Health care is a bit like a house on fire. Where do we throw the water today?
For a quarter century, Canada has known it is losing ground in the quiet arithmetic of care — five million citizens without a family doctor, and no reliable map of where the need is deepest or the supply most thin. The country's federal-provincial architecture, in which Ottawa funds but provinces govern, has produced not a system but a series of competing local improvisations. What emerges from the data gaps and the stalled commissions is a familiar human predicament: a problem too large to ignore and too fragmented to solve.
- Five million Canadians have no primary-care provider, yet the country cannot say with precision which specialties are missing, in which regions, or in what numbers — the shortage is felt everywhere but measured nowhere.
- Newfoundland's medical association walked away from contract negotiations after years of underpayment and a provincial minister who suggested that hospitality, not investment, was the cure for a physician exodus.
- Nova Scotia's newly elected government moved fast — firing health authority leadership, opening a recruitment office, and retaining doctors within its first week — but every doctor it wins may be one another struggling province loses.
- Children and marginalized communities bear the sharpest edge of the crisis, arriving at hospitals late and sicker, carrying preventable behavioral and mental-health burdens that primary care might have caught.
- Decades of royal commissions, task forces, and federal promises have accumulated without producing a national health human-resource plan, leaving provinces to compete on an uneven field with no shared data and no shared strategy.
David Peachey gave up his rural Ontario family practice to spend twenty-five years building sophisticated models of physician supply and demand — mapping billing patterns, career intentions, population demographics, and disease burden across eight provinces and territories. And still, after all that work, the foundational question eludes him and everyone around him: What should Canada actually do?
The Canadian Medical Association puts five million Canadians without a primary-care provider. That number commands broad agreement. Almost nothing else does. CMA president Dr. Katharine Smart, a pediatrician in Whitehorse, describes the system as a house on fire, the only question being where to throw the water. Once doctors graduate, no one reliably tracks where they go. No one knows which specialties are most needed, or where.
Newfoundland offers a portrait of what happens without a national framework. Nearly one in five of its 520,000 residents lacks a regular health-care provider. When the province hired Peachey in 2019, he concluded it needed 60 family doctors immediately and 20 more each year for the following nine years. The provincial health minister responded by noting that doctor numbers were at historic highs and suggesting that a warm welcome to newcomers might close the gap. The province's medical community was furious. Gross payments to Newfoundland doctors ran 20 percent below the national average in 2019, and by October the provincial medical association had abandoned contract negotiations entirely, warning that the system was being driven into the ground.
Next door, Nova Scotia moved differently. A new Conservative government swept to power in August, immediately replaced health authority leadership, and opened an Office of Health Care Professionals Recruitment. Within its first week, the office had placed three specialists in Cape Breton and persuaded two departing family doctors to stay. Its CEO was empowered to cut licensing red tape, explore alternatives to fee-for-service models, and help build collaborative clinics. The contrast with Newfoundland was sharp — though the recruitment office's own leader acknowledged the zero-sum reality: every jurisdiction is competing for the same small pool of physicians.
The deeper failure is national. The Canada Health Act promises equal access for all Canadians, but the system has no mechanism to deliver on that promise across provincial lines. Health care straddles federal and provincial jurisdiction — Ottawa pays, provinces manage — and the coordination gap has never been closed. Decades of commissions and task forces have recommended a national physician credential repository and coherent workforce planning. None of it has taken root.
Smart sees the human cost in her own clinic. Children without primary care arrive at hospitals late, carrying preventable behavioral, learning, and mental-health burdens. The harm falls hardest on those already most vulnerable. A federal election promise of 7,500 new health workers over four years has been made, but without the data infrastructure to know where they are needed, the promise risks becoming another entry in a long ledger of good intentions. Until Canada can answer where the need is greatest and how many providers are required to meet it, provinces will keep competing, regions will keep suffering, and Peachey's question will keep going unanswered.
David Peachey spent a quarter-century chasing a question that ought to have a simple answer: How many doctors does Canada actually need? A former rural family doctor in Ontario, he abandoned his practice for economics and founded Health Intelligence Incorporated, a firm that now works with governments across eight provinces and territories to forecast health-care demand. His work goes beyond mere counting. He breaks down physician numbers by years in practice, billing patterns, scope of work, career intentions, and gender. He maps population demographics, disease burden, and the shifting landscape of primary care—including the rise of nurse practitioners working alongside family doctors. And yet, after all this sophisticated analysis, Peachey and the experts around him still cannot answer the foundational question: What should Canada do?
The Canadian Medical Association estimates that five million Canadians have no primary-care provider. That number sits like a fact everyone agrees on, even as disagreement blooms everywhere else. Dr. Katharine Smart, the CMA's president and a pediatrician in Whitehorse, describes the situation with a metaphor that cuts to the bone: "Health care is a bit like a house on fire. Where do we throw the water today?" Once doctors graduate from Canadian medical schools, no one reliably tracks where they choose to work. No one knows which specialties are most needed, or in which regions. The data simply does not exist.
Newfoundland and Labrador offers a case study in what happens when one province tries to act without a national framework. Nearly one in five of the province's 520,000 residents lacks a main health-care provider, according to polling by the Newfoundland and Labrador Medical Association. In 2019, the NLMA hired Peachey to quantify the gap. He concluded the province needed 60 family doctors immediately, plus another 20 for each of the following nine years. Provincial Health Minister Dr. John Haggie, himself a general surgeon, responded by insisting the province had more doctors than ever before in its history. In August, he suggested that physician recruitment was a matter of hospitality—that a welcoming gesture to newcomers would solve the problem. The comment provoked fury from the province's medical community. According to the Canadian Institute of Health Information, gross payments to Newfoundland doctors in 2019 ran 20 percent below the national average. On October 14, the NLMA abandoned contract negotiations, citing "zero new investment in physician services." Dr. Susan McDonald, the association's president, issued a stark warning: "We can get our act together if we truly want to. Or we can play the status quo and drive the system into the ground."
