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Sick patients continue to face challenges in accessing primary care


Improving access to primary care has been a key priority of the Ontario Ministry of Health and Long-Term Care for the past decade. 

The number of Ontarians who have a regular family doctor has increased dramatically.

However, patients who are chronically ill continue to have problems accessing primary care.

More family doctors and more rostered patients

The 2003 Ontario Liberal Party platform promised better access to family doctors and nurse practitioners. To achieve this objective, the government provided additional funding for family doctor training and also created new group practice structures and compensation models for family doctors. These new models included substantial financial incentives for doctors to take on new patients.

The Ontario Medical Association reported last November that more than two million Ontarians have been newly rostered with a family doctor – meaning that both the family doctor and the patient have agreed to enter into an ongoing relationship – since 2003. Rostering means that a patient is formally registered with a family doctor or primary care practice.

However, does rostering two million Ontarians mean that those who most need a primary care now have access to care when they need it?

Challenges accessing primary care 

One senior health care decision maker who wished to remain anonymous told healthydebate.ca that Ontario currently has “financial incentives in place to roster patients… but limited incentives and accountability to improve access to urgent care within primary care practices.”

In September 2011, healthydebate.ca covered the issue of timely access to primary care. One feature of the new primary care models is that they are structured to encourage doctors to provide timely access to patients for urgent concerns. When doctors work within a Family Health Team, for example, they are required to provide access to patients to their practice by offering extended hours and telephone availability. However, these systems are not always implemented in a manner that adequately meets patient needs.

Health Quality Ontario recently reported that less than half of Ontarians are able to see their family doctor on the same or next day when they are sick. Canada ranked near the bottom in a survey of fourteen countries for the ability to get a same or next day appointment when sick. For this and other reasons, many patients continue to visit walk-in clinics or emergency departments when their needs might be met by their regular family doctor. Other patients don’t have a family doctor at all.

New patients and Health Care Connect

The Ontario government launched Health Care Connect in February 2009 to help patients find a primary care provider. Patients call Health Care Connect, which is based at their local Community Care Access Center, to register with the program. A “nurse connector” asks for the patient’s health information and helps the patient find a primary care provider. Primary care providers who agree to accept patients through Health Care Connect receive a one time incentive fee to enroll these patients – $200 for most patients and $850 for patients who are deemed by Health Care Connect to be “complex and vulnerable.”

According to the Health Care Connect website, over 140,000 patients have registered with the program since its launch. Over 90,000 of these patients have been “referred” to primary care providers through the program – meaning that a family doctor has agreed to accept the patient. However, there is significant variation across Ontario in terms of referral rates. In some regions more than 90% of patients who register are referred. In Toronto for example, only about one-third of patients are successfully referred to a family doctor.

Patients with chronic medical problems continue to face challenges

More than 7,000 of the patients referred to family doctors by Health Care Connect have been deemed to be “complex and vulnerable.” Joanne Greco, Director of Client Services with the Toronto Central Community Care Access Centre says that complex and vulnerable patients are given priority within the Health Care Connect program and that “when the program was created there was a desire to make sure that those with the greatest needs are matched before those who can wait.” Health Care Connect reports that 78% of registered high needs patients to the program have been referred to a primary care provider.

What is less clear however is whether patients who are “referred” by Health Care Connect build lasting relationships with their new family doctors. Lynn Wilson, chair of the Department of Family Medicine at the University of Toronto says that she is concerned about the effectiveness of Health Care Connect in improving access to care for more complex, difficult to serve patients. Wilson says “while tremendous strides have been made in rostering patients, now we need to make sure that the hard to serve patients have adequate access to primary care.”

Compounding the problem is that many vulnerable patients, such as those with dementia or severe mental illness, are simply unable to navigate the Health Care Connect process without substantial help from someone else.

Shifting the focus to patients who need help the most

Rick Glazier, a family doctor and researcher at St. Michael’s Hospital noted in a Journal of the American Medical Association article that the new compensation models in Ontario have in some cases provided “strong incentives to drop precisely those patients with higher health needs and complex care.” Not only are family doctors penalized when their patients visit walk-in clinics, they also receive the same monthly payment for a healthy patient who visits once a year as they do for a complex patient who needs to be seen every week.

Jan Kasperski, CEO of the Ontario College of Family Physicians argues that “family doctors need to be reassured that accepting hard to place patients into their practice will not be overwhelming.” Kasperski also notes that many difficult to place patients are living with mental health and addiction issues. She warns that focusing on rostering patients with high needs can overwhelm doctors, particularly new graduates who are often those accepting new patients, saying that “if all new graduates are getting is a high intensity, high resource population, they will drown” and that some doctors will respond by closing their practice to new patients. Danielle Martin, a family doctor at Women’s College Hospital in Toronto disagrees, saying, that “while complex patients can be difficult to manage … people go to medical school to learn how to take care of sick people.”

