Primary care physician engagement in health systems transformation

Abstract

Physician engagement is critical to the success of primary care transformation, yet strategies to support meaningful engagement remain understudied. Despite existing research, gaps persist in understanding how physician engagement unfolds within system-level initiatives in primary care. This paper examines physician engagement through the development of the London Middlesex Primary Care Alliance (LMPCA), a regional initiative uniting primary care providers in Southwestern Ontario to advocate for system improvements and support health system transformation, including the Middlesex-London Ontario Health Team (ML-OHT). Rather than centering solely on physician perspectives, our study explores physician engagement as part of a broader collaborative effort involving healthcare administrators and support personnel. Data were collected through interviews (n = 13; including primary care physicians, healthcare administrators, and administrative support personnel), document analysis, and an environmental scan. Findings highlight the importance of grassroots leadership, governance structures, and system-level supports in driving physician engagement. The role of a primary care transformation lead emerged as a key facilitator, while lack of compensation for system-level work remained a barrier. This study provides insights into the formation of a sustainable, self-governing primary care organization and offers considerations for scaling engagement strategies while mitigating burnout and ensuring long-term participation.

Introduction

Physician engagement is a broad term that encompasses a physician’s active and positive contribution in a clinical setting and the health care organization they work for, including their commitment and involvement with the organization [1, 2]. The term can refer to psychological presence, performance disposition, or a combination of these constructs [2]. There is growing evidence that greater levels of physician engagement can lead to better performance in hospitals, improved patient outcomes, and enhanced quality and delivery of care [2]. Health care systems where physicians are more engaged can achieve better patient outcomes and facilitate a more effective work environment [3]. Physician engagement has been linked to numerous positive organizational outcomes, including increased commitment, improved job performance, and reduced staff turnover [4, 5]. Spurgeon and colleagues (2008) state that engagement should be a two-directional process where the organization must reciprocate physician engagement by establishing conditions that motivate and enable physicians to participate [6]. This can involve establishing an organizational culture that supports physicians taking on leadership and management roles, as well as fostering activities to increase confidence and empowerment, and improve efficacy when faced with health care challenges [7, 8].

Within the primary care setting, the use of physician engagement ensures the best patient outcomes, quality and safety but also prevents physician burnout [9]. Primary care is seen as the foundation of all health systems and is a focus of Canada’s health care system [10]. Primary care is often the first point of contact for individuals seeking medical attention. In Canada, primary care is usually provided through publicly funded healthcare systems that offer universal access to medical services. This type of health care is administered by nurse practitioners, family physicians, pharmacists, and allied health care providers in a variety of clinical settings [11, 12].

Physician engagement is often framed around participation in clinical practice improvement; however, their involvement in system reform is equally critical. Health system transformation requires active participation from frontline providers, as their insights into patient care, resource allocation, and system inefficiencies are essential for meaningful and sustainable change [5]. Engaging physicians in system reform facilitates more effective policy implementation, governance decisions, and the alignment of reforms with real-world clinical challenges [13].

Ontario, Canada’s most populous province, is currently undergoing one of the largest health care system transformations in decades. Bills 41 (Patient’s First Act) and 74 (People’s Health Care Act) introduced in 2016 and 2019 respectively aimed to move towards a primary care-focused, and sustainable integrated care approach, designed around the needs of local populations [14, 15]. These bills collectively set the road for integrated care in Ontario, with Ontario Health Teams (OHTs) introduced as a model of integrated care delivery systems [16]. OHTs aim to streamline patient connectivity through the health care system and improve outcomes aligned with the Quadruple Aim. The Quadruple Aim is a framework to improve the delivery of care in a health care setting [17]. The framework consists of creating better health outcomes for people in communities, better patient and healthcare provider experience, and better value per capita [15, 18]. OHTs will include providers of diverse areas such as primary care, acute care, long-term care, mental health, and home care [19]. OHTs are based on the premise that healthcare is best delivered when health care providers in these settings work collaboratively and share information within a region [20]. In 2019, there was a push by the Government of Ontario to ‘end hallway health care’, the problem of patients waiting too long to receive care in overcrowded emergency rooms and ensuring they are provided with care in the appropriate setting [21]. Thus, OHTs will serve a critical role in connecting and delivering care that is more connected in their local communities and improve overall health system coordination, leadership and development [22].