Meanwhile, in neighbouring Nova Scotia, a different story unfolded. Conservative leader Tim Houston swept to power with a majority government on August 17 and immediately fired the provincial health authority's CEO and board. He then opened a new Office of Health Care Professionals Recruitment. Within its first week, the office had hired three new specialists for Cape Breton and convinced two family doctors considering departure to stay. The office's CEO, orthopedic surgeon Dr. Kevin Orrell, was granted authority to cut through licensing red tape, offer alternatives to fee-for-service payment models, and help establish clinics where different types of providers could work together. "We're not just going out hiring people," Orrell said. "We're looking across the health-care system to make the province more acceptable to people who want to work here." Dr. Heather Johnson, president of Doctors Nova Scotia, expressed cautious optimism. "They seem to want to work with us. They're entertaining all kinds of ideas, which feels like a refreshing change."
But one province's gain is another's loss. Orrell acknowledged the zero-sum nature of the competition without apology: "The playing field is small and every jurisdiction needs to be competitive." McDonald worried aloud that Nova Scotia's aggressive recruitment would further drain Newfoundland's already depleted physician workforce. On October 18, however, Haggie announced that Newfoundland would undertake a full health human resource plan and establish its own recruitment and retention office, mirroring Nova Scotia's model. The East Coast drama exposes a deeper national failure. How did Canada reach a point where underserved regions compete with one another for doctors? The Canada Health Act promises equal access to health care for all Canadians, yet the system has no mechanism to ensure that promise.
Decades of reports have piled up without resolution. There was the 1975 Report of the Requirements Committee on Physician Manpower. The 1999 Task Force on Physician Supply in Canada. The 2002 Royal Commission on the Future of Health Care in Canada. The 2006 Task Force Two. Earlier in 2021, the C.D. Howe Institute released another report. Recommendations for a national repository of physician credentials have been made repeatedly. Yet nothing has taken root. The structural problem is clear: health care straddles federal and provincial jurisdiction. Ottawa pays; the provinces manage. Everyone acknowledges that solving a shortage requires first understanding its dimensions. But no one agrees on who should gather that data or how.
Smart sees the human cost firsthand in her Whitehorse practice. Children without primary care arrive at hospitals late in their illnesses, often carrying behavioral problems, learning difficulties, and mental-health concerns that might have been prevented or caught early. The burden falls heaviest on children already marginalized by poverty or other circumstances. During the fall federal election campaign, the governing Liberals promised to hire 7,500 family doctors, nurses, and nurse practitioners over four years. Yet Canada still lacks a coherent national human health-resource plan. "We know there's a shortage," Smart said. "But what we don't really know is: Where is the biggest need? How many doctors are needed in different locations? How might new ways of delivering team-based primary care impact those numbers? It makes it very challenging to do human health-resource planning when you don't have the data." Without that foundation, provinces will continue to compete, regions will continue to suffer, and the question Peachey has been asking for twenty-five years will remain unanswered.
Notable Quotes
We can get our act together if we truly want to. Or we can play the status quo and drive the system into the ground.— Dr. Susan McDonald, president of the Newfoundland and Labrador Medical Association
We know there's a shortage. But what we don't really know is: Where is the biggest need? How many doctors are needed in different locations? It makes it very challenging to do human health-resource planning when you don't have the data.— Dr. Katharine Smart, president of the Canadian Medical Association
The Hearth Conversation Another angle on the story
Why does it matter so much that we don't know where doctors go after they're trained?
Because you can't solve a problem you can't see. If you don't know whether a newly licensed doctor ends up in Toronto or Whitehorse, in family medicine or surgery, you can't plan. You're flying blind.
But surely the provinces know their own doctor numbers?
They know who's licensed to practice in their jurisdiction, yes. But they don't know the full picture—how many are actually working, how many are part-time, how many are about to retire. And they definitely don't know what the other provinces are doing, so they end up competing with each other instead of solving the problem together.
Is that what's happening between Newfoundland and Nova Scotia?
Exactly. Nova Scotia moved fast, opened a recruitment office, and started pulling doctors in. Newfoundland watched its doctors consider leaving and couldn't compete because it hadn't invested in the same way. Now Newfoundland is scrambling to catch up. Both provinces are trying to solve the same national problem in isolation.
Why hasn't the federal government just stepped in and created a national database?
Because health care is split between two levels of government. Ottawa funds it; the provinces run it. So when Ottawa says "we need a national plan," the provinces say "that's your job." And when the provinces say "we need funding," Ottawa says "that's your job." The data falls through the crack between them.
What happens to patients while this gets sorted out?
Children show up at emergency rooms with problems that could have been caught and treated in a family doctor's office—if they had one. Behavioral issues, learning problems, mental-health crises. The sickest and most vulnerable people end up in the most expensive part of the system because there's no one to see them earlier. That's the real cost.
So what would actually fix this?
Someone—probably the federal government—would need to create a national repository of physician data. Track where doctors work, what they do, how long they stay. Then you can actually plan. But that requires someone to take responsibility, and right now, everyone's pointing at someone else.