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Advancing team-based primary health care: a comparative analysis of policies in western Canada Suter, Esther; Mallinson, Sara; Misfeldt, Renee; Boakye, Omenaa; Nasmith, Louise; Wong, Sabrina T Jul 17, 2017

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RESEARCH ARTICLE Open AccessAdvancing team-based primary health care:a comparative analysis of policies inwestern CanadaEsther Suter1, Sara Mallinson2*, Renee Misfeldt2, Omenaa Boakye3, Louise Nasmith4 and Sabrina T. Wong5AbstractBackground: We analyzed and compared primary health care (PHC) policies in British Columbia, Alberta andSaskatchewan to understand how they inform the design and implementation of team-based primary healthcare service delivery. The goal was to develop policy imperatives that can advance team-based PHC in Canada.Methods: We conducted comparative case studies (n = 3). The policy analysis included: Context review: We reviewedrelevant information (2007 to 2014) from databases and websites. Policy review and comparative analysis: We comparedand contrasted publically available PHC policies. Key informant interviews: Key informants (n = 30) validated narrativesprepared from the comparative analysis by offering contextual information on potential policy imperatives.Advisory group and roundtable: An expert advisory group guided this work and a key stakeholder roundtableevent guided prioritization of policy imperatives.Results: The concept of team-based PHC varies widely across and within the three provinces. We noted policy gapsrelated to team configuration, leadership, scope of practice, role clarity and financing of team-based care; few policiesspeak explicitly to monitoring and evaluation of team-based PHC. We prioritized four policy imperatives: (1) alignmentof goals and policies at different system levels; (2) investment of resources for system change; (3) compensationmodels for all members of the team; and (4) accountability through collaborative practice metrics.Conclusions: Policies supporting team-based PHC have been slow to emerge, lacking a systematic and coordinatedapproach. Greater alignment with specific consideration of financing, reimbursement, implementation mechanismsand performance monitoring could accelerate systemic transformation by removing some well-known barriersto team-based care.Keywords: Health policy, Policy analysis, Policy options, Primary care, Team-based careBackgroundIn 2000, First Ministers — heads of governments includ-ing the Prime Minister of Canada and the provincial andterritorial ministers— agreed that “improvements to pri-mary health care are crucial to the renewal of healthservices” and highlighted the importance of multi-disciplinary teams [1]. The subsequent launch of the$800 M Primary Health Care Transition Fund wasmeant to accelerate innovation in primary health caredelivery [2–4]. Initiatives have experimented with servicedelivery models that integrate physicians into interpro-fessional health care teams [3–6]. Recent reportsapplaud the progress made and conclude that primaryhealth care has entered a period of transformationalchange [2–4, 6–9].Despite these positive changes, Canada continues tolag behind other countries in primary health care infra-structure and performance [9, 10] and team-basedprimary health care remains fragmented [5]. Some haveascribed this to the provincial nature of health policyand the lack of a pan-Canadian vision on primary healthcare reform [3]. Others argue that the engrained waysin which primary care has historically been organized(e.g., physicians as independent business owners with* Correspondence: sara.mallinson@ahs.ca2Health Systems Evaluation and Evidence, Alberta Health Services, 10301Southport Lane SW, Calgary, AB, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Suter et al. BMC Health Services Research  (2017) 17:493 DOI 10.1186/s12913-017-2439-1direct billing to the provincial government for ser-vices provided) create significant barriers for team-based primary health care [11].Primary health care reform remains a critical policyissue on national and provincial agendas [12]. For thepurpose of this study, we defined health policies asthe “decisions, plans, and actions undertaken toachieve specific health care goals within a society”[13]. Policy is driven by the unique political, socialand economic contexts. The absence of a pan-Canadian vision for primary health care has led todifferent conceptualizations of team-based primaryhealth care service delivery, the application of differ-ent policy levers, and, consequently, implementationof different policies across the province to supportprimary health care reform [4, 6, 10, 11].It is unclear if and how current policy and regula-tory landscapes advance or constrain progress towardsteam-based primary health care. There are few de-tailed examinations of the policy context for team-based primary health care including the key drivers ofpolicy development and implementation [3].The goal of this project was to develop policy impera-tives to advance team-based primary health care inCanada. The objective was to analyze and compare rele-vant policies in three provinces to understand currentpolicy landscape and gaps. The research question was:how do policies, including regulation and legislation inBritish Columbia, Alberta and Saskatchewan, inform thedesign and implementation of team-based primaryhealth care service delivery? Sub-questions were: a) Howis team-based care within primary