What does “