Advancing Interprofessional Primary Health Care Teams in Québec: A Policy Analysis

Paul Wankah¹ and Aisha Zerbo²

1. Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Québec, Canada

2. Health Standards Organization, Montreal, Québec, Canada

• The integration of allied health professionals into Québec’s family medicine groups was made possible by the convergence of system pressures (increasing complexity of patient needs and access gaps), available policy solutions (strong evidence of team-based care models), and sustained political commitment to primary health care reform.
• Early evidence suggests that the reform enhanced timely access to psychosocial services and strengthened holistic care; however, its implementation has been marked by role ambiguity, delayed supports, and persistent governance challenges.
• The long-term success of interprofessional primary care in Québec will require clearer role definition, stronger coordination across governance structures, and the institutionalization of evaluation frameworks to ensure sustainable system transformation.

• L’intégration des professionnels de la santé et des services sociaux dans les groupes de médecine de famille du Québec a été rendue possible par la convergence de pressions systémiques (complexification des besoins des patients et lacunes d’accès), de solutions politiques disponibles (preuves solides en faveur des modèles de soins en équipe) et d’un engagement politique soutenu envers la réforme des soins primaires.
• Les premières données probantes suggèrent que la réforme a amélioré l’accès rapide aux services psychosociaux et renforcé une approche de soins holistique; toutefois, sa mise en œuvre demeure marquée par une ambiguïté des rôles, des soutiens tardifs et des défis persistants de gouvernance.
• La réussite à long terme des soins primaires interprofessionnels au Québec dépendra d’une clarification des rôles, d’une meilleure coordination entre les structures de gouvernance et de l’institutionnalisation de mécanismes d’évaluation afin d’assurer une transformation durable du système.

Primary health care systems worldwide are under mounting pressure, driven by population aging, increasingly complex patient needs, the growing burden of chronic disease, and the pervasive influence of social determinants of health on outcomes (Hutchison et al. 2011). These epidemiological and demographic transitions have exposed the limitations of fragmented, episodic models of care that are poorly equipped to address complex, long-term, and social health needs. In response, integrated care approaches have gained increasing prominence, broadly defined as the coordinated organization and delivery of health services across the care continuum to ensure comprehensive, continuous, and person-centred care tailored to individual needs over time (Goodwin 2016; Kodner and Spreeuwenberg 2002). Interprofessional team-based care is a core component of integrated care, as it brings together diverse health professionals, such as physicians, nurses, social workers, and other allied providers to collaboratively plan and deliver care that is responsive to the multi-dimensional needs of patients (Kodner and Spreeuwenberg 2002; Suter et al. 2009).

In Québec, Canada, a series of health system reforms, beginning in the early 2000s, fundamentally reshaped the organization and delivery of primary health care services towards integrated team-based care. Central to these reforms was the creation of family medicine groups (groupes de médecine de famille, or GMF) in 2002, which aimed to improve accessibility, continuity, and coordination of care through interprofessional team-based models (Breton et al. 2013; Pomey, Martin, and Forest 2009). The evolution of GMFs represents a significant shift from Québec’s historically physician-centric, fee-for-service primary care model. Initially, GMFs comprised 6-12 family physicians working collaboratively with one or two nurses and administrative support staff to serve registered populations of 10,000 to 20,000 individuals (Breton et al. 2013; Pomey, Martin, and Forest 2009). However, as the model matured and the evidence accumulated regarding the increasing complexity and multi-faceted needs of primary care populations, policy attention turned to expanding interprofessional team composition. In a previous longitudinal analysis of integrated team-based primary health care policy analysis of Québec, we highlighted the 2016 Program for Funding and Professional Support for Family Medicine Groups (Gouvernement du Québec 2016) as a significant development, enabling the allocation of allied health professionals (AHPs), including nurse practitioners, social workers, pharmacists, occupational therapists, amongst others, into GMFs to strengthen comprehensive primary health care delivery (Wankah et al. 2022). This manuscript deepens the analytical focus of prior work by examining the policy process underlying the allocation of AHPs to GMFs in Québec.

Drawing on Kingdon’s Multiple Streams Framework (Kingdon and Thurber 2011), this article explores how the convergence of problems, policy and politics streams created a policy window for integrating AHPs into Québec’s GMFs. By tracing this convergence, the study illuminates key socio-political drivers, influential actors and policy instruments behind this reform, moving beyond descriptive accounts to deliver a theoretically grounded explanation of workforce policy change and the political construction of team-based care in evolving primary health care systems.