What should Ontario do to improve access to primary care for complex patients?

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9 comments

  1. Catherine Richards

    The only part of this article I appreciate is the final comment by the doctor from Women's College Hospital, which happens to be an amazing healthcare facility in downtown Toronto and I have had experience within its system and with some of its compassionate, caring and qualified staff. The whole idea of doctors classifying patients who happen to be people as "complex" due to mental health issues or dementia is absolutely ludicrous! I too have experience with relatives who've been diagnosed with both labels and in all instances they see/saw their family doctors no more often, and in some cases less, than I, and I see mine less than most others I know about. Ontario's healthcare system is far too over-analyzed and badly managed by its insiders, and we the patients when under its care are in many cases notoriously under-served by too many arrogant, insensitive, selfish and poorly educated doctors and nurses who have little true concern for the rights and feelings of their patients and a disgusting abundance of concern for their own agenda. Perhaps instead of all the extensive and expensive data research going on in the province our healthcare system could be improved for no cost at all if those working in it actually listened to, respected and acted upon the feedback from the people affected by it. And there should be no financial incentive awarded to doctors for accepting any "type" of patient. We are not lepers. They are not gods. Today I happened to visit my family doctor. It was a planned visit to have stitches removed from my face after surgery to remove a skin cancer last week. When I arrived at the office the doctor told me he didn't have the right supplies and then suggested that I go to a walk-in clinic. I didn't feel comfortable going to a walk-in clinic which I see as a total last resort and I said so. Seeing as it is my face that the stitches are to be removed from, I want someone I know and trust to be competent to do the job. My daughter called Women's College and got me an appt for tomorrow morning. No hassle. Trust is an issue for me when it comes to healthcare because I have had it violated on too many occasions and have to live with the consequences of bad decisions made by some very unscrupulous and heartless people who answered the call to heal others and somewhere along the way forgot to do no harm. I suggested to my family doctor today that perhaps he should refrain from referring others to the original dermatologist he had referred me to as two of the doctors there dismissed my concerns that I had a recurrence of skin cancer and applied only liquid nitrogen to the lesion. I have a history of skin cancer. The doctor then said cavalierly to me, "Doctors are human, they make mistakes." Obviously. While his remark was made from a place of defensiveness and seemed insensitive to how I was feeling, I trust and respect this doctor and will continue to see him as my family doctor in future because he also listened to me, understood why I felt upset, and then said those magic words that few doctors ever say with genuine feeling, "I'm so sorry." Fortunately, my family doctor and I have established a good relationship which includes us being able to speak frankly with one another. We have a rapport. I see empathetic, strong communication skills as the single most important credential of any good doctor. My point to him today was that perhaps in light of the fact that these other two doctors had both made serious mistakes that caused me to now have a large scar in the middle of my face that could have been prevented if they had treated it properly in time, he might want to prevent another of his patients from having a similar unfortunate experience. There is little to no accountability in the healthcare field and I have direct experience that causes me to say so and I know of many others who feel this same way due to theirs. I am not interested in suing these doctors. I simply want doctors to A. Acknowledge when mistakes are made and then be transparent about themselves or other doctors who make them with their patients. Doctors in my mind have an obligation to protect the best interest of their patient over protecting the reputation of a colleague. Honest disclosure allows the patient to make an informed choice. B. Don't categorize and then stereotype patients as "complex" because of certain illnesses or conditions they have and then feel justified to reject potential patients because of these judgments, not to mention that doctors should be leading the charge against stigmatizing "vulnerable" patients, not actively avoiding them. When a doctor accepts a young healthy patient they have no clue how the person's health will be down the road. I have known personally some healthy people who will visit a hospital emergency room when they have a common cold and I also know some with several chronic conditions/illnesses that medications keep under control who see their doctor only occasionally. Having co-existing conditions is another thing that gets spun by the healthcare industry and drives these convenient assessments of people as "high-needs" and "complex" and I have seen this done and used as an excuse to exonerate themselves when they ignore actual symptoms of illness and then rely on the excuse when the patient dies stating that they had so many underlying and contributing factors, and yet these had nothing to do with the death, and everything to do with the symptoms of an unrelated and neglected health crisis. It's like the current spin that all dementia patients in long term care homes are difficult, complex and even violent. Nonsense. It is in fact scary to me to think that this spin will be used more and more to justify the inappropriate treatment of patients suffering with dementia and Alzheimer's, not to mention that the healthcare industry and the media seem to want to convince us that there's a huge rise in the number of cases that will totally incapacitate the healthcare system. A slow rising panic is systematically created and encouraged and all for a purpose and from my vantage point it is neither accurate or ethical. In my lifetime I have been fortunate to know a few great family doctors, and have come in contact with some fabulous nurses, but I must say that these people stand out because in my experience they are much more rare and rarely encountered than the majority who give the healthcare system its bad reputation. Lousy attitudes and a lack of accountability by those working in the healthcare field, from the front line workers to those in the higher echeleons of the ministry itself, create huge barriers for patients when trying to access humane, efficient and compassionate healthcare in our province. The decline since this government has been in power is noticeable and the public's lack of confidence in the healthcare system should be enough to convince all working within it that a change in attitude, and most likely a change in leadership, is necessary for things to improve.