The involvement of primary care is crucial for the effective implementation of OHTs, and primary care physicians serve an important role as stakeholders in this process [11, 23]. In response to this, primary care physicians in Southwestern Ontario worked to formalize their sector engagement through the development of the London Middlesex Primary Care Alliance (LMPCA). The LMPCA became a key partner in the development and implementation of the Middlesex-London Ontario Health Team (ML-OHT). The LMPCA is a grassroots network of primary care physicians, nurse practitioners, health care administrators and support personnel (i.e., communication specialist, transformation lead) which aims to represent the voice of primary care physicians across the region and engage physicians in leadership roles [18].

Describing the context, foundation and early beginnings of the LMPCA was important. While there was some effort to galvanize primary care prior to 2019, the introduction of the OHTs required organization and coordination within the primary care sector in London-Middlesex, and arguably across the province. The OHTs were designed to replace the existing Local Health Integration Networks (LHINs), which had been in place since 2006 [20]. LHINs were described as “a critical part of the evolution of health care in Ontario from a collection of services to a true system that is patient-focused, results-driven, integrated, and sustainable” [24]. The LHINs aimed to move away from a fragmented and poorly coordinated “non-system” to an integrated and efficient system that offered continuous, cost-effective care across the care continuum as cited by Bhasin & Williams (2007) [24]. Part of the reason why the LHINs had not succeeded was due to the lack of collaboration, a united approach, and the top-down approaches that were associated with them. Additionally, the LHINs were an extension of the government, whereas the LMPCA operates as a grassroots organization, entirely independent from any ministry mandates or policies.

While there is research supporting the benefits of physician engagement, literature on physician engagement has focused on hospital administrators, boards of directors, executives or leaders rather than the voices of physicians particularly in primary care [19, 20]. There is limited empirical research on bottom-up or grassroots physician engagement and its impact on overall system integration. Current literature lacks context on physician engagement within health systems work in Canadian settings and has focused on quality improvement and safety initiatives in hospital settings [21, 22]. Our research set out to fill this gap. Ontario’s health system transformation has created a unique opportunity for health care professionals, physicians, and researchers in the province to enhance care delivery while directly involving physicians in health systems work. The purpose of this research is to describe the development of a primary care alliance and understand how physicians are engaged within the regional health system. Three objectives guided the study. (i) Describe context and foundation for LMPCA development; (ii) Explore strategies for engagement at local and regional levels; and (iii) Discuss the barriers and facilitators to primary care physician engagement in health system transformation.

Methods

Setting and participants

The LMPCA aims to present a united voice around primary care initiatives and activities in the region. Middlesex County is in Southwestern Ontario and is home to over 500,000 residents [13]. The major city in Middlesex County, London, has several health service organizations, such as London Health Sciences Center (LHSC), and St. Joseph’s Health Care London, which have made it an important hub for health care innovation and education partnerships with the region’s local university and college (Western University and Fanshawe College) [23].

The Middlesex-London Ontario Health Team (ML-OHT); previously known as the Western Ontario Health Team (W-OHT), is a collaborative group of healthcare providers and community members dedicated to improving health outcomes and enhancing the patient experience for the residents of Middlesex County [13]. The ML-OHT has over 30 partner organizations, including hospitals, community health centers, mental health and addiction services, primary care providers, and social service agencies which focus on improving health outcomes through coordinated care and information sharing across the healthcare system [13]. We utilized the Consolidated Criteria for Reporting Qualitative Research (COREQ) framework to ensure the quality and rigor of our reporting [25]. The framework guided the structuring of our methods to ensure a systematic approach to data collection, and data analysis, improving the credibility of our findings.

Participants were recruited through convenience sampling. Convenience sampling is a non-probability sampling method where researchers select participants based on ease of access rather than through random selection [26]. The researchers who conducted the interview had no prior relationship established with participants. In this study, the research team contacted the leads of the LMPCA and ML-OHT to distribute recruitment materials. Interviews were conducted with participants from both organizations.

Thirteen participants consented to the study. The participants included four primary care physicians specializing in family medicine, three health care administrators serving as executive directors of London-Middlesex’s primary care organizations. Additionally, six administrative support personnel, including a transformation lead, communication lead, and practice and facilitation lead, were part of the London Middlesex Primary Care Alliance (LMPCA) or the Middlesex-London OHT (ML-OHT). The breakdown of the participant demographics can be found in Table 1.