Historically, primary health care in Québec has been delivered predominantly through privately operated medical clinics, characterized by limited integration and weak formal linkages with public health care organizations (Arpin, Gautier, and Quesnel-Vallée 2025; Turgeon, Deschênes, and Simard 2016). In the early 1970s, the Castonguay-Nepveu Commission marked a transformative moment in the organization of Québec’s health system, notably through the creation of local community service centres (centres locaux de services communautaires, CLSCs), which were designed as the cornerstone of primary care delivery (Arpin, Gautier, and Quesnel-Vallée 2025; Pomey, Martin, and Forest 2009; Turgeon, Deschênes, and Simard 2016). CLSCs embodied a population-based and prevention-oriented model, anchored in geographically defined communities and supported by broad interprofessional teams. In principle, they represented an early attempt to operationalize integrated care by aligning a variety of professionals, including physicians, nurses, occupational therapists, physiotherapists, nutritionists, psychologists and social workers under a single organizational structure (Pomey, Martin, and Forest 2009; Turgeon, Deschênes, and Simard 2016). However, the model faced important limitations. Most notably, physicians resisted practicing as salaried employees under the administrative authority of CLSCs, preferring instead to maintain professional autonomy within private practice arrangements (Breton et al. 2013; Pomey, Martin, and Forest 2009). This misalignment between policy design and professional interests significantly constrained the CLSC model’s capacity to fully realize its integrative ambitions.

Subsequent provincial inquiries, including the Clair Commission of 2000, highlighted persistent systemic challenges underlying public dissatisfaction with primary care, notably limited access to a regular family physician, long wait times for services, and overcrowded emergency departments (Arpin, Gautier, and Quesnel-Vallée 2025; Turgeon, Deschênes, and Simard 2016). The Clair Commission underscored the need to strengthen coordination across levels of care and to better align organizational structures with provider practices and patient needs, ultimately paving the way for the creation of GMFs in 2002. In contrast to CLSCs, GMFs were deliberately designed to accommodate physicians’ preferences, permitting them to remain in private practice while fostering collaboration with nurses through the provision of public funding and organizational support. The introduction of the program for funding and professional support of GMFs in 2016 marked a pivotal policy shift, accelerating their transformation into more complex interprofessional structures. By facilitating the integration of a broader range of health and social care professionals, this reform aimed to strengthen the capacity for interdisciplinary collaboration and advance more comprehensive, team-based primary health care delivery in Québec.

Explicit goals

The reform was grounded in several explicit policy goals, as articulated by the government to support its implementation (Gouvernement du Québec 2016). First, it sought to enhance access to primary health care services by expanding service capacity beyond physicians, facilitating more timely and continuous care for registered patients, and supporting compliance with accessibility requirements, including extended service coverage. Second, the reform aimed to institutionalize interprofessional, team-based care by formally defining GMFs as collaborative entities composed of physicians and other health and social service professionals, and by allocating structured full-time and part-time equivalent positions for nurses, social workers, and other AHPs. Finally, it endeavoured to strengthen the continuity and comprehensiveness of care by ensuring that GMFs provide both medical and professional services to a defined registered population, thereby addressing a wider spectrum of patient needs across clinical and psychosocial dimensions. Taken together, these goals established AHP integration as a central policy lever for advancing more accessible, comprehensive, coordinated, and person-centred primary health care in Québec.

Implicit goals

Beyond its explicit objectives, the design of the reform suggests two main implicit goals. First, it sought to strengthen the accountability of GMFs for the public resources allocated to them. Funding and professional resources were linked to factors such as the number and characteristics of registered patients, expected service availability, and compliance with program requirements (Gouvernement du Québec 2016). GMFs were consequently required to provide information supporting their level of funding and continued eligibility. These arrangements reflected an implicit effort to connect public investment more closely to measurable organizational obligations, including patient registration, accessibility, service hours, and continuity of care. Second, the reform appears to have sought to increase the effective capacity of GMFs by redistributing appropriate clinical and psychosocial activities across a broader team. Embedding AHPs within GMFs enabled physicians to refer patients internally for needs that did not require physician-specific expertise.

Multiple Streams Framework

The reform was shaped by several interrelated factors. Analyzed through the lens of Kingdon’s Multiple Streams Framework (Kingdon and Thurber 2011), it can be understood as the product of a strategic convergence between the problem, policy, and politics streams, which collectively created a policy window enabling the allocation of AHPs, most notably social workers, into GMFs in Québec.

Problem stream

The problem stream was characterized by persistent challenges in primary health care that existing physician-nurse teams of GMFs were inadequately equipped to address and growing recognition by the Québec government as conditions warranting policy action. A fundamental driver of problem recognition was accumulating evidence that primary care patients presented with substantial complexity and psychosocial needs that extend beyond traditional biomedical concerns (Roberge et al. 2016). Research documented a high prevalence of mental health issues, social isolation, financial hardship, housing instability, and other psychosocial challenges, particularly among patients with chronic diseases, where these factors shape disease management, treatment adherence, and outcomes, highlighting that physicians and nurses alone cannot adequately address these complex needs (Roberge et al. 2016). Primary care clinicians reported feeling ill-equipped to manage psychosocial dimensions of patient care, lacking both time and specialized training to provide comprehensive psychosocial support (Roberge et al. 2016). This gap between patient needs and provider capacity constituted a clear problem requiring policy attention.