health care conceptu-alized and defined within the policy documents, regula-tions and legislation? b) What are the common keyapproaches taken within policy documents (e.g., leader-ship, scope of practice, skill mix, role clarity, communi-cation) that guide the implementation, oversight andadministration of team-based primary health care servicedelivery? c) What policies, regulations and legislation areconducive to promoting team-based service delivery inprimary health care in the three provinces?MethodsWe conducted a comparative policy analysis of primaryhealth care policies in three western Canadian provinces,British Columbia, Alberta and Saskatchewan, treatingeach province as a case study. These provinces werechosen because of the different and unique contexts inwhich team-based care was considered a policy priority.The policy triangle framework by Walt and Gilsonguided our analysis of relationships and processes in-volved in primary health care policy across the provincialcontexts [14] Additional file 1: Fig. S1: The healthpolicy triangle.The framework says that health policies are formedthrough the complex inter-play between the context,content, process, and actors involved [14]. Policycannot easily be separated from health care politics,which comprises the interactions of political actorsand institutions in the health care arena [12, 14].Comparative analysis of the policy context withinwhich health reform is formulated and implemented,as well as the processes involved, can contribute tostrategies that increase the political feasibility ofreform [15, 16]. Walt and Gilson’s framework is ap-propriate because it accounts for the complexity ofprimary health service delivery and the provincialhealth system context in which it takes place [17].The policy triangle approach shaped the type of infor-mation we collected and our analysis. We needed toidentify and acquire materials from diverse sources sowe organized the review into several stages:Context review: We conducted a high-level scan of di-verse evidence (review papers, reports, newspaper arti-cles, editorials and other opinion pieces, briefings andbook chapters) to examine the recent context of primaryhealth care evolution nationally and in the three prov-inces. We searched Medline (through Pubmed), GoogleScholar and the following websites Health Edition (*nolonger operating), Health Council of Canada, CanadianFoundation for Healthcare Improvement, EnhancingInterdisciplinary Collaboration in Primary Health Care(EICP), Conference Board of Canada, Canadian Health-care Association. Key words used in website searcheswere: “interprofessional”; “collaborative practice”; “col-laboration”; “health care teams”; “Canada”; “Saskatch-ewan”; “Alberta”; “BC”; “British Columbia”; “primarycare”; and “primary health care”. We systematicallyscreened hits from the searches for inclusion using abrief appraisal tool to assess relevancy according to thefollowing criteria: 1) Published between 2007/8–2013(within 5 years); 2) Published in English; 3) Substantialfocus on Canadian primary health care, that is, docu-ments that described a national strategy and vision forprimary health care, and/or focused on Alberta, BritishColumbia and Saskatchewan primary health care devel-opment, and/or focused on political, social and eco-nomic forces and primary health care reform in Canadaor the three provinces.We noted key events that occurred earlier but had im-pact that extend into our timeframe. The diverse infor-mation was collated into succinct narratives describingthe national and provincial landscapes. We also devel-oped visual provincial timelines to highlight a range ofevents that were shaping the development of primaryhealth care and team-based care [18].Policy review and comparative analysis: We identi-fied and retrieved publically available primary healthSuter et al. BMC Health Services Research  (2017) 17:493 Page 2 of 9care policies in British Columbia, Alberta and Saskatch-ewan. We only included formal policies (i.e., policies thatare adopted by an organization and have authority todrive action) published between 2007 and 2014. Othersupporting documents were considered as part of thecontext analysis [18]. We assigned one researcher toeach province to initially extract information from re-trieved policies into tables; a second researcher reviewedthe policies and the extractions and edited or amendedwhere needed. Reviewers resolved all disagreements byconsensus discussions. The primary reviewer then devel-oped concise narratives for each province, which wereread and validated by the secondary reviewer. In a finalstep, the three reviewers compared and contrasted keyfindings and emerging themes from the three provinces,taking into account provincial context. Based on theanalysis, we drafted potential policy imperatives.Key informant interviews: We invited key informantsfrom the provincial ministries and departments ofhealth, regional health authorities, primary health careorganizations, and professional colleges and associationsin each province to provide feedback on the provincialnarratives and to offer additional information on localpolicy context and potential policy imperatives. Thesame three researchers that conducted the policy ana-lyses also conducted the interviews for their respectiveprovince. Interviews lasted 45 to 60 min and were digit-ally recorded and transcribed. To begin the analysisprocess, 3–4 transcripts were independently read andmarked by the research team. Early interpretations