Table 1 Demographics and characteristics of the study participants (n = 13)

Data collection

Data were collected from a variety of sources to explore physician engagement including: interviews, document analysis, and an environmental scan. Interviews were used as the primary data collection method to gather the experience of the participants from the LMPCA and ML-OHT. Interviews were conducted by AJ (first author) using digital platforms (Microsoft Teams and/or Zoom), lasted between 30 and 60 min (see supplemental files for interview guide). The interviews were audio recorded and transcribed verbatim to help in the development of our themes. Document analysis was used to understand the major events of the LMPCA. This helped to outline the development of the LMPCA including key milestones and ML-OHT physician engagement activities. Our environmental scan involved a comprehensive internet search to identify similar grassroots primary care alliances in Ontario. An environmental scan is a method used to gather information about factors that impact an organization, project, or initiative. In our study, we intentionally searched for similar alliances within the province to identify trends, opportunities, and commonalities [27]. Our environmental scan involved reviewing reports, newsletters, and summaries from organizations across the province. Throughout the research process, written reflexive notes were created by the researchers to help surface our positionality and beliefs to inform our interpretations. Reflexivity was iterative throughout the research which helped the researchers maintain their decisions, assumptions and potential influences [28]. This study received ethical approval from Western University’s Health Sciences Research Ethics Board (Study ID 121041).

Data analysis

The analysis followed an iterative and inductive approach supported by NVivo 13 [29]. The findings and reported themes identified from the collected data were developed using an inductive approach to data analysis. This method involved examining data without reliance on preconceived theories or frameworks, allowing patterns and themes to be derived from the data itself [2, 24, 26]. This approach is particularly useful in this type of exploratory research, where the goal is to explore unique features and share learnings based on observed trends and insights. Data sources were first analyzed by the research team independently to identify concepts and ideas. In this first stage, the analysis process was open and inclusive to create a comprehensive coding list. The data were coded and organized multiple times by the four researchers through meetings and discussions. Next, data sources were analyzed in aggregate to explore ideas and concepts developing into overarching themes. These themes were grouped into broad categories. Member checking was conducted with participants from the LMPCA and ML-OHT: a summary of the overall study and themes were emailed to all 13 participants to review. After reviewing the summary, the participants provided feedback to clarify or confirm the study’s results which was integrated into our results.

Results

The results are presented according to our three research objectives: (i) context for LMPCA development; (ii) strategies for engagement at local and regional levels; and (iii) the barriers and facilitators to primary care physician engagement in health system transformation. Six themes were developed from the data: (1) context for change; (2) branding; (3) response to COVID-19; (4) leadership development in the LMPCA; (5) drivers for engagement; and (6) barriers to engagement and sustainability (Table 2).

Table 2 Table of themes and subthemes

Objective 1: context for LMPCA development

Context for change

A dedicated group of physicians, health care administrators, and support personnel from primary care organizations collaborated to galvanize the LMPCA from its historical origins to provide an organized and united voice for primary care throughout the region.

The LMPCA formed in response to the changing landscape of the health system and the need to adapt in the primary care sector. This change was driven by the introduction of OHTs. The goal was to engage physicians and bring more organization to the sector. The formation of an OHT in the London-Middlesex region was a driving factor behind the solidification of the LMPCA.

There was some value in terms of trying to get our sector organized… that was where things were when the OHTs started up and realizing we needed to coordinate our sector in order to participate successfully with the Ontario Health Team. (Physician, PCP_003, Interview).

Participants viewed the development of the ML-OHT as a catalyst for formalizing the organization of Middlesex-London’s primary care sector and encouraging primary care physicians to engage in health systems work, including the drafting of the OHT application.

Participants described how physicians often operated in silos, with little affiliation to any primary care entity other than hospitals or governing medical associations like the Ontario Medical Association or the College of Family Physicians of Canada.

I think just the traditional way of being in primary care, where you’re all in silos and you’re doing your own thing, and your affiliation is to a hospital, and to your regulatory body, you know the Ontario Medical Association (Support Personnel, SP_005, Interview).

The desire to establish primary care specific groups for physicians played a vital role in the formation of the LMPCA. Participants highlighted the importance of formalizing primary care groups within the region to involve physicians, establish better connections, and provide them with a network for engagement.

The LMPCA served as a forum for primary care providers to coordinate, collaborate, and implement activities in the London-Middlesex region, while establishing a collective voice for primary care (January 2020, Document; Terms of Reference, Document). Participants felt other organizations, such as hospitals, were speaking about primary care without consulting appropriate members, namely physicians themselves. This lack of consultation was perceived as diluting the representation of physicians across the sector. The need to address the missing voice of primary care was a concern shared by many participants.