Further, despite the introduction of GMFs in 2002 with the explicit goal of improving accessibility and continuity of care, evidence accumulated that these objectives were not being fully achieved. Studies found that GMFs did not consistently improve patient access to care or reduce emergency department utilization, while patient perceptions of care quality yielded mixed results — with some gains in continuity but persistent accessibility challenges (Carter et al. 2016; Tourigny et al. 2010). Of particular concern, existing primary care teams failed to improve equity in access; socioeconomic disparities in family physician affiliation and primary care utilization remained stable or worsened between 2005 and 2010 (Ouimet et al. 2015). Consistent with Kingdon’s framework, these conditions entered the problem stream only as government actors interpreted available indicators and feedback as evidence that the existing GMF model required further adjustments. By the mid-2010s, official policy documents and legislative initiatives had explicitly identified access to family medicine as a government priority. The Ministère de la Santé et des Services Sociaux (MSSS) Plan stratégique 2015-2020 established objectives related to attachment to a family physician and timely primary care (MSSS 2015), while Bill 20 framed inadequate access as a problem requiring stronger government action and more effective use of medical and financial resources (Gouvernement du Québec 2014). The subsequent GMF funding and professional-support program further acknowledged that service capacity and team composition needed to be adjusted according to population needs (Gouvernement du Québec 2016). This suggested that the GMF model, while an improvement over traditional solo practice, remained insufficient to meet the needs of vulnerable populations facing multiple barriers to care. The persistence of these challenges signalled that the model required further changes.

Policy stream

The policy stream developed through the gradual emergence of interprofessional team-based care as a technically feasible and increasingly accepted response to limitations in primary health care delivery. Research from Québec suggested that interprofessional collaboration could improve coordination, responsiveness, and the management of patients with multi-dimensional needs (Bareil et al. 2015; Sicotte, D’Amour, and Moreault 2002). This evidence contributed to a broader policy environment in which expanding the composition of GMF teams could be regarded as a plausible extension of the existing model. Interprofessional primary care models implemented elsewhere in Canada also formed part of the broader repertoire of available policy alternatives. Ontario’s family health teams, for example, demonstrated that publicly supported primary care organizations could incorporate professionals such as social workers, pharmacists, dietitians, and other allied providers. For instance, Breton et al. (2011) explicitly examined whether Québec’s GMF model could benefit from Ontario’s family health team experience. They concluded that expanding GMF team composition to include AHPs, along with enhanced funding and governance structures, could improve system performance. The proposed expansion was also compatible with Québec’s existing institutional arrangements. GMFs already provided an organizational platform for collaboration between physicians and nurses, allowing additional professional roles to be incorporated without replacing the established model. By the mid-2010s, the integration of additional health and social service professionals had therefore emerged as an available and implementable policy option when the political environment became receptive to further GMF reform.

Politics stream

The politics stream was shaped by sustained governmental concern about primary care access and successive commitments to strengthening the GMF model. Following the Clair Commission’s 2000 report, consecutive Québec governments invested in the establishment and expansion of GMFs through financial incentives, publicly funded nursing positions, administrative support, and targets for patient registration and service availability (Pomey, Martin, and Forest 2009; Rodríguez and Pozzebon 2010). By the mid-2010s, GMFs had become a central component of Québec’s primary care strategy. Persistent political pressure to improve access, attach more patients to family physicians, and reduce reliance on emergency departments increased the government’s receptiveness to further expansion of GMF teams (Laberge and Gaudreault 2019). The election of the Québec Liberal Party in 2014 and the government’s emphasis on access, efficiency, and system reorganization created a favourable political context for modifying the GMF model.

Bill 20, introduced in 2014, illustrates the political salience of access to family medicine and the government’s willingness to use regulatory and organizational instruments to improve primary care performance (Gouvernement du Québec 2014). The 2015 health-system restructuring occurred within this broader reform agenda and created an institutional context in which the allocation of additional professionals to GMFs became administratively feasible. Specifically, the 2004 creation of health and social service centres and their subsequent consolidation into integrated (university) health and social service centres (I(U)HSSC) in 2015 brought a broad range of health and social service professionals under the administrative authority of territorially organized public institutions (Wankah et al. 2022; Wankah et al. 2018). These I(U)HSSCs could employ and remunerate social workers and other AHPs while deploying them to GMFs located within their territories. This arrangement enabled the government to expand the interprofessional capacity of predominantly privately operated, physician-led GMFs without requiring the GMFs themselves to become public-sector employers. The structural reforms therefore provided an administrative bridge between public health and social service organizations and community-based medical practices.