andideas for themes were discussed and key themes andsub-themes were agreed. The transcript data were thensummarized and re-ordered into thematic tables [19].The research team regularly discussed progress to en-sure shared understanding of the themes and appropri-ate interpretation of the data. A second reader checkedthe analysis of each transcript and any discrepancies ininterpretation were resolved through team consensus.Advisory group and roundtable: We engaged an ex-pert advisory group to guide the review and to take partin the identification and refinement of policy impera-tives. A facilitated roundtable event was held with 15representatives from the provincial ministries of health,regional health authorities, regulatory bodies and profes-sional associations [20]. The goal was to further developand prioritize the policy imperatives for action.Ethics and operational approval was obtained from eth-ics board in each of the investigator’s universities and fromthe different health authorities.ResultsStaying true to Walt and Gilson’s policy triangle [14],we reviewed our source materials with a view to con-text, content, process and actors involved in primaryhealth care policy. The context review highlightedthat all three provinces promote team-based primaryhealth care guided by overarching frameworks andstrategies. New structures have emerged that reflectthe unique context of each province. For example,British Columbia invested in Integrated Health Net-works and Divisions of Family Physicians; in Albertathe Primary Care Networks and Family Care Clinicsemerged; and Saskatchewan implemented innovationsites. Political leadership changes often altered thefocus of policies and primary health care structures.We analyzed 45 policies from the three provinces(British Columbia n = 12, Alberta = 15, Saskatch-ewan n = 28) including strategy documents (e.g.,charters, frameworks) and business plans from pro-vincial ministries and health authorities (Table 1).Despite the unique provincial contexts and ap-proaches, common issues and gaps emerged that willbe further discussed below. These relate tostakeholder involvement in policy development,conceptualization of team-based primary health careand policy tools for implementation.Policies shaping team-based care: Development processesand stakeholder involvementAll three provinces position team-based primary healthcare in the wider context of primary care reform, under-pinned by an overarching policy: British Columbia’s Pri-mary Health Care Charter (BC1), Saskatchewan’sPrimary Health Care Framework (SK1), and the recentPrimary Health Care Strategy in Alberta (AB1). Thesedocuments set the vision for primary care reform withsome notable differences. Saskatchewan’s Frameworkserves as a roadmap for the “where to” rather than the“how to” and allows teams to be configured based onlocal needs. Alberta’s Primary Health Care Strategy em-phasizes an approach to team-based primary health carethat integrates public health, wellness services, socialservices and community-based services (AB1). Incontrast, British Columbia’s Primary Health Care Char-ter sets out a broad strategy for creating an effective andsustainable primary health care system with physiciansfirmly at the centre, supported by other providers (BC1).The ministries of health together with the medicalassociations were the driving forces behind policydevelopment in the three provinces. Saskatchewan,and more recently Alberta and British Columbia, en-gaged a broader range of stakeholders (providers,regulatory and education sectors) through workingand advisory groups (BC1, AB1, SK1). We noted alack of patient advocacy representation in policydevelopment across the three provinces despite apatient-centred philosophy.Suter et al. BMC Health Services Research  (2017) 17:493 Page 3 of 9The conceptualization and composition of primary healthcare teamsPolicies include limited guidance on team compos-ition and the organization of teams, such as teamleadership roles or lines of accountability. Notableexceptions are the policies for Family Care Clinics inAlberta (AB2, AB3), which set minimum require-ments for teams whilst still allowing flexibility toaddress community needs. Many policies ascribe(implicitly or explicitly) team leadership to familyphysicians (BC1, AB1). In addition, much of thefunding for team-based primary health care is fun-neled through physicians (e.g., General PracticeServices Committee in British Columbia (BC2), Pri-mary Care Networks in Alberta (AB4), underscoringphysician leadership and accountability. Somepolicies in Saskatchewan offer more flexibility asthere is no requirement to have a physician as ateam member or leader of the team (SK1). This isalso the case in recent policies around team-basedcare for Alberta’s Family Care Clinics (AB2, AB3),which a physician or a nurse practitioner can lead.A key concept emerging from the policies is the abilityof all team members to work to full scope of practice.Saskatchewan’s Framework states that primary healthcare teams flourish when providers work to their fullscope of practice (SK1). Alberta’s Primary Health CareStrategy notes under the principle of collaboration thatmembers will work to full scope of practice and withdefined roles and responsibilities (AB1). Neither policymentions role clarity issues that might ensue fromoverlapping scope of interprofessional team membersor how to resolve them. Policies are also silent onteam liability.Policy tools to advance the implementation of team-basedprimary