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.
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Hi — this is a great & informative article. However, when I speak to my friends about healthcare or these kinds of issues, virtually all of them have gone to or still continue to go to a walk-in clinic for occasional care. No one seems to know why they should or shouldn’t go to a walk-in. The main reason my friends give is because their family physician is located farther away from their home than they wish to travel they head, instead, to the nearest walk-in. I think the real issue is most people have no idea about what their doctors or clinics provide including after-hours services or walk-ins. People just want to see a doctor quickly & go wherever is closest & most convenient at the time. I think the biggest challenge is educating the public about the variations of health services available through their own doctors/clinics. Even my own family physician, who is great, has never really explained to me how her practice works and/or what services are part of the practice. I know I get good care but am still a bit unsure about how it all works! I also wonder about the future possibility of my family physician calling me (like my dentist does) to remind me to book a physical or follow-up appointments.
Ann-Marie T
Agreed All patients should be educated on the types of primary care provided in this province. We may then actually get more people active about making it more effective. Much of the “private business model” that is Walk-in Clinics is partly extra income for primary care providers so “rocking the boat” is not on their priority list.
It is poor Acute care and poor short term diagnostic preventive care as well as extremely poor public policy. This model needs to be re-imagined. We have the infrastructure of Local Integrated Health Networks to do this.
We have a lack of public education and political will . . .
Fee-for-Service is wrong headed if cost containment and effective Health provision across the spectrum of that definition is to be embraced.
Health is NOT a business. Health for humans and the planet as a whole is a right to the best life possible.
The last and final time I went to a walk-in clinic I had a bad case of bronchitis that did not react to the first antibiotic used. I asked to see the same doctor who treated me three days earlier and I was told this was not permitted. I couldn’t believe that they could not understand the importance of continuity in treatment but was told that this was clinic policy. Although I felt pretty awful, I waited until the office covering for my primary doctor was open the next day and learned that I now had pneumonia. In my opinion, walk-in -clinics can provide a convenient short-term service. However their effectiveness is limited by this type of policy and exacerbated as they do not share information with other components of the system (another example of the costs of not having a comprehensive health information system).
This is an important and timely discussion. We absolutely need more information about walk-ins. We need to start with a clear definition of walk-in clinics. I don’t think it’s as black and white as many people think. It may be a little bit like pornography or art in that it’s hard to define but easy to identify.
We can define emergency care. We can also define comprehensive family practice, using some sort of basket of services that is provided to patients on an ongoing basis. It’s less easy to define Urgent Care Centres. The MOHLTC has designated some places as UCCs, but others who appear to offer similar services are left out. But what is a walk-in clinic?
Some practices provide what I would call comprehensive family practice to some patients while providing walk-in type care to others. These are a sort of hybrid. And they appear to offer excellent care.
In this time of economic restraint we need to make sure that money is well spent on all types of care and that means we should evaluate the value added to the system for walk-in care. But we really need to spend some time making sure we all have a common definition that makes sense.
Lastly I would like to point out that while it makes intuitive sense that improving the access for a patient to his or her usual primary care physician or NP will decrease the demand for walk-in clinics, I’m not sure that there is a lot of evidence to support that assumption. Many physicians have worked valiantly to implement advance access or day of choice scheduling and still see their patients go to walk-ins. At some point we need to have a serious discussion about patient accountability.
For me, my schedule, and my family, our local walk-in clinic is the best solution to our busy and varied schedule for important, non life threatening issues.
Our family doctor was semi retired, and although he would have been my first choice, most times it wasn’t possible to see him without taking time off work or school for my sons, or waiting a week or so for an appointment. Since then I’ve signed up with the local NP clinic, with my previous physician as consultant, which is good, but if there is an urgent, non life threatening issue, I will still visit the local walk-in clinic. The last thing I want to do is wait 8 hours, possibly more, at our local hospital, and pay $4.00 per hour parking.
There is a gap between between hospitals and physicians’ practices that walk-in clinics fill, and I’m happy to continue using the walk-in clinic when needed. It’s a matter of not having to take time off work or school, lose money, and so on. The walk-in clinic is more convenient and efficient.