  2. Jill Alston

    I was surprised at the number of seniors I came cross on a geriatric rotation that did not have family physicians. Half probably had some cognitive decline, most had numerous medical conditions and since it was a rehab facility, most had major physical limitations that made it more difficult for them to access care. Not having a family physician was a major issue when planning their discharges home. Providing frail seniors and those with complex care needs should have even greater priority than it does now. It will take more than financial incentives for the physician. We need to further pursue practical ways to deliver care that is convenient to the patient (such as house calls prgrams), and Other preventive care strategies (wg more falls prevention clinics, diabetic educators etc) involving allied health care workers.

  3. Rick Glazier

    Thank you for taking up the topic of access to care and for providing a superb summary of the main issues in the ‘problem space’. The ‘solution space’ is much less well-delineated, so here are my musings about a high functioning health care system for Ontario:
    Imagine that every primary care practice was mandated to do patient experience surveys (as the hospitals now do) and that every practice regularly measured and publicly reported on how long it took to get an appointment, whether the doctor listened and spent adequate time with patients, and whether patients knew which medications they were on, what tests and referrals they were having and what the reasons for them were. Each practice would also regularly measure and publicly report on how often and with what success they addressed tobacco, alcohol, drug use, mental health, and diet and exercise, along with control of chronic conditions like diabetes and heart failure and preventive health care such as immunizations and cancer screening. Practices would also be responsible for their surrounding community, not just the patients who crossed their thresholds. Does this all sound far-fetched? This is routine in the U.K. and other countries today.
    Now imagine that doctors were accountable for how they did on these measures but that they were also supported to continually improve and to centre their care around their patient’s needs. Further, imagine that primary care teams aligned to meet patient needs including care in the hospital and in the community, especially after a hospital admission or emergency department visit. Primary care teams would have care coordinators, case managers and outreach workers to ensure that all parts of the system were working well together. Imagine the whole system measuring and being accountable for avoidable emergency visits, hospital admissions and readmissions, as well as the patient’s overall experience of care. And that the responsibility was for the whole community. Far-fetched? Again, this is routine elsewhere, including several examples in the U.S.
    Do you think our access problems would improve if we organized care around community and patient needs, linked disjointed parts of our system together, and measured and held providers and teams accountable for every member of their community? I do. Do you find these ideas merely wishful thinking? Ask around in the U.K., the Netherlands, or Anchorage, Alaska and you’ll find that this is how health care is provided today, with demonstrated cost savings. Why should we settle for less?

  4. IMG

    And why ‘Continue to increase the number of family doctors who are being trained by medical schools in Ontario’? Why only trained in Ontario? Why ignore more than 2000 IMGs in Ontario with exams completed? More importantly, I hope the formulation of this question doesn’t reflect the stance of healthydebate.ca on the issue of helping IMGs to get into medical practice…

  5. Claudia Mariano

    The role of Nurse Practitioners (NPs) in improving access to primary health care has been overlooked. A growing body of research confirms that NPs are accessible, highly knowledgeable, cost effective, and that patients are very satisfied with health care received by an NP. Our current funding models do not allow most Ontarians to access an NP directly. Because NPs are not currently permitted to roster patients, for example, access to timely primary health care is still dependent on a physician who is likely juggling a heavy patient load. In many northern and remote parts of Ontario, NPs are under-employed, while residents of those communities struggle to find accessible health care. Several NP Led Clinics in underserviced areas are already at capacity, with waiting lists of patients eager to receive care from an NP.

    We need to expand our vision of how primary health care is delivered in Ontario, and ensure each patient sees the right provider at the right time.

  6. Tanya

    I had a problem today, at work: my stomach hurt, I became nauseated and went to our school’s health / nurse office to lay dawn for 20-30 min.Later I threw up and having a stomachache decided to leave a school at 12:00 and go to my new doctor’s office.
    I visited my PCP a month ago,and he advised me to come again in 6 months.
    I unfortunately became sick today, and he was furiots that I came to his office and not to E R…
    I’m a teacher with very limited time and don’t want to sit for 5-6 hours in,a low profile very crowded hospital with no chance even to park there..
    You have to work a lonf distance to a main entry, What I was unable to do today…
    He said directly that his patientartainment don’t walk into his office at the same day..and when I tried to discuss it, silently left his room.

  7. Tanya

    Sorry for my errors: I was really over welded today..

  8. Tanya

    Sorry for my errors: I was really over welmed today..
    When I asked him about a nurse – practitioner, he said they’re not available, although I found out that the office had a NP..

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