health care policiesWe found a significant number of policies from healthauthorities that speak to team-based care (e.g., AB5,SK2, SK3). These policies ranged widely in level of detailand the extent to which they offer implementation guid-ance. With a few exceptions (e.g., AB3), most policy doc-uments do not provide direction on tools that could beused to facilitate implementation of team-based care.Some policies contained quality improvement goalsto advance team-based primary health care (SK1).Quality improvement was framed in general termsthrough recommendations for using evidence-basedquality improvement practices but with unclear linksto team-based care. Other tools related to workplaceculture. For example, in Alberta’s Primary Health CareStrategy, a key goal is to enhance collaborative practiceand this is reinforced by reference to standards andframeworks (AB1). The Family Care Clinic policydocuments (AB2, AB3) cited the Alberta CollaborativePractice and Education Framework for Change [21] asa tool to support collaboration and team-based care.Table 1 Key policy documents cited in the manuscriptaBritish ColumbiaBC1: British Columbia Ministry of Health. (2007). Primary Health Care Charter:A Collaborative Approach. Victoria, BC: British Columbia Ministry of Health.http://www.health.gov.bc.ca/library/publications/year/2007/phc_charter.pdfBC2: British Columbia Government, British Columbia Medical Association& Medical Services Commission (2012). Physician Master Agreement.Retrieved from: http://www2.gov.bc.ca/assets/gov/health/practitioner-pro/medical-services-plan/pma-2012-consolidated-amendment-7.pdfBC3: British Columbia Ministry of Health. (2013). Health Professions Act.Victoria, BC: British Columbia Queen’s Printer. http://www.bclaws.ca/Recon/document/ID/freeside/00_96183_01BC4: British Columbia Ministry of Health. (2011). Bill 10–2011 NursePractitioners Statutes Amendment Act. Victoria, BC: British ColumbiaMinistry of Health. https://www.leg.bc.ca/39th4th/3rd_read/gov10-3.htmAlbertaAB1: Alberta Health. (2014). Alberta’s Primary Health Care Strategy.Edmonton, AB: Alberta Health. http://www.health.alberta.ca/documents/Primary-Health-Care-Strategy-2014.pdfAB2: Alberta Health. (2013a). Family Care Clinic Reference Manual. Edmonton,AB: Alberta Health. https://open.alberta.ca/publications/6859089AB3: Alberta Health. (2013b). Family Care Clinic Governance andAccountability Guidelines. Edmonton, AB: Alberta Health. https://open.alberta.ca/publications/family-care-clinic-governance-and-accountability-guidelinesAB4: Alberta Health and Wellness, Alberta Medical Association AlbertaHealth Services (2008). Primary Care Initiative Policy Manual 10.1.Edmonton: Alberta Health and Wellness. Available at: https://www.pcnpmo.ca/access/Documents/PCN%20Policy%20Manual.pdfAB5: Alberta Health and Alberta Health Services (2010). Becoming theBest: Alberta’s 5-Year Health Action Plan. Edmonton, AB: Alberta Health.https://open.alberta.ca/publications/9780778582861SaskatchewanSK1: Saskatchewan Ministry of Health. (2012). Patient Centred CommunityDesigned Team Delivered: A Framework for Achieving a High PerformingPrimary Health Care System in Saskatchewan. Regina, SK: SaskatchewanMinistry of Health. https://www.saskatchewan.ca/~/media/files/health/additional%20reports/other%20ministry%20plans%20and%20reports/primary%20health%20care.pdfSK2: Regina Qu’Appelle Health Region. (2008). Primary Health Care StrategicPlan 2008–2013. Regina, SK: Regina Qu’Appelle Health Region http://www.rqhealth.ca/programs/primary_healthcare/pdf_files/strategic_plan.pdfSK3: Regina Qu’Appelle Health Region. (2013). Strategy for TouchwoodPrimary Health Care Collaborative. Regina, SK: Regina Qu’Appelle HealthRegion. http://www.rqhealth.ca/service-lines/master/files/rqhr_primary_care_strategy_touchwood.pdfSK4: Government of Saskatchewan (2014). The Pharmacy and PharmacyDisciplines Act. Chapter P-9.1 of the Statutes of Saskatchewan, 1996(effective January 1, 1998). Regina: Queen’s Printer.SK5: Government of Saskatchewan (2007) The Midwifery Act beingChapter M-14.1 of the Statutes of Saskatchewan, 1999 (effective February23, 2007. Regina: Queen’s Printer.aFor a complete list of the policy documents we reviewed see Additional file 2Suter et al. BMC Health Services Research  (2017) 17:493 Page 4 of 9Policies in all three provinces discuss funding primaryhealth care transformation, although the type and direc-tion of investments vary in scale and focus. In somecases, investments are explicitly short-term to attractand retain family physicians in places with demonstratedneeds. Such was the case in British Columbia wherefamily physicians received targeted funds to expand theirprimary care service offerings. Most policies did not dis-cuss funding to support the introduction of team-basedcare models (e.g., through education or mentorship pro-grams), enhanced infrastructure for shared electronichealth records or workspace for teams. There was alsolittle evidence within the policies of long-term invest-ments to sustain culture and practice changes.Although remuneration is an important considerationin primary health care redesign, few policies make explicitreference to payment models. A notable exception is theAlberta Primary Health Care Strategy (AB1), which in-cludes the improvement and alignment of compensationmodels as a strategic goal (AB1). Funding and incentivesto attract and retain physicians are mentioned in BritishColumbia’s Primary Health Care Charter (BC1).Another potential mechanism