LMPCA started because people were tired of other people, in other organizations speaking for primary care. There were a few meetings where people have shared with me that how does someone in the hospital know what’s going on in primary care when they’re not in primary care? (Support Personnel, SP_001, Interview).

Prior to the formation of LMPCA, previous groups in Middlesex-London struggled to represent a unified voice for primary care as effectively as the LMPCA. Participants acknowledged that when the LMPCA was engaging with physicians and partners, it was ensuring its decisions were authentic and receiving feedback from physicians.

Branding

The theme of branding was described in the context of portraying the LMPCA as different from other alliances in the London-Middlesex region. Participants recognized the importance of acknowledging the history of previous attempts to galvanize primary care in the region, but also emphasized the need to learn from the past to facilitate the growth and development of the LMPCA. This involved recognizing the challenges encountered by the previous health system structure (a regional model), particularly in terms of ineffective attempts to engage primary care in the region. The LMPCA choose to move past this history and continue their goal of embedding primary care in health systems work in the region.

I think it was also building the brand of the LMPCA, because it was being done away from the [previous regional health authority] umbrella. The LMPCA was gaining its own identity outside of what the [previous regional health authority] was supporting (Physician, PCP_001, Interview).

Response to COVID-19

Participants perceived COVID-19 pandemic as a critical point in accelerating the solidification of the LMPCA. The LMPCA responded with two key initiatives during the pandemic: a personal protective equipment (PPE) hub and vaccination clinics.

The COVID-19 pandemic brought the LMPCA members closer, promoting cohesiveness and collaboration with community organizations. As described by participants, cohesiveness was facilitated during the PPE hub and vaccination clinics.

In the pandemic, there were multiple times where we worked together. We came together over PPE, we came together over vaccines at the Assessment Centre, the urgent COVID assessments, and at the clinical assessment centre’s (Physician, PCP_004, Interview).

The LMPCA was instrumental in the establishment of a PPE hub, providing a vital response to the substantial shortage of PPE in the primary care sector during the pandemic. This initiative was acknowledged widely as a success, it was appreciated by participants from both the LMPCA and the ML-OHT. Participants believed the PPE hub showcased the importance of having a primary care alliance in the community, as physicians and other primary care providers were able to turn to LMPCA for assistance and support during a critical time.

It really did highlight that the need for like a group like the LMPCA. The LMPCA said they were able to provide to all these physicians who were looking for that information or looking for PPE. They were able to create a name for themselves through that work too (Support Personnel, SP_002, Interview).

Participants also viewed the LMPCA’s role in the COVID-19 vaccination clinics as an important initiative that brought primary care physicians together to work towards a common goal. The vaccination clinics not only facilitated physician engagement, but also saw many local physicians volunteering their time to assist with the vaccination rollout. The vaccine clinic supported partnerships between the LMPCA and community organizations, which aided in their growth and contributed to a more cohesive primary care sector.

We were able to connect with Middlesex London community partners and help work with them for the vaccination rollouts. That would obviously be of a high interest to our colleagues, so that all kind of helped us to get [the LMPCA] out there a bit more. I think that helped to make us feel like we were truly an entity that was able to be interactive with our medical community at large (Physician, PCP_003, Interview).

Objective 2: strategies for engagement

Leadership development in the LMPCA

Cohesiveness and leadership were described by participants as how physicians can achieve better outcomes by working together. Participants believed LMPCA demonstrated collective benefits despite the common perception that they prefer to work independently. This promoted growth and development among physician leaders of the LMPCA.

As physicians, we do better in our collectives…[Physicians] want to provide leadership; they’re trained to provide leadership in teams. I think the Primary Care Alliance, if we’re looking at engagement, we need to have things that are clinically relevant that are going to affect practice and that are going to improve outcomes that are going to provide a collaborative community (Physician, PCP_002, Interview).

The LMPCA also helped build trust and foster new ways of collaboration. In turn, trust facilitated greater collaboration amongst physicians and further improved leadership within the alliance and across the region.

LMPCA created a container to engage other places such as the public health unit and providers where there had been misconceptions in the past. It created this ability to build trust and new ways of working together (Health Care Administrator, HCA_002, Interview).

Participants noted that relationships, particularly their access and connection with other healthcare providers, traditionally depended on individual connections. However, participants believed that relationships facilitated through LMPCA facilitated the growth and maturity of the primary care sector. Ultimately this led to increased engagement and more effective collaboration.

