In this way time and space have been central to overcoming mistrust and beginning the transformation towards PHC

Where some health systems outside of Canada have what might be called command-and-control relationships with their family physicians, the MoH and AHS along with their counterparts in the other provinces work with independent contractors, not salaried employees

Time has also, in combination with the committees and co-planning obligations of the newly created governance structures, made space for intellectual and cultural contact between the worlds of clinical, administrative, and policy people. For their part, the PCNs have benefited from the time required to move from feeling their way in a new space with few doctors signed up as members, to being confident, seasoned teams able to function not just in the Frontier Era of few rules and little oversight, but in an era of Accountability where they act as hosts for difficult cross-cultural conversations amongst the MoH, AHS, and the vast majority of the province’s family physicians who have signed up. The s, tear down, and try again has been invaluable, allowing the PCNs not just to adapt their services to local conditions, but to transform themselves from being disbursers of capitation funding to players at the table, co-planning services with the larger acute care system.

Cultural adaptation

Meeting what have been called the ‘adaptive challenges’ of change management generally and healthcare quality improvement specifically [63–65] has been identified as a necessity when seeking to transform the practice of not just FFS family physicians in Canada, but around the world. Adaptive challenges here are those tied up in the values, social practices, policies and path dependencies – writ large, the culture – of the operational environment where transformation is being attempted. The implementation history of the PCNs suggests an evolving and nuanced role for cultural adaptation as a strategy for achieving longevity, popularity, and transformation towards a physician-focused interpretation of PHC. Our findings suggest a super structure of cultural transformation has emerged from and been made possible by a base layer of requisite, legally re-enforced cultural adaptation.

Furthermore, those contractors enjoy significant legally protected autonomy when it comes both to treating their patients, and in their relationships with the rest of the health system [30, 39]. In Alberta, as elsewhere in Canada , this independent contractor status, and the autonomy it affords physicians, are legacies of decisions made in the 1960s as Canada’s universal publicly funded healthcare system was put in place [26, 32]. These legal legacies are overlain by a western Canadian frontier narrative, as well as professional and operational cultures that valorize the ideal of lone generalists enjoying long term relationships with their patients [66, 67]. Given this admixture of law and culture it is perhaps unsurprising that these independent contractors, or ‘non-system’ members of the Canadian health system, have proved resistant to ‘system’ changes [26, 30]. While Alberta and Canada will be idiosyncratic in some ways, this clash between the cultures of physician and system is a phenomena observed in jurisdictions around the world, even those with more command-and-control capacity [68, 69]. Acknowledging this reality, policy makers aiming to achieve transformation towards PHC have focused on voluntary, discretionary, participatory, and incentivising mechanisms to secure the buy-in of ‘non-system’ members . As such, opting for local (not central) solutions, and a fragmentary ‘a la carte’ (not a unitary, command-and-control) approach to PHC policy implementation was, in many respects, a necessary foundation on which to build the first PCNs.

A culturally concordant, as well as economically viable, way of doing the business of PHC was at the core of how the original policy entrepreneurs designed the PCNs. They emerged from the mutually reinforcing values of the frontier town thinking –Canada’s particular version of the Wild West cultural trope – economic entrepreneurialism, and primary care’s identities and values . These three tropes overlap at, and emphasize, self-reliance, independence, autonomy, and rapid locally initiated, locally tailored action . As identified elsewhere, acknowledging and adapting interventions to these closely held cultural values is clearly a key element in making PHC transformation not just possible but seen as legitimate by family physicians . In Alberta’s case that legitimacy, generated out of cultural concordance and a sense of local ownership of self-made solutions has held [61, 74, 75]. Indeed, it has thrived, with over 80% of the province’s physicians making the decision to sign contracts and remain members of their PCNs even as the Era of Accountability with its opposing cultural values arrived. The PCNs have survived and grown in popularity in part because they offer a cultural redoubt where independence and local action are protected and respected.

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