for change is enhan-cing scopes of practice or introducing new providerroles. Scope of practice was expanded for Nurse Prac-titioners in British Columbia (BC3) and pharmacistsin Alberta (AB5) and Saskatchewan (SK4); Saskatch-ewan also introduced regulated midwifery services(SK5). The regulatory changes allow existing and newproviders to assume more comprehensive roles in pri-mary health care. However, none of the policies wereexplicitly intended as a mechanism to advance team-based primary health care. One possible exception isthe Health Professions Act in BC, which “urges” col-laboration between providers (BC4).Lastly, a number of key policies outline accountabil-ity and performance monitoring criteria and processes(AB1, SK1) there is, however, no common account-ability framework or consistent approach to measur-ing outcomes of team-based primary health caremodels. Some policies merely suggest the need forevaluation or plans to develop an evaluation frame-work (e.g. BC1, AB2); Alberta’s Primary Health CareStrategy has an evaluation logic model that includesthe assessment of interdisciplinary collaborative care,although specific metrics are not elaborated on (AB1).Stakeholder feedbackThirty representatives from health ministries, regionalhealth authorities and professional organizations (BCn = 9, AB n = 10, SK n = 11) commented on the draftprovincial policy narratives. Overall, key informants feltthat the narratives were accurate. It was noted that there are many good examples ofteam-based care but that there was a lack of ways toshare these examples; many commented on thelimited operational guidance or practice resourcesto support implementation of team-based care. Almost every key informant raised concerns aboutthe distribution and control of funding streams,which may hinder progressive policy development.They argued that it is essential to finding betterways to remunerate all the members of primaryhealth care teams and fund team development. Stakeholders stressed the importance of movingbeyond collaborative practice as a strategic goal andthe need for appropriate investment in changemanagement to overcome years of inertia. Theneed for infrastructure (collaborative space, IT)and education for collaborative practice was arecurrent theme. Informants gave illustrations of the ways in whichpoor alignment of policies and practices acrossthe health system impedes the development ofteam-based care.The key informant interviews helped us understandthe context in which certain policies were developed andhow they were implemented on the ground. Informantsalso shared valuable insights on potential policyimperatives.Advisory group and roundtable feedbackThe research team identified a long list of policy impera-tives from the policy synthesis and stakeholder inter-views. After review and individual ranking by ourresearch advisory team (based on perceived relevancyand feasibility), four policy imperatives rose to the top.These included alignment of goals and policies at differ-ent system levels, investment of resources for systemchange, compensation models for all members of theteam and accountability through collaborative practicemetrics. Roundtable participants identified the key ele-ments for each of the four policy imperatives and theinherent conflicts and potential trade-offs that may arise[20]. Further discussions focused on the most importantoutcomes and critical implementation factors. Table 2describes the final policy imperatives thought to be feas-ible and effective in advancing team-based primaryhealth care service delivery.DiscussionThe policy landscapeMore than a decade ago, the First Ministers agreed toteam-based care as a cornerstone of primary health carerenewal in Canada [1]. This comparative policy analysisexamined how existing key policies in British Columbia,Suter et al. BMC Health Services Research  (2017) 17:493 Page 5 of 9Alberta and Saskatchewan speak to team-based primaryhealth care and support or hinder progress. Based onour policy triangle approach and analysis, which includesthe contextual review, comparisons of policies, validationof policy narratives with key informants and the advisorygroup and roundtable feedback, we make the followingobservations about the policy landscape.Lack of details on implementation and evaluation:Many of the current publicly available policy frameworksreference team-based primary health care, but howteam-based care is conceptualized and defined varieswidely. They also lack details on team configuration,leadership, scope of practice and role clarity; there is sel-dom reference or guidance on the policy tools (e.g., in-vestments in education or mentorship programs) thatcould facilitate collaboration by health care providers.We also note that few policies speak explicitly to moni-toring and evaluation of the new service delivery models.These significant policy gaps may hamper full imple-mentation of team-based care.Watson and Wong, based on their critical policy andcontext review of the Enhancing InterdisciplinaryCollaboration in Primary Health Care Initiative (EICP),made a similar observation 10 years earlier [22]. Theyconcluded at the time that until a national vision forteam-based primary health care exists and permeatesregulatory frameworks and policies, it will be difficult toadvance team-based care on the ground. Deber andBaumann echoed this statement by suggesting that pro-vincial regulatory frameworks for interprofessional col-laboration are needed urgently, with particular