Accessing primary care in Ontario
Increasing access to primary care providers, such as family doctors or nurse practitioners, has been a government priority. Better access to primary care is also associated with improved population health.
Although the percentage of Ontarians with a regular primary care provider has increased in recent years, fewer than half can see their primary care provider in a timely fashion when they are sick.
Achieving timely access to primary care requires changes to how primary care providers are organized and practice. There are good reasons to believe that both access and the quality of primary care in Ontario can be improved.
Access to primary care
Ontarians are more likely than other Canadians to have a regular primary care provider. Between 2006 and 2009, the percentage of adults without a family doctor in Ontario declined from 8.2% to 6.5% of the population. However, there are still about 850,000 people in Ontario who still do not have a regular primary care provider, and finding a family doctor who has room to take on new patients is a challenge. Gloria Galloway, a Globe and Mail reporter in Ottawa, called 84 family practices in her area before she was able to find a family doctor. When Galloway finally found a practice that was open, she waited in line with about a thousand people for the opportunity to join that practice. Galloway describes her search here.
Simply having a family doctor though is not enough. While the percentage of Ontarians who have a regular family doctor has grown, most people in Ontario are unable to get an appointment to see their doctor the same day or the next day when they become sick. Rick Glazier, a primary care doctor and researcher at the University of Toronto says that “it really undercuts the value of having primary care providers if you cannot see them when you need them.” Like Ontarians without a family doctor, these individuals then end up visiting walk-in clinics, urgent care centres or emergency departments. In fact, it is estimated that about a quarter of Ontarians with a family doctor have been to a walk in clinic in the past year.
Primary care & access to after hours and urgent care
The Ontario government has developed information for the public about the health care system, known ‘Health Care Options’, which includes a campaign to educate the public about options for urgent primary care.
Some argue that if primary care providers were better organized and responsive to patient needs, these kinds of marketing and awareness campaigns would not be necessary. There are a number of pilot programs in Ontario to improve patient flow and office efficiency in primary care, many of which are led through the Quality Improvement & Innovation Partnership (QIIP). Brian Hutchison, a primary care doctor and researcher at McMaster University, who helped develop QIIP, says “we have to provide primary care providers with training and support to address issues of timely access and efficient office systems design.” He says that “the appointment systems aren’t well organized so that practices, even when they have the potential to provide timely access, are not able to deliver.” In contrast, Kaiser Permanente, an integrated, non-profit health system in the United States was able to improve timely access to primary care by introducing a secure system of email and phone calls. This new system reduced office physician visits by 25%, and improved access for patients with urgent health care needs.
New models of practice
In the last six years, the Ontario government has invested in new models of care for primary health care providers. The most frequently used new model, the Family Health Team, is made up of doctors, nurses and other health care professionals working together to deliver comprehensive primary care, and in principle allowing for more flexibility and coverage of more patients. Family health teams are required to offer after hours or weekend care with an on-call doctor four days a week, and one day on the weekend. There are about 200 Family Health Teams in Ontario, employing nearly 1500 family doctors and serving about 2 million Ontarians.
The government has also invested in training more primary care doctors, with the number practicing in Ontario growing from 10,654 in 2005 to 11,817 in 2009. Hutchison, however, says that further increasing the number of primary care doctors may not be necessary, as “in some areas of the province there are doctors looking for patients, and in others there is a relative shortage of primary care providers.”
Has timely access to primary care improved?
The Ontario government has spent billions of dollars in the past decade to improve access to primary care. While more Ontarians than ever have a primary care provider; more than 50% of the time, they are unable to be seen by that provider in a timely way. The problem of timely access to primary care goes beyond Ontario, and a recent international survey ranked Canada the second worst amongst eleven comparable countries.
A senior health care leader interviewed by healthydebate.ca said that the government has put “financial incentives in place to roster patients. The next step, they argue is “to align incentives that can improve access to care, and quality of care for patients”. ‘Wait times’ in primary care need to be better measured and reported so that the issues of wait times for urgent primary care are better understood by both providers and the public. This would require the development of new systems to measure the quality of primary care.
Glazier says that “primary care has few accountabilities, and very little measurement” and notes that “until you start measuring, you cannot know whether changes have led to improvements.”
Improving system performance and accountability through monitoring and measuring performance has been supported by the provincial government through initiatives such as the Wait Time Strategy, and others focused on measuring and improving health system performance. Primary care, however, has not had the same prominence given to accountability and performance. Ontario has “taken the first step by turning isolated small family practices into larger group practices, but hasn’t yet taken the step of bringing them into the rest of the health care system”, said the senior health care leader.