Prioritize disadvantaged people for primary care and screening access, report says

TORONTO — A panel of doctors, nurses and patients from across Canada has issued recommendations on how to make health care more equitable for disadvantaged people.

In a paper published in the Canadian Medical Association Journal on Monday, the panel came up with 15 disease prevention and screening recommendations that health-care providers could use to help address barriers to care.

"There are known inequities that could be addressed by interventions like cancer screening (and) screening for cardiovascular disease,” said lead author Dr. Nav Persaud, who is the Canada Research Chair in Health Justice and a family physician at St. Michael's Hospital.

"Our approach was not to just bemoan these inequities, but to ask 'what can we do to address them?'"

Indigenous and racialized people, members of LGBTQ+ communities, people with low incomes and those living in rural or remote parts of Canada may be among the populations without equal access to life-saving preventive screening and testing, the paper said.

"Preventive care access is not equitable for a variety of reasons, including poor connections with primary care, limited availability to attend appointments, mistrust of health care and discriminatory practices within health care. Stigmatization related to mental health conditions, substance use, HIV and other infectious diseases is (also) a barrier to care," it said.

The paper calls for government investment in giving every person in Canada access to a primary health-care provider — including community health clinics — but said the "first step" should be prioritizing people experiencing disadvantages.

The costs of automatically enrolling disadvantaged patients with a primary-care provider "have not been precisely estimated," the paper said, but "might involve increasing primary care spending by $100 per capita for the entire population, or by around $3.8 billion annually."

The exact cost would depend on the mix of providers, which would include family doctors, nurse practitioners and nurses, it said.

The paper did not specify what level of government should supply that funding, but Persaud noted that a much bigger amount of money would be saved by preventing expensive health-care interventions down the road.

Regardless of the cost, access to primary care should be a right, he said.

"It would be unacceptable if a family contacted a school or school board and was told, 'no, there's not enough room in the school, so you'll have to homeschool your child," Persaud said.

"But you can call a family doctor's office and be told 'no, there's not enough room for you so you're not going to get primary care.’"

People in Canada should be "automatically enrolled in primary care the same way that you can be automatically enrolled in a school or a school board,” Persaud said.

Doris Grinspun, CEO of the Registered Nurses’ Association of Ontario, said she welcomed the recommendation, but "the devil is in the details."

Getting enough primary care providers for everyone would require governments to "massively increase the number of nurse practitioners in Canada," Grinspun said — a measure she said is long overdue.

The time spent in school is much shorter for nurse practitioners than family doctors, and studies show that clinical results and patient satisfaction are just as good, she said.

The College of Family Physicians of Canada also supported the recommendation, saying "equitable access to primary care is the foundation of an efficient and responsive health-care system."

The college's executive director, Dr. Lawrence Loh, said in a statement that Canada's health-care system is "broken," with one in five Canadians unable to access a family doctor due to shortages.

The need for "comprehensive, continuous primary care has never been more crucial. There is a deepening crisis in family medicine that needs action now," Loh said.

Meanwhile, primary care providers can promote equity by prioritizing their disadvantaged patients and encouraging key screenings and tests, Persaud said.

Making some screenings more accessible is another way to reach disadvantaged people, even when they don't have a primary care provider, he said.

Here are a few of the paper's recommendations:


Fecal testssent to people's homes after they turn 50 are an example of how screening can be more accessible, Persaud said, but some disadvantaged populations need further outreach.

That outreach could happen through community health workers, the paper said.

Recent immigrants to Canada and people living in lower-income neighbourhoods have lower colorectal cancer survival rates — and screening can save lives, it said.

Because it may take longer to reach disadvantaged populations and get them to complete the screening, the process should start earlier — at age 45 instead of 50, the recommendation said.


Like the at-home colorectal cancer screening tests, self-swabs to detect human papillomavirus (HPV), which can cause cervical cancer, could also be sent to people's homes, Persaud said.

That could help overcome barriers to getting tested for HPV, the recommendation said, as research shows women with disabilities, Black women, people who identify as LGBTQ+ and people born outside of Canada are less likely to be screened. In addition, people who have suffered sexual trauma may be less likely to go to a doctor's office for a Pap smear.


The panel recommendsprioritizing cardiovascular risk assessment for women, racialized people and people with mental health conditions by taking their blood pressure, among other measures, and following up with treatment if needed.

Research has shown women are less likely to be screened for cardiovascular disease risk. Studies in other countries have shown Black people are less likely to have their blood pressure controlled. People with schizophrenia and bipolar disorder don't receive enough care for high blood pressure, the recommendation said.

The paper also recommends proactive screening for lung cancer, diabetes, depression, HIV/AIDS, hepatitis C, tuberculosis, substance use and dental cavities among disadvantaged people.

The panel also recommends that primary care providers screen patients for social factors in health, including poverty and intimate partner violence.

This report by The Canadian Press was first published Sept. 25, 2023.

Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.

Nicole Ireland, The Canadian Press