attentionto the division of responsibilities between provincialgovernments and professional regulatory bodies [23].They further suggested that attention be paid to thescope of practice for each profession, how scope is de-fined across jurisdictions and the distinct and overlap-ping competencies of different providers. There hasbeen much movement over the past years with newlegislative policies redefining the scope of registerednurses, nurse practitioners and pharmacists in severalprovinces, elevating their role in team-based primaryhealth care [24, 25]. These legislative changes can workto accelerate reform if leveraged properly. However,some have argued that these roles have not always beenintroduced with sufficient articulation of how they willbe integrated into existing service delivery models orhow they will impact the scopes of practice of otherhealth professions [25]. Also, these innovations requirecareful evaluation of outcomes associated with differentteam-based models of care. There is consensus in theliterature that clear reporting expectations must exist forcontinuous improvement of team-based care butcurrent policies offer limited guidance in that respect[2, 9, 23, 24, 26].Funding issues: Current policies do not adequately ad-dress the funding of team-based primary healthcare.Funding pertains to two distinct areas: firstly, targeted,evidence-based and sustainable funding and resource al-location for infrastructure, change management plans,educational programs and training, and adequate tech-nology to facilitate collaboration; and secondly, changesin compensation models for all health care providers (in-cluding those in the community) to incentivize team-based care. Both issues have been extensively discussedin the literature as key barriers to the adoption of team-based care [2, 9, 10, 22–25]. The primary health care re-form agenda was supported by hefty, albeit time limitedinvestments from provincial and federal levels that createdthe impetus for new service delivery models [10, 24].However, some argue that not enough resources were al-located to training and coaching for culture change toovercome entrenched social values that act as barriers toteam-based care [9]. Also, in the absence of clear fundingguidance and regulatory changes, many jurisdictions havemaintained their two-stream system where health author-ities and physicians have different funding structures andaccountabilities. It has long been recognized that fee forTable 2 Policy imperatives for advancing team-based primaryhealth carePolicy imperative #1: To align health system goals, policies, workforceand structuresThe lack of system alignment between the ministries of health, regionalhealth authorities and private practices’ priorities and agendas impedesteam-based care. To align health system goals, policies, workforce andstructures requires a shared vision on team-based care, resource sharingand inclusion of the broader community in policy deliberation and im-plementation. We urge leaders to stay the course for team-based pri-mary health care as it is foundational to health care reform in Canada.Policy imperative #2: To invest adequate resources to support systemchange structuresProvinces need to invest adequate resources to support system changeto foster team-based primary health care. This requires that provincesprovide sustainable funding for team-based care and invest in proper in-frastructure, adequate technology and change management plans. Im-proved evidence is required to guide decisions on resource assignment.Policy imperative #3: To develop appropriate and sustainablecompensation modelsExisting compensation models can negatively impact team-based ser-vice delivery. The third policy imperative is therefore to develop appro-priate and sustainable compensation models. This imperative is notdirected solely at physician remuneration; we need to consider compen-sation models for a wider range of team members including those inthe community.Policy imperative #4: To integrate collaborative practice metrics inprimary health care monitoring and evaluation structuresThe fourth policy imperative, integrate collaborative practice metrics inprimary health care monitoring and evaluation, will improveaccountability for team-based service provision. Investments need to bemade in shared data elements and indicators so we can learn from suc-cesses and failures, target our investments and disinvest in initiativesthat do not yield the desired outcomes.Suter et al. BMC Health Services Research  (2017) 17:493 Page 6 of 9service remuneration is incompatible with the develop-ment of interprofessional teams in primary health careand that payment models need to be reformed to alignwith overall health system goals [24, 27–30].Lack of policy evolution and alignment within andacross systems: Our analysis across three provinceswould suggest that policies during this period to supportteam-based primary health care have been slow toemerge and have lacked a systematic and coordinatedapproach across sectors and geographic areas. More im-portantly, the policies lacked alignment in the strategicplanning for primary health care between provincialMinistries of Health, regional health authorities andclinics. Alignment pertains to a clearly articulated visionand consistent messages, realignment of ministry ofhealth, regional health authorities and private practices’priorities and agendas, and alignment of the acute care/primary care interface. In his examination of health re-form across