In terms of what you got access to, and what you had the ability to connect with, it was all organic, and based on just our individual relationships, more than any sort of structured approach to understanding how to engage (Physician, PCP_004, Interview).

Drivers for engagement

When asked about the best ways to engage physicians in leadership roles, organizational or systems work or primary care alliance initiatives, participants identified six drivers: recognizing value, intrinsic motivation, organized procedures, strong communication, grassroots approach, and the primary care transformation lead.

Recognizing value meant acknowledging the potential benefits that physicians would gain when engaging in primary care alliance activities and systems work.

This required being clear about what was ‘in it for them’ if they engaged and what value they would gain because of their engagement.

[Physicians] really need to prioritize their time and attention so being clear at why this initiative is going to be a good use of their time. Even if it doesn’t get immediate payoff, making it clear what’s in it for them is important (Health Care Administrator, HCA_002, Interview).

One key example discussed by participants was the value-add of engaging with LMPCA during the pandemic. A physician participant shared their experience describing how engaging with the alliance during COVID-19 provided increased support for physicians and an opportunity to help treat their patients better.

Participants noted that there was a personal investment, or intrinsic motivation, that drove many physicians to engage with the alliance. Physicians who were engaged within the LMPCA saw LMPCA as more than just an organization, they understood the greater need and appreciated the positive potential of the alliance. The hard work and dedication of all individuals engaged in the LMPCA’s endeavors was quite clear to participants.

All of those people really put in a lot of blood, sweat, and tears. I think because there was a degree of personal investment, there was a value created because of that personal investment. Because people saw themselves in the organization. And it wasn’t just an organization, it reflected all of our individual character and effort that really started to create the LMPCA (Physician, PCP_004, Interview).

Participants explained that physicians who are passionate about the primary care activities across the region were more likely to commit to “engage within health systems work and involved with volunteer activities (Support Personnel, SP_005, Interview).”

Participants discussed the importance of having structured meetings and agendas that addressed their concerns and issues. These organized procedures ensured that the meetings were productive and respected everyone’s time. Many participants, particularly physicians, acknowledged that regular, well-organized meetings were essential for continued and sustained engagement.

Participants also acknowledged the importance of structuring engagement activities around physicians’ schedules and accommodating clinical hours and preferences. This included clearly communicating the expectations of meetings and organizing how physicians’ involvement would be structured. The organized procedures helped drive engagement.

Frequent and tailored communication ensured that the LMPCA’s initiatives were effectively reaching the primary care sector and promoting physician engagement. This involved using multiple methods to connect and contact physicians through newsletters and e-Blasts (short monthly newsletters or organizational summary) that informed them of the LMPCA initiatives, events and offered information on how physicians could become involved. The LMPCA hosted town hall meetings approximately five times a year and to share the activities occurring within London-Middlesex’s primary care sector and promote physician engagement.

We often will have those town halls and the purpose of them is to provide information but also to get more engagement. Each town hall we talk about the LMPCA, who we are, what we are, what we’re trying to accomplish. We talk about our newsletters and trying to get people to sign up for the newsletters as well. I think all those things are all physician engagement activities and they’ve all been quite successful (Physician, PCP_003, Interview).

Participants felt the LMPCA’s grassroots approach was important in facilitating physicians’ participation in health system leadership work. The LMPCA’s initial success was achieved by the coming together of individuals who shared the same drive and interest to generate a meaningful impact at a system level.

[Our initiatives] worked because it was grassroots, because it was bottom-up. It’s like you had random doctors, and we would just do a callout to for example to say, “Who’s really good at vaccinating?“. Literally was what the LMPCA was about. And then we’ll pull the group together. It’s the approach I would say that worked. (Support Personnel, SP_001, Interview).

Further, participants believed that the LMPCA was a strong alliance because of this bottom-up approach. Instead of relying on top-down decision-making, LMPCA reached out to individual doctors with specific skills or interests to work together. The whole process of grassroots engagement was to achieve a common goal of improving the delivery and efficacy of primary care.

A primary care transformation lead was an independent and adaptable position that supported various health care providers (in particular, physicians) and aimed to improve the effectiveness and efficiency within the LMPCA. Participants emphasized the primary care transformation lead’s critical role in providing administrative support and organizing routine administrative tasks that would otherwise detract from physicians’ clinical work.