How the reform was implemented

The reform was achieved through a multi-faceted implementation strategy that combined policy design, phased deployment and implementation supports. In terms of public policy instruments, the reform was operationalized through the introduction of the Program for Funding and Professional Support of Family Medicine Groups, which bundled the allocation of AHPs with financial support for GMFs. The program explicitly required collaboration with a range of professionals, including nurse practitioners, social workers, pharmacists, kinesiotherapists, physiotherapists, occupational therapists, and inhalotherapists (Gouvernement du Québec 2016, 12), and established a dual-governance structure whereby AHPs operate under the clinical authority of GMF physicians while being administratively managed and remunerated by their I(U)HSSC. By framing AHP integration as one component of a broader system of organizational and professional development supports, policymakers reduced the perception of disruption and positioned the reform as an enhancement to existing structures rather than a radical departure from traditional practice models.

Implementation translated into concrete action, beginning with the introduction of approximately 400 social workers into GMFs in 2016 as an initial large-scale investment (Couturier, Pépin, and Martin 2025; Pépin et al. 2021). This first phase represented a deliberate choice to prioritize social workers, whose scope of practice complemented the psychosocial and chronic disease management needs increasingly recognized as central to primary care. The decision to deploy social workers first allowed the system to test and refine integration mechanisms before expanding to other AHPs. This first phase was followed by the development of implementation infrastructure, including practice guidelines, training programs, and evaluation frameworks (Pépin et al. 2021; Poitras et al. 2022). The creation of evidence-based practice guides for both registered nurses and social workers, coupled with train-the-trainer educational interventions, provided a structured foundation for role clarity and interprofessional collaboration (Poitras et al. 2022).

Importantly, the reform did not fundamentally change the physician-payment model. Family physicians practicing in GMFs continued to bill the Régie de l’assurance maladie du Québec predominantly on a fee-for-service basis. The new program primarily financed organizational infrastructure and non-physician personnel rather than creating a common team budget or introducing salaried or capitated remuneration for physicians.

Despite the ambitions of the reform, no formal government-led evaluation has been conducted to assess its implementation and outcomes. Nevertheless, emerging empirical studies on the allocation of social workers to GMFs provide valuable insights into its early effects. A study indicated that patients felt the integration of social workers in GMFs helped care teams better understand their medical, social, and psychological needs, leading to more complete and responsive care (Pépin et al. 2021). The same study found that patients were surprised by how quickly they could see a social worker, often within 24 to 48 hours. GMF family physicians also appreciated being able to refer patients so quickly to social workers, without having to go through the I(U)HSSC system, which they viewed as slow, bureaucratic, and inefficient (Pépin et al. 2021). For social workers, working in GMFs gave them more autonomy and some distance from large institutional structures (Couturier, Pépin, and Martin 2025; Pépin et al. 2021). This allowed them to work more freely with patients and use approaches that build on patients’ strengths.

These positive changes came with important implementation challenges. One major issue is that the role of social workers in GMFs is not always clear, and some team members continue to misunderstand what social workers can contribute to primary health care settings (Pépin et al. 2021). The transition from I(U)HSSC to GMF was also difficult for many social workers. Some had to leave their previous workplace involuntarily, and many arrived in GMFs with limited orientation, weak onboarding, and little organizational support (Pépin et al. 2021). These challenges were compounded by practical constraints, such as insufficient workspace, professional isolation due to fragmented integration, and gaps in early practice guidelines (Pépin et al. 2021; Poitras et al. 2022). Moreover, social workers were required to adapt to a primary care model oriented toward routine and rapid service delivery, which may not always align with the depth and continuity required for psychosocial interventions (Couturier, Pépin, and Martin 2025; Pépin et al. 2021).

Importantly, some key implementation supports were put in place long after the reform had already started. For example, the formal practice guide for social workers in GMFs was only published in 2019, after the initial rollout (MSSS 2019). This suggests that social workers began working in GMFs while their roles and practices were still being clarified. Finally, the way social workers are governed creates ongoing tensions. Social workers worked day-to-day inside GMFs, but they are still formally managed by the I(U)HSSC. In practice, family physicians often have a strong influence on how GMFs function, including how teams work together and how care is delivered, even when official rules or ministerial guidelines suggest shared management (Couturier, Pépin, and Martin 2025; Pépin et al. 2021). Together, these findings point to a reform that has the potential to improve access and responsiveness but continues to face structural, organizational, and governance-related challenges that may affect its long-term sustainability and impact.

The authors acknowledge that funding for this research was provided by the McGill University Internal Social Sciences and Humanities Development Grant.

Health Reform Observer – Observatoire des Réformes de Santé, Volume 13 | Issue 1 | Article 2. https://doi.org/10.13162/hro-ors.v13i1.7066.