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 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.

Should the government publicly report on measures of timely access to, and quality of, primary care?

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This article has been closed to comments. 7 comments

  1. Jeremy Petch

    Possibly one of the most fruitful courses that can be taken to improve timely access to one’s family doctor is for more family practices (whether traditional practices or family health teams) to introduce Open Access Scheduling (also known as Advanced Access or Same-Day Scheduling). Open Access is surprisingly straightforward – rather a family practice booking all of its appointments in advance, it begins booking only preventative and annual physical exams in advance, leaving a significant section of each day free for same-day or next day appointments. When this approach has been implemented elsewhere, patients report increased satisfaction (less waiting!) and emergency room visits tend to be reduced (the issue is dealt with by the family doc).

    The College of Family Physicians of Canada provides information on Open Access as part of their toolkit for family physicians, with some links to resources for implementation and research on efficacy. (

    Open Access scheduling in one component of BC’s Practice Support Program, which provides physicians with support and incentives to move towards new models of patient care. The Cape Breton Health Authority has also experimented with Open Access and has reported significant improvements in emergency room visits and patient satisfaction. The move to Open Access was included by CHSRF in compiling a collection of best practices in primary care (a link to the casebook of best practices, an excellent read for anyone interested in primary care innovation, can be found at

    Open Access is a promising approach. As with everything in health care, it is not a one-size-fits-all solution. It might not be right for all practices or patient populations, but it may be a good fit for many. Ontario should consider this approach, and possibly introduce incentives to help family practices (who believe it is right for them) to switch their scheduling to Open Access.

  2. Linda Murphy

    I am lucky enough to have a family physician who has used this approach for the last few years and it has really helped increase accessibility. She has also been converting patient files to digital form and now generates all new records and prescriptions through this system. In her words – there is an initial investment to set up and gain comfort with the system, but it is well worth it for the return – future efficiency AND ability to initiate more health promotion and prevention approaches. I suspect – but don’t knnow – that it will also permit a search function that may assist in identifying health and symptom patterns.

    Would you consider doing an update on Ontario’s electronic health record project and how it might speed up introduction of some of the potential innovations in or health systems?

  3. Jeremy Petch

    Oh, just a public service announcement: there is a family doctor in the St. Lawrence Market area of Toronto accepting new patients. If someone reading this is struggling to find a family doc, consider contacting them.

    Dr. Cam Inch
    Front Fredrick Health
    (416) 362-8777

  4. Shirlee O'Connor

    Since every measurement that the government does comes from the billing codes of MD’s, it always faills to capture the work of other members of the Health Care Team such as Nurse Practitioners. Since patients can only be rostered to MD’s, the over 300 patients that I care for in our family health team are unaccounted for, not just in terms of their receiving care, but also in terms of measuring their preventative care such as mammograms, and paps. This is probably also true in other FHT’s.

    • Jeremy Petch

      I don’t know that this is true of very many FHT’s, at least for the preventative services mentioned. Both Mammograms and Paps are covered by service enhancement codes, meaning FHT’s receive significant financial bonuses for ensuring their patients receive them. The same is true for the flu vaccine, childhood immunizations and colorectal screening. If your FHT is really not recording these and sending them to the ministry (regardless of who is doing them), then it could be losing out on nearly $13,000 of income per physician, per year. Importantly, these claims are not filed by the physician as part of shadow-billing, but are filed by the FHT itself on behalf of its physicians. Assuming a nurse practitioner is seeing patients rostered by physicians in their FHT, the preventative care should be logged and captured by the government when the claims are filed annually. by the FHT.

  5. Brad

    A simple approach to increase accessibility is to have the Family Health Care clinics open on Saturday and Sunday.

    I understand we are all busy ; however, working parents and students have to juggle priorities.

  6. Tanya

    Really great piece. With respect to the question: “Should the government publicly report on measures of timely access to, and quality of, primary care,” my response is absolutely yes, with a strong caveat – government needs to work with primary care professionals, measurement experts and its citizens to determine what these measures are and validate that they are accurate measures/ proxies of what you want to evaluate. Using the most available data only for example (billing data or ER data) to measure quality of primary care, is not going to give you a “real” picture of quality and is in fact dangerous if this information is to be used for decision making.

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