The topic we selected for the very first issue of Healthcare Papers in 1999 was primary healthcare, and so it seems timely that we should revisit the topic almost 10 years later. Primary healthcare was considered to be of particular interest and importance in the late 1990s. Primary care was considered to be in a state of crisis in many parts of the country, from both practitioner and policy perspectives. During the prior 10-15 years, there had been numerous reports both nationally and provincially about what needed to happen to improve both the effectiveness and efficiency of the way we organize and finance primary healthcare in Canada. Many of the reports were similar in their conclusions and recommendations, but, without exception, there had been little action. Indeed, reforming primary healthcare was predicted to improve access to healthcare, decrease inappropriate use of hospital emergency departments, result in a better use of health resources, improve outcomes for patients and provide some resolution to the reported problems of physician shortage/maldistribution.

In the first issue, Rosser and Kasperski outlined a new model for family medicine's role in primary care for Ontario from the perspective of the Ontario College of Family Physicians. They advocated that the role of primary care be augmented to become a basic building block to better coordination and integration of services. The reviewers of the Rosser and Kasperski paper were diverse and emphasized different perspectives on primary healthcare and where it should go in the future.

In the 2008 version of primary care revisited, Brian Hutchison is the lead author and eminently qualified to provide an overview of events in primary care in Canada over the past 10 years. He begins by asking the question, "Is it possible that, after decades of false starts and faint-hearted initiatives, transformative change in Canadian primary healthcare is finally under way?" He describes how, in the early 2000s, new thought processes about primary care emerged, reflecting lessons learned that:

• policy legacies limit the possibilities for change - under current and foreseeable circumstances, cumulative, incremental change is all that is possible;
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• there is no single "right" primary healthcare model - pluralism of models is both unavoidable and desirable;
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• funding and payment methods are no panacea for the ills of primary healthcare; and
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• primary healthcare renewal requires major investments in infrastructure (e.g., appropriate premises and staffing, information technology and tools and facilitation to support quality improvement and coordination of care).

Hutchison delineates how new primary care models have evolved in different provinces and territories. He indicates that implementation is most broadly based in Quebec, Alberta and Ontario, where medical associations have had a strong hand in shaping primary healthcare policy. He points out that this

reflects the ability of medical associations to block or seriously compromise the implementation of changes in the organization and delivery of care that they find objectionable and to facilitate those that are seen as responding to, or at least not threatening, their members' interests. In the Canadian context, systemlevel innovation in primary healthcare is only possible with the support or, at a minimum, the acquiescence of organized medicine. That support is most likely to be achieved if medical associations are present at the policy table. To the extent that other stakeholders (including those with a legitimate claim to represent the public interest) are not represented, policy initiatives may incorporate features that enhance their attractiveness to physicians at the expense of other stakeholders or blunt the potential impact of the policy innovation in order to accommodate physician interests.

Hutchison goes on to compare primary care initiatives in Canada with those in other developed countries such as the United Kingdom, Australia, The Netherlands, the United States, New Zealand and Germany. His conclusions suggest that, in general, Canada does not compare well in almost all of the primary care characteristics, such as information systems, infrastructure, quality improvement, coordination of care, access and equity, funding and payment mechanisms, management systems and innovation and evaluation.

In concluding his paper, Hutchison suggests that priority areas for investment are integrated health information systems, quality improvement, interdisciplinary primary healthcare teams and group practices and systematic evaluation of primary healthcare innovations and ongoing system performance. He argues that the most important of these investment areas is integrated information systems. Recognizing that major investments are needed, he suggests that without these, very little progress can be made in advancing primary care in Canada.

We have excellent responses from commentators who, in general, agree with the principles in the Hutchison paper but also add greatly to the discussion. Mary van Soeren and her colleagues suggest that the primary care system lacks overall policy direction and wonder whether even the small steps of success can be sustained. Marsha Barnes and Hugh Macleod, speaking from the perspective of the Ontario Ministry of Health and Long-Term Care, conclude that there needs to be greater commitment to the evaluation of clinical outcomes and patient experiences. Hal Swerissen of La Trobe University in Victoria, Australia, agrees with Hutchison that incremental change is most likely to be successful. Alan Katz of Manitoba believes that we have not yet reached a tipping point in primary care, and that the advancement of primary care does not easily connect with the current focus on wait times. Paul Lamarche speaks from the perspective of Quebec, which has always been in advance of other provinces in organized primary care. In responding to Hutchison's view that organized medicine can in fact influence the extent to which healthcare policies are implemented, he suggests that the time may have come "to develop two different processes of policy formulation: one concerning the practice of medicine, which could be mainly professionally dominated, and one concerning the organization of the practice, which could be democratically dominated. Mixing the two is likely to produce less favourable results." Wendy Nicklin, of the Canadian Council on Health Services Accreditation, suggests that primary care renewal is moving forward and that CCHSA will work with colleagues to promote quality and patient safety in primary care services. Finally, Barbara Starfield, from Johns Hopkins Bloomberg School of Public Health, quite rightly takes Canada to task for not keeping pace with making changes in primary care. She believes that Canada has to take bold steps to take advantage of its population health perspective on health services delivery, and that its population-based system could form the foundation for the future.

Hutchison has the last word and has provided an excellent summary of the debate. I urge you to read the details of this issue of Healthcare Papers. The lead paper is outstanding, and the commentaries add greatly to the directions for the future.

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