I’ll highlight that having a primary care transformation lead was a big jump for the organization, because we had someone who could be dedicated to the work of transforming primary care. Not just physicians trying to do that leadership work, especially off the side of their desks but there was a dedicated person hired for the LMPCA and that accountable to the LMPCA (Physician, PCP_001, Interview).

Objective 3: barriers and facilitators to primary care physician engagement

Barriers to engagement and sustainability

When asked about the challenges to physician engagement, participants identified lack of funding or remuneration to compensate physicians for involvement, inadequate administrative support, and insufficient representation and acknowledgement of physician voice. It was also emphasized that there is a need for succession planning to ensure the sustainability of the LMPCA.

Participants identified remuneration as a barrier to physician engagement, as physicians were compensated less, or sometimes not at all, for their engagement in leadership and systems work. The LMPCA’s physicians on Executive Council were from different payment models across the London-Middlesex region. This presented a challenge, as physicians’ primary responsibility (and method of compensation) was to their patients, and any time spent on systems work resulted in reduced compensation and possible negative impact on patient care.

If you are going to ask physicians to participate during times where they’d be seeing patients, they have to be compensated for that time. Right now, I’m paid to do leadership, it’s part of my responsibility but a lot of physicians if they’re at a meeting or doing system work, they’re not in front of their patients so they’re not billing and it’s an economic impact to them (Health Care Administrator, HCA_002, Interview).

Participants emphasized remuneration for physicians as a need to encourage and sustain engagement in systems work. Appropriate remuneration was also noted to increase equity and accessibility for physician engagement across various renumeration models across Ontario’s health care system.

Lack of administrative support

Participants described the added stress of having to handle administrative tasks in addition to their clinical responsibilities. Physicians noted that having administrative support to handle these tasks can facilitate engagement in systems and leadership and avoid burnout.

Participants noted that organizations (i.e., hospital, teaching or government institutions) often dictate what physicians should do, and that physicians’ clinical expertise does not seem to be valued. Participants felt this was a persistent issue across the London-Middlesex region, both in the present and the past.

Physicians are finding in particular that their clinical voice is not as valued. And so, the government has done a good job with that one and I think it’s a culture that’s permeated down (Physician, PCP_002, Interview).

To engage physicians in health system transformation, participants emphasized coordinated efforts to recognize their voice as essential to effective primary care and overall system improvement. During the discussions, the importance of adequate representation of physician voice in sustaining the role of primary care in system work was emphasized. Participants acknowledged the challenge of effectively including all types of physicians and their perspectives but believed it to be essential to ensuring proper representation of physician voices.

Participants highlighted the importance of succession planning and the involvement of new leaders, to ensure the sustainability of the LMPCA and engagement in systems work. Participants described how the same group of highly engaged physicians had been leading and engaging in leadership activities in the primary care sector for a long time. The leadership was crucial in the establishment of the LMPCA, but the participants recognized that it was not sustainable.

I am worried that 20% of core physicians that we started with are still the same people that are involved today, and I notice that they’re burning out. We need to get more leadership engaged; we can’t have the 20% doing 80% of the work (Health Care Administrator, HCA_002, Interview).

Consequently, there was a need to address succession planning to ensure LMPCA sustainability by identifying and developing new leaders to assume leadership roles. It was noted by participants that over time several physician leaders were now reducing their involvement with the systems work and the LMPCA.

Discussion

Development of the LMPCA

The exploration of physician engagement has primarily been seen in quality improvement work, safety, and hospital settings ​ [30]​. This study addressed this gap in the research by exploring physician engagement in systems work through a grassroots primary care alliance called the LMPCA. The organization comprises primary care physicians, nurse practitioners, healthcare administrators, and administrative support personnel from various primary care organizations in the region [18]. This network was chosen for our study due to its development and the highly engaged participants who recognized and pushed for a coordinated approach within the sector. By exploring the development of the LMPCA, we were able to share the success story of the LMPCA and identify effective approaches to physician engagement in practice across the London-Middlesex region. Beyond improving clinical practice, the LMPCA was a mechanism for system reform, creating opportunities for physicians to shape governance structures, contribute to regional decision-making, and advocate for policies that align with frontline realities.

