Sure.
It is well known that in any health care system we need a strong primary level base, and then a secondary and a tertiary level of care. The tertiary is the highly specialized care that a much smaller proportion of the population requires. You see that in the care of patients with hypertension, for example. Not all patients with hypertension need to go to a cardiologist; a lot of it can be really well controlled at a primary level.
It's the same thing for palliative care. If we provide what I say are the “generalists” with those basic competencies from a palliative care perspective—how to assess symptoms; how to start managing them; how to ask about the understanding of the illness; what the psychological, social, or spiritual needs are; and how one can help—then we start implementing that palliative care approach.
If we start equipping those professionals who are not palliative care specialists with those basic skill sets, they can start initiating a palliative care approach much earlier, which means the much smaller group of specialists can then focus on doing certain things, such as caring for patients and families with complex needs; leading education; leading quality improvement in hospitals, in long-term care, and at home to improve palliative care; and doing research.
Unfortunately, at the moment, in some provinces that triangle with primary care is upside down. Ontario is an example. In a study I published with some colleagues about a year and a half ago, we discovered that most of the palliative care, including primary level palliative care, was being done by a very small group of palliative care specialists. There are only about 260 palliative care specialists in this province to do all the care for cancer patients, heart patients, nephrology patients, and geriatric patients, etc.
First of all, there is a significant lack of those specialists' services in many parts of the country. We need them. Second, there are problems with funding mechanisms. In Ontario, for example, much of the funding of palliative care specialists is by a fee-for-service model, so it drives the specialists to take over palliative care, to do the clinical work only, but it doesn't pay the specialist to teach and build capacity. That needs to be changed to models using existing funding that can build capacity, rather than undermining that primary level that is so critical.