western countries, Hacker elaborates on therelationship between governance structure, financingand health reform. He argues that in political structures,such as in Canada, where implementation of health re-form is under provincial jurisdiction, “…rapid or decisivestructural policy change has proved far more elusive”(p694) [31]. He further points out that countries likeCanada with many veto points (introduced by federal-ism, powerful judiciary, distributed administrative andpolitical responsibility for planning), may be more proneto policy stalemate as the political system makes changedifficult. In such constellations, the federal Governmentlacks the capacity to formulate objectives and monitorprogress, and practice change occurs within existing pol-icy frameworks. Ettel et al. make a similar observation incomparing health planning in New Zealand andGermany. They comment on the fragmented planning inGermany, attributed to federalism and corporatism,which has resulted in great diversity in response [31]. Incontrast, due to the central authority of the governmentin health care planning in New Zealand, planning is rela-tively coherent and promotes alignment across sectorsand geographical boundaries.Several authors have noted that primary health carereform in Canada has been primarily implemented vol-untarily, based on incentives [9, 24]. Much of the changehas been negotiated, largely preserving the autonomy ofphysicians [6, 9]. Many new models are criticized as be-ing limited and lacking the characteristics of highperforming models, having only partial interdisciplinarityand remaining physician-centred [9, 32].Policy imperativesThe main goal of this research was to identify policy im-peratives to advance team-based primary health care.We used our observations about commonalities andgaps in existing policies, stakeholder interviews, and ad-visory group priority ranking to arrive at four policyimperatives: To align health system goals, policies, workforce andstructures, To invest adequate resources to support systemchange structures, To develop appropriate and sustainablecompensation models, To integrate collaborative practice metrics inprimary health care monitoring and evaluationstructures.The roundtable discussion, at which key health systemrepresentatives discussed relevance and feasibility,strongly affirmed the policy imperatives [20]. Partici-pants argued against prioritizing them as they saw thepolicies as equally important and interconnected. Ini-tially termed policy options, they recommended to usethe term policy “imperatives” to avoid the risk of“cherry-picking” that might occur if presented asoptions. There was consensus at the end of the day thatswift action is required and that collectively, the fourpolicy imperatives have the potential to advance team-based primary health care across Canada. The next step,which was beyond the scope of this project, is to engagethe provinces in a detailed review of implementationconsiderations for these imperatives.LimitationsThis work was not without challenges, many of themmethodological. Conducting searches of diverse evi-dence, agreeing on criteria for inclusion, and developingextraction tools and ways to validate information all re-quired some creativity. Testing policy research methodsand ways of engaging stakeholders is vital to supportevidence-based policy development. Another challengeis the ever-evolving nature of policy within the threeprovinces throughout our project period. We acknow-ledge that our research took a snapshot of policieswithin a specific timeframe. Nevertheless, the four policyimperatives emerging from this policy synthesis remainrelevant and may constitute the cornerstones for a pan-Canadian framework.ConclusionHacker’s analysis of health care reform has referred toa paradoxical pattern of policy reform that hedescribed as “reform without change and changewithout reform” (p721) [31]. The latter seems befit-ting for the way team-based primary health care hasevolved across the three western provinces and acrossCanada. There is evidence of pockets of innovationsSuter et al. BMC Health Services Research  (2017) 17:493 Page 7 of 9that fit unique contexts in the absence of overarchingpolicy reform across levels. Using a policy trianglelens for our policy review helped to focus our inquiryon the relationship between context and policy evolu-tion in different places and what this may mean fornational policy development [14].Through this comparative policy study, we identifiedfour policy imperatives that speak to the gaps and limita-tions evident in the current policies in three Canadianprovinces. These policy imperatives could present amechanism to advance team-based primary health carewithout stifling local innovation. The four policy impera-tives are interrelated and need to be incorporated intopolicies as a total package to achieve system wide re-form. Given the federalist nature of the Canadian healthcare system, some believe that a national vision forteam-based primary health care might be elusive andlocal context and power dynamics will continue to drivepolicy solutions [31, 33]. We argue, however, that push-ing the policy frameworks towards greater alignmentwith specific consideration of financing, reimbursement,implementation mechanism and performance monitor-ing could accelerate progress by removing some well-known barriers to team-based care. Based on our re-search, we concur with recent reports that urged theCanadian governments at all levels to make a sharedcommitment