Ask a health planner what threatens primary care access, and you'll hear about physician shortages, panel sizes, or funding models. Rarely do you hear about leases. Yet across much of Canada, community primary care runs on an unusual piece of infrastructure: physicians who don't just treat patients, but also own the clinic business. When that physician retires and no one takes over the business, the clinic may disappear.

We don't have a clear national figure for how many community clinics in Canada are structured this way. However, in the provinces we've examined, the underlying pattern persists, even where the surrounding structures differ and where provinces have layered additional funding and staffing models on top. A family physician signs the lease, hires the staff, purchases the equipment, and carries the financial risk, all while practising medicine. It's been the default model for long enough, and in enough of the country, that much of the system has stopped questioning it.

That default is now colliding with a generation of physicians who may want to practise differently. In our own engagement work with new-to-practice physicians and residents in an urban area of B.C., 94% wanted to divide their week across more than one work setting, and only about one in five expected to spend more than three days a week in a family practice clinic. Canadian research has similarly found a strong preference among family medicine residents for varied, team-based practice. None of this directly measures interest in clinic ownership, but it raises an important succession question: if more physicians build careers across multiple settings, how many will want to take on the additional responsibility of owning and operating the clinic itself?

It isn't difficult to understand why. Clinic ownership typically means signing a five-year commercial lease, often with a personal guarantee, in a business with slim and largely fixed margins. Clinic overhead, including staff, rent, equipment, insurance, and other operating costs, can commonly consume 25% to 35% of a family physician's income. And that's when the clinic has enough physicians contributing to cover those costs. Ownership also means employing and managing staff, responsibilities for which most physicians receive little formal training. It means absorbing whatever liabilities, leasehold obligations, or underperforming years the outgoing physician leaves behind. The upside is limited. The downside carries considerable risk.

That asymmetry also works against succession. Starting a clinic from scratch can require substantial upfront capital. A recent feasibility assessment for a proposed 2,500-square-foot, eight-exam-room primary care clinic in View Royal, B.C., estimated $562,500 in leasehold improvements and another $190,000 for equipment and furnishings. Taking over a colleague's practice, with its patient panel and equipment already in place, should be the less expensive path to ownership. But when neither option makes financial sense, there is no guarantee that a clinic losing its owner will be replaced. Some will simply close.

Meanwhile, the physicians who do own clinics are aging out. Nearly a quarter (24%) of Canada's family physicians were 60 or older in 2024. In Ontario, an OMA survey found that 40% of physicians were considering retirement within five years. In our own review of public materials from B.C.'s 36 Divisions of Family Practice, more than half showed evidence that succession or retirement planning was a concern, while one-third had identified it as an explicit priority.

When enough of these transitions fail at once, the consequences extend beyond any single clinic. Patients lose their family doctor with no clear path to another. Communities lose a piece of health infrastructure that took years, and sometimes an entire career, to build. And the questions that follow aren't clinical. Will corporate consolidators fill the gap? Will some clinics simply close?

Primary care succession isn't just about replacing retiring physicians. It's also about preserving the infrastructure they leave behind.

None of this is inevitable, but it does require treating succession as a system-level design challenge rather than an individual physician's retirement checklist. That could mean grant programs that make it financially viable for a new physician to take over a clinic. It could mean business and leadership training being integrated into medical education and early-career support, so that ownership isn't a skill physicians acquire by accident, if at all. It could mean practice-readiness assessments and mentorship programs that pair outgoing owners with incoming ones well before the outgoing physician is ready to leave. It could also mean practical support at the point of transition, such as legal reviews of how staff and physician contracts carry over to a new owner, so that the mechanics of a handover do not become the reason it fails.

In some communities, succession may require questioning the ownership model itself and considering whether municipalities, non-profits, health authorities, or other entities could preserve clinic infrastructure while allowing physicians to practise without personally assuming the risks associated with leases, staffing, and operations.

Every retiring family physician who owns a clinic is quietly asking a question the system hasn't yet answered: what happens to this clinic when I can no longer run the business?

Until we treat that as a health-system capacity question, rather than simply an individual physician's retirement or real estate problem, we'll continue discovering the consequences one clinic at a time, one community at a time.

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