch patients.
• The lack of access does not appear to be an issue of funding: Canadian spending on primary care is comparable to spending by Germany and the Netherlands, albeit with sub-optimal results.
• In the absence of timely access to primary care, patients often end up in emergency rooms, with 30% of all ER visits across Canada between April 2022 and March 2023 being for nonurgent or less urgent issues.
• Not only do these unnecessary ER visits add to health system costs, but they also contribute to lengthening wait times in the ER, leaving patients languishing and leading to additional complications.
• Besides delays in accessing care, long wait times can result in patients leaving the ER without being seen at all. In Quebec in 2022-2023, 11.5% of the patients who visited an ER left without being treated, over 1/4 of whom were categorized as urgent.

Chapter 2 – The Key System Differences That Allow for Increased Access to Primary Care in Germany and the Netherlands

• The German and Dutch systems allow for more patient and provider choice, more system flexibility, and more competition, all of which have the result of increasing access to primary care in comparison with Canada’s system.
• What defines the Canadian system is that insured patients and health professionals alike face a public single-payer, without any choice in insurer or plan, for medically necessary care.
• This contrasts sharply with the situation in Germany and the Netherlands, where there are plenty of insurers to choose from, encouraging the improvement of service quality as well as expanded benefits to attract and retain customers.
• The ability to choose among (and change) insurers ensures that patients are active participants in their healthcare decisions, something that has been shown to increase patient satisfaction.
• Though the objective of a strict gatekeeping system like Canada’s is to reduce expenditures, what it achieves is to shift the cost onto patients by increasing the physical, psychological, and social tolls of waiting to receive specialist care.
• The healthcare systems in Germany and the Netherlands allow patients greater choice in how they access specialist care, which has a direct positive effect on their access to primary care.
• Canada’s strong discouragement of mixed practice is an exception among highly developed countries. Among other high-income countries with universal healthcare systems, such as Germany and the Netherlands, such regulation is virtually nonexistent.
• Mixed practice is important, as it allows greater flexibility for primary care professionals and improved access for patients.

Chapter 3 – Public Policy Recommendations to Improve Access to Primary Care for Canadians

These reforms to increase Canadians’ access to primary care, while ambitious, relate to the administration and delivery of healthcare services and are wholly within provincial jurisdiction to implement.

• Recommendation 1 – Allow Duplicate Private Insurance. Allowing duplicate private insurance in Canada would infuse a level of competition and patient choice that is currently non-existent.
• Recommendation 2 – Remove the Gatekeeper for Specialist Care. Canadian provinces should relax their gatekeeping requirements and allow patients to consult with specialists directly.
• Recommendation 3 – Allow Mixed Practice for Healthcare Workers. Allowing healthcare workers to divide their time between the public sector and the independent sector would make more efficient use of limited resources.

Germany and the Netherlands have been able to maintain universal healthcare coverage and primary care access while addressing common challenges seen in the Canadian system such as wait times and resource allocation. Our proposed changes would expand patient choice, increase health provider flexibility, and allow for improved overall access to primary care services for Canadians. As wait times continue to grow and access problems persist, it is imperative that provincial governments take steps toward implementing meaningful healthcare reform, for the sake of all Canadians.

Introduction

A well-functioning healthcare system is one that is available when called upon, that is responsive to patients’ needs, and that improves the health of individuals. Fundamental to these goals is primary care, a collection of services offered by a range of providers that often serves as the first line of healthcare defense, a patient’s first point of contact with the healthcare system.

Primary care is commonly provided in outpatient settings such as community clinics, and primary care or private practice clinics. It typically consists of prevention, diagnosis, treatment, and management of a wide range of conditions and illnesses, as well as health promotion.

Primary care providers frequently coordinate care and refer their patients to specialists when necessary. While some patients may seek primary care services outside of an outpatient or clinic setting, such as in an emergency room, especially if they lack access to a regular primary care provider, this type of hospital care is not considered primary care for the purposes of our analysis, even if it does provide the first line of care. This is because ERs are intended for acute, urgent, or emergency situations, and are not designed for the provision of primary care; while the ER can provide immediate care for non-emergency conditions, this is not its intended purpose.

There is nearly universal agreement on the importance of primary health care and its potential to offer significant benefits, both to Canadians and to the larger healthcare system that serves them.(1) Despite this recognition, Canada’s primary healthcare system is not living up to its potential. In 2023, 14% of Canadian adults did not have regular access to a primary care provider or place to get care.(2) For those who did have access, almost three quarters were unable to secure a timely appointment.(3)

This compares unfavourably with other high-performing universal healthcare systems in countries like Germany or the Netherlands, whose patients have greater access to primary care. In fact, only 4% of Germans and 1% of the Dutch were without regular access to a primary care provider or place to get care—a fraction of the proportion of Canada.(4) In terms of timeliness, 51% of German patients and 54% of Dutch patients were able to get a same- or next-day appointment, double the proportion of Canadians.(5)

To increase access to primary care, it is imperative to learn from better-performing systems such as those of the Germans and Dutch. Doing so will empower Canadian policymakers to guide improvements in healthcare policies so as to better meet population health needs, as well as enable them to design systems that improve primary care delivery.

This research paper explores primary care and the differences in such systems across these three countries. Chapter 1 will explain the importance of primary care and outline the performance differences between Canada, Germany, and the Netherlands. Ultimately, Canada’s underperforming primary care system has a ripple effect which can be seen in every corner of the healthcare system as a whole. This comparison forms the foundation of our assessment and, in turn, of our case for change.

Chapter 2 will outline three key differences between the models in these three countries in terms of their ability to impact a patient’s access to primary care. These include the way the system (and by extension, primary care) is funded, how patients are able to access specialist care (gatekeeping by primary care providers), and whether, or to what extent, healthcare workers are allowed to operate in both public and independent sectors simultaneously (permitting mixed or dual practice). These differences impact patient choice, provider choice, and freedom, and put varying levels of pressure on primary care. Despite their variations, Canada, Germany, and the Netherlands all aim to provide universal access to primary care, regardless of a patient’s income.

Chapter 3 will present practical recommendations that can be applied to Canadian health care in order to increase access to primary care. Not only are our pragmatic recommendations likely to increase access to primary care for Canadians, but they have the potential to reduce disability and disease, and to lower health system expenditures as well.

Read the Research Paper (in PDF format)