to scale up innovations and create coor-dinated systems of funding, financing, remunerationand education that enable team-based models of carethat align with patient outcomes and optimal scopesof practice [2, 25].Additional filesAdditional file 1: Contains a full list of policy documents reviewedin this study. (DOCX 21 kb)Additional file 2: Contains an diagram of the health policy triangle(DOCX 27 kb)AcknowledgementsWe would like to thank Amanda Wilhelm for assisting with this research.FundingThis project was funded under the Canadian Institutes for Health ResearchHealth Care Renewal Policy Analysis Program (grant # HRA 288824).Availability of data and materialsPolicy documents and other sources used in the policy analysis are publiclyavailable (see Additional file 1). To protect the confidentiality of interviewparticipants, in accordance with ethical approvals obtained for this study,interview transcripts will not be shared.Authors’ contributionsAll authors were members of the research team and contributed to datacollection and/or analysis. ES wrote the first draft of the manuscript. Allauthors reviewed, revised, and approved the final manuscript.Ethics approval and consent to participateThis research received ethical approval from the following committees:University of Calgary CHREB, University of British Columbia BREB, Universityof Saskatchewan Research Ethics Office, and University of Regina ResearchEthics Board. All participants provided written informed consent to beinvolved in this research.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Department of Social Work, University of Calgary, 2500 University Drive NW,Calgary, AB T2N 1N4, Canada. 2Health Systems Evaluation and Evidence,Alberta Health Services, 10301 Southport Lane SW, Calgary, AB, Canada.3Population, Public, and Indigenous Health, Alberta Health Services, 2210-2ndStreet SW, Calgary, AB, Canada. 4University of British Columbia, 400-2194Health Sciences Mall, Vancouver, BC, Canada. 5Centre for Health Services andPolicy Research, University of British Columbia, 201-2206 East Mall,Vancouver, Canada.Received: 2 March 2016 Accepted: 7 July 2017References1. Health Canada. Primary Health Care Transition Fund. No date. http://www.hc-sc.gc.ca/hcs-sss/prim/phctf-fassp/index-eng.php. Accessed 5 Feb 2016.2. Naylor D, Girard F, Mintz J, Fraser N, Jenkins T, Power C. Unleashinginnovation: excellent healthcare for Canada. Government of Canada:Report of the Advisory Panel on Healthcare Innovation; 2015. http://healthycanadians.gc.ca/publications/health-system-systeme-sante/report-healthcare-innovation-rapport-soins/alt/reporthealthcare-innovation-rapport-soins-eng.pdf. Accessed 10 Feb 20163. Mable A, Marriott J. Canadian primary healthcare policy: the evolving statusof reform. Canadian Health Services Research Foundation: Ottawa; 2012.http://www.cfhi-fcass.ca/Libraries/Commissioned_Research_Reports/MariottMable-Jan2012-E.sflb.ashx. Accessed 5 Feb 20154. Stumpf E, Leveque J-F, Coyle N, Hutchinson B, Barnes M, Wedel RJ.Innovative and diverse strategies toward primary health care reform: lessonslearned from the Canadian experience. J Am Board Fam Med. 2012;25(Suppl 1):S27–33.5. 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Summaryreport. 2014. http://www.albertahealthservices.ca/assets/info/res/if-res-wre-policy-primary-care-roundtable-report-2014.pdf Accessed 5 Feb 2016.21. Government of Alberta. Collaborative practice and education: framework forchange, background information for the collaborative practice andeducation Workplan for change. Edmonton: Government of Alberta; 2012.22. Watson D, Wong S. Canadian policy context: interdisciplinarycollaboration in primary health care. Enhancing InterdisciplinaryCollaboration in Primary Health Care: Ottawa; 2005.23. Deber R, Baumann A. Barriers and facilitators to enhancinginterdisciplinary collaboration in primary health care. EICP Initiative/Conference Board of Canada: Ottawa; 2005. http://tools.hhr-rhs.ca/index.php?option=com_mtree&task=att_download&link_id=5305&cf_id=68&lang=en. Accessed 5 Feb 201624. Levesque J-F, Pineault R, Grimard D, et al. Looking forward to movingforward: a synthesis of primary health care reform evaluations in Canadianprovinces. Report of the knowledge synthesis and exchange forum on theimpact of primary health care organizational models and contexts 2012.www.dsp.santeMontreal.qc.ca/dossiers_thematiques/services_preventifs/thematique/sante_des_populations_et_services_de_sante/documentation.html. Accessed 5 Feb 2016.25. Nelson S, Turnbull J, Bainbridge L, Caulfield T, Hudon G, Kendel D, et al.Optimizing scopes of practice: new models for a new health care system.Canadian Academy of Health Sciences: Ottawa; 2014. http://www.cahs-acss.ca/wp-content/uploads/2014/08/Optimizing-Scopes-of-Practice_REPORT-English.pdf. Accessed 5 Feb 201626. Cheung KK, Mirzaei M, Leeder S. Health policy analysis: a tool to evaluate inpolicy documents the alignment between policy statements and intendedoutcomes. Aust Health Rev. 2010;34:405–13.27. Brossart B, Donnelly L. Primary healthcare transformation: moving fromcommon sense to common practice. Healthc Pap. 2012;12(2):46–50.28. 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Assessing health care planning – aframework-led comparison of Germany and New Zealand. Health Policy.2012;106(1):50–9.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Suter et al. BMC Health Services Research  (2017) 17:493 Page 9 of 9


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