Collaboration and engagement

A critical factor in the solidification of the LMPCA was the recognition among primary care physicians and healthcare administrators of the need for collaboration and engagement within the sector to contribute to the work of the OHT. This aligns with international trends in primary care reform, such as those in Australia, where efforts to enhance general practitioner (GP) engagement and care coordination have shown positive impacts on healthcare quality and sustainability [5]. A study by Everall et al. (2022) found that many physicians and administrators involved in OHTs experienced uncertainty regarding the process of establishing an OHT [17]. While some participants in our study expressed uncertainty, the support from engaged LMPCA members helped drive OHT development in London-Middlesex, fostering greater engagement and confidence among participants. Key members from the LMPCA, including physicians and healthcare administrators, were engaged from the inception of OHTs and helped draft the initial OHT application [31] This facilitated the growth of the LMPCA and created a platform for physicians to participate in system-level work [24, 32]. Our findings suggest that grassroots physician-led models, such as the LMPCA, may serve as a scalable approach to embedding physician leadership in system reform, ensuring that changes are both effective and enduring.

Engagement strategies and key drivers

As in many areas of research, context is important in physician engagement. It is important to explore strategies for engagement at local and regional levels. The literature on physician engagement underscores the importance of structured approaches, including organized meetings and effective communication strategies, to foster engagement [30, 33]. Our findings echo these themes while highlighting two unique drivers of physician engagement within the LMPCA: the role of the primary care transformation lead and the grassroots approach to engagement.

The primary care transformation lead played a unique role in supporting physicians, nurse practitioners, and healthcare administrators. While administrative support has been widely recognized as critical for allowing physicians to focus on clinical activities [34,35,36], the transformation lead extended beyond traditional administrative support by facilitating physician engagement in system-level work. Additionally, this dedicated role ensured continuous progress and momentum within the LMPCA. Implementation science highlights the importance of engaging key stakeholders, including physicians, to drive system-level change, as their buy-in and leadership are crucial for the adoption and sustainability of reforms [35, 37, 38]. Without physician engagement at the system level, health reforms risk being misaligned with clinical realities, facing resistance from frontline providers, or failing to achieve intended outcomes [36]. The LMPCA model demonstrates that physicians are not passive actors in system reform but can be key drivers of policy development, resource allocation, and service integration.

The grassroots approach taken by the LMPCA was another key driver of engagement [35]. Grassroots models in healthcare have been applied in areas ranging from chronic disease management to health promotion frameworks [39,40,41]. These approaches involve assessing community needs, developing tailored strategies, and forming partnerships with local organizations, community members, and healthcare providers to create sustainable, high-impact initiatives [35, 42, 43]. By fostering community ownership and investment, grassroots models enhance engagement, trust, and provider decision-making [39, 42]. Despite their effectiveness, grassroots strategies remain underexplored in health systems literature. A study by Pariser et al. [41] identified grassroots approaches as an effective means of engaging physicians in quality improvement initiatives through repeated and targeted engagement strategies. This approach was one of the few studies that highlighted the benefits of a grassroots approach in physician engagement literature.

Another central factor in the LMPCA’s success was its self-governance structure. Physicians hold significant influence in health systems due to their professional authority, control over medical knowledge, and decision-making power. Historically, medical dominance has shaped healthcare governance, allowing physicians to drive health policy and institutional reforms [44,45,46]. However, previous regional health authorities in Ontario struggled to engage the primary care sector effectively, particularly in the Middlesex-London region. Participants indicated that this failure stemmed from rigid, top-down administrative structures that limited physician agency. This aligns with literature on health systems governance, which highlights how centralized models can create administrative barriers that hinder collaboration [26, 27, 45]. The LMPCA’s self-governing structure provided an alternative model, fostering physician-led decision-making and facilitating authentic partnerships across the region.

Barriers to physician engagement

One of the most frequently cited barriers to physician engagement is lack of remuneration [19, 30, 47]. Participants in our study indicated that much of the LMPCA’s work was conducted on a voluntary basis, in addition to physicians’ clinical responsibilities. While some initiatives provided compensation for leadership roles, others required physicians to engage in systems-level work without financial reimbursement [47]. This challenge is particularly pronounced in fee-for-service models, where physicians are compensated per service provided and lack flexibility to engage in administrative activities [28]. In contrast, capitation and blended models, which provide physicians with a fixed salary, offer greater flexibility to allocate time to system-related work. Participants in our study highlighted these structural differences in physician compensation and their impact on engagement.

