Policy analysis lessons for primary care education reform: What can the UK learn from Canada’s attempt to expand family medicine residency training?

Problem

Primary care systems in many countries are struggling, and many policy interventions have targeted improved access, quality of professional life, and interprofessional team work. This presentation demonstrates the relevance of policy analysis to understanding health system transformation efforts, using the example of a failed Canadian initiative to expand family medicine residency training from two to three years. This education effort aimed to increase the proportion of family physicians providing comprehensive, community-based care in interprofessional teams in order to improve access to primary care, health system cost, and clinician satisfaction.

Approach

This is an interpretive policy analysis conducted by two education policy scholars engaged as consultants on the residency expansion project. Data are public materials including reports, open letters, publicly available recordings of annual member meetings, news coverage, social media discussion. Analysis was guided by the 3I+E framework, describing and explaining how this education reform arrived on the agenda and why implementation ceased. We discuss examples of the Interests, Institutions, Ideas, and External factors which shaped this recent trans-jurisdictional education policy reform initiative, paying particular attention to the forces which coalesced to result in termination of the reform effort.

Findings

There are conflicts at each level of the 3I+E framework. Primary care access challenges have been exacerbated since the Covid-19 pandemic. This set the stage for political involvement and competing discourses about how family physicians should be trained, remunerated, and deployed. Conflicting explanations about the origins and solutions to the problem of access played out in debates about residency expansion, alongside rhetorical arguments about the quality and type of evidence needed to justify education reform. While political, professional, and regulatory interests interacted in public discourse, the voices and interests of patients were absent. The autonomy and remuneration of physicians was prioritized in many discourses opposing residency expansion.

Consequences

This presentation documents multiple conflicting interests which coalesced in the cessation of efforts to expand family medicine residency in Canada. By doing so, it analysis demonstrates the challenge of education reform and the importance of aligning interests, institutions, and ideas to initiate primary care policy change.