Filling a gap: Ontario’s walk-in clinics
About one in four Ontarians visit a walk-in clinic each year.
While the government has made access to family doctors a key priority, there is no policy framework for walk-in clinics.
Although walk-in clinics have been part of Ontario’s health care landscape for decades, they remain controversial. Walk-in clinics have generally been excluded from government efforts to improve access to primary care services, and little is known about the services that walk-in clinics provide and the reasons why patients frequent them.
In the past decade, the Ontario government has made significant reforms to primary care, including a shift toward group practice models such as Family Health Teams and away from fee-for-service medicine. However, doctors who work in walk-in clinics in Ontario continue to be paid almost exclusively by fee-for-service (i.e., a payment for each visit or service) and usually work without the help of an interdisciplinary team.
Some experts argue that walk-in clinics promote duplication of health care services and can drive up health care costs as patients seek care from multiple providers in an uncoordinated way. Yet the convenience of walk-in clinics cannot be ignored, especially for patients who do not have a family physician or cannot see their family physician when they need to.
“Bottom of the heap” when it comes to timely access to family doctors
Ontario’s Action Plan for Health Care, announced in February 2012, includes “faster access to stronger family health care” as one of the top three priorities for Ontario’s health care system.
This priority makes sense given that half of Ontarians are currently unable to obtain a timely appointment with their family doctor or a nurse when they are sick. In fact, in an international survey of fourteen countries, Canada ranks near the bottom in accessing primary care when it is needed urgently. Rick Glazier, a family doctor and researcher at St. Michael’s Hospital in Toronto says “Canada is at the bottom of the heap when it comes to timely access to care, which explains why we’re at the top of the heap when it comes to emergency department visits.”
In the United Kingdom, more than 70% of people are able to get same or next day care. The National Health Service also operates walk-in centres that focus on treating minor issues. These walk-in clinics see nearly 3 million patients per year and take pressure off traditional primary care practices as well as emergency departments. However, they are more integrated into the rest of the primary care sector than walk-in clinics in Ontario, and are often staffed primarily by nurses rather than doctors. Jonathon Tomlinson is a general practitioner (GP) who works in a family practice in Hackney, a suburb of London. His practice includes a walk-in clinic that serves both registered patients who do not have a scheduled appointment as well as patients who have never registered with the practice.
Like many family doctors in Ontario, Tomlinson believes that patients are best served when they can visit their regular practice. He notes that “if the problem is that patients aren’t getting appropriate access to GPs, the answer isn’t to go to a walk-in around the corner from the GP, it’s to fix GP practices.”
In contrast, David Peachey, a family doctor who works in a Toronto walk-in clinic and previously served as Director of Professional Affairs for the Ontario Medical Association says that “the proper role of walk-in clinics is to be a safety valve in the system, to assist traditional family medicine practices.” Yet, walk-in clinics in Ontario are not required to provide information to a patient’s regular family doctor after providing care to a patient.
The government’s Action Plan includes a commitment to improve “access to the right care, at the right time, at the right place” and notes that Ontarians have a number of different options other than emergency departments when they are in need of immediate care for non-urgent concerns. The website includes a video, reproduced below, describing the services that walk-in clinics offer, as well as a tool to locate nearby walk-in or after hours clinics. Yet the clinics themselves operate in a relative policy vacuum.
What we know (and do not know) about walk-in clinics
An annual survey conducted by the Ministry of Health and Long-Term Care until 2010 found that about 25% of Ontarians used a walk-in clinic in any given year. Tori Gass, a Ministry of Health and Long-Term Care spokesperson, noted in an e-mail to healthydebate.ca that “walk-in clinics are considered private businesses” and that the Ministry of Health and Long-Term Care “is not always made aware if a clinic closes or a new one opens.” As a consequence, the Ministry of Health and Long-Term Care does not know exactly how many walk-in clinics we have in Ontario.
Rick Glazier adds that “we have very little data on walk-in clinics in Ontario” and it is currently “not possible [for the Ministry of Health and Long-Term Care or a researcher] to easily figure out whether a primary care service was delivered in a family doctors’ office where they provide comprehensive care, or if it’s in a walk-in clinic.” We also don’t know whether patients visit the same walk-in clinic repeatedly for many years, in which case the clinics may be providing ongoing care, or whether the care is more episodic in nature.
There is also a lack of recent data describing the characteristics of walk-in clinics and the patients they serve. The most recent information about patient satisfaction and the characteristics of walk-in clinic doctors comes from the Ontario Walk-In Clinic Study, which was conducted nearly a decade ago.
Innovation to improve access to primary care
One Ontario initiative designed to improve primary care is the Learning Community organized by Health Quality Ontario. This initiative was previously known as the Quality Improvement and Innovation Partnership, and provides primary care practices with training and support for quality improvement activities. One activity supported by this initiative is Advanced Access, a scheduling philosophy that promotes same day access.
If better scheduling could improve access to family doctors, then perhaps fewer people would need to use walk-in clinics. However, many patients use walk-in clinics because they are more conveniently located than their regular family doctor, and not because their regular doctor doesn’t provide same day access. For example, someone who lives in the suburbs but works in downtown Toronto might visit a walk-in clinic near their office rather than going to their family practice closer to home.
Rick Glazier suggests that in spite of ongoing reforms and efforts to improve access to primary health care services “there will always be a need from patients for quick access to care for minor, but acute, issues.” Walk-in clinics are likely to always have a place in our health care system, and Ontario’s primary care strategy needs to consider what their optimal role should be.