Even when financial barriers are addressed, avoiding burnout and ensuring leadership succession are critical for sustaining physician engagement. Succession planning involves a systematic, long-term process of identifying future leadership needs and developing strategies to ensure smooth transitions [48]. Participants expressed concerns about the longevity of current physician leaders, emphasizing the risks of leader fatigue and burnout. Physician burnout, characterized by emotional exhaustion and dissatisfaction, has been exacerbated by the COVID-19 pandemic [49]. While participants acknowledged these challenges, they did not provide specific strategies for mitigating burnout or facilitating leadership transitions. Future research should explore mechanisms to sustain physician engagement in system transformation, particularly in a post-pandemic healthcare landscape.

Engaging physicians in cost-management efforts aligns their clinical autonomy with system goals through collaborative decision-making and financial incentives [44, 47]. Supporting work-life balance fosters a positive practice environment, reducing burnout and enhancing job satisfaction [44]. Structured incentives such as financial rewards and career development opportunities will be essential for sustaining long-term physician engagement and positioning physicians as integral partners in healthcare system reform. Our findings suggest that grassroots physician-led models, such as the LMPCA, may serve as a scalable approach to embedding physician leadership in system reform, ensuring that changes are both effective and enduring.

Strengths, limitations

One of the study’s strengths lies in the inclusion of highly engaged participants who played a key role in the development of the LMPCA. The sample encompassed a diverse range of participants, including primary care physicians, healthcare administrators, and administrative support personnel. Together, these perspectives contributed to the rich description presented in this research. However, there are a few limitations worth noting. One possible limitation of this study was recruitment. Participant recruitment for the study commenced in late fall, coinciding with the aftermath of the waves of the pandemic which could have added to physician fatigue in participating in an interview. Additionally, when reaching out to schedule the interviews, the late fall period was characterized as the ‘flu season,’ which further added to the workload of physicians as they dealt with a higher number of patients seeking medical attention. Despite these challenges, we believe that the collected findings were appropriate as data saturation was reached and verified from our member checking [50]. Another limitation of this study is the lack of theoretical underpinning. While this limitation is acknowledged, we emphasize the study’s value in capturing real-world perspectives, providing insights into physician engagement and LMPCA development.

This study supports physician engagement in health systems within a Canadian context. While important, the lessons learned in our contexts may not be directly applicable to different primary care settings in another context [51]. This study focused on LMPCA and OHT development. Future research should explore perspectives and reasons for physicians who choose not to engage within health systems work.

Conclusion

The exploration of physician engagement has primarily been seen in quality improvement work, safety, and hospital settings [30]. This study addressed this gap in the research by exploring physician engagement in systems work through a grassroots primary care alliance called the LMPCA. We have provided a rich description of the formation of an organization that is continuing to shape and grow in membership and governance. The findings emphasized the benefits of a coordinated approach in the London-Middlesex region. The LMPCA provided a platform for physicians to participate in primary care and contribute to systems transformation. This study emphasized the unique drivers of utilizing a grassroots approach and the role of the primary care transformation lead when exploring engagement opportunities at the local and regional levels. Beyond description, our findings illustrate the structural and relational factors that facilitated physician engagement and sustained participation. The study highlights the idea that physician engagement must go beyond clinical practice improvements to include leadership in system design and governance. The LMPCA model illustrates that when physicians are embedded in system-level decision-making, they can play a transformative role in shaping primary care structures and service delivery models.

Our findings provide a rich description of how a new, loosely organized body worked to embed structure and function in its earliest years. These insights can inform the design of future physician-led initiatives, ensuring that engagement strategies align with system-level priorities while maintaining grassroots autonomy. Further research (namely, talking to more physicians) is needed to better understand physician engagement across the health system. Provider engagement encompasses physicians, nurse practitioners, and other health care providers who are involved in initiatives to improve the health care organization or system [51, 52]. Future research should explore how similar grassroots engagement models can be leveraged to drive policy changes, improve health system integration, and ensure that reforms align with the needs of frontline providers and the communities they serve.

Collectively, this research work along with additional, similar studies will be able to contribute to the development of a framework that improves physician engagement and enhances the primary care sector across diverse regions of Ontario. Future research should set out to create a robust framework to support physician engagement within systems-level reform.

This study contributes to existing literature by providing an empirical example of primary care physician engagement in health systems work in a Canadian context. The findings from our research offer valuable insights for regional health organizations to enhance physician engagement initiatives and successfully involve physicians in clinical leadership roles. By identifying key facilitators and challenges, this study provides actionable lessons for policymakers and health system leaders seeking to strengthen physician involvement in decision-making and governance. Focusing on these factors of physician engagement can ultimately improve our health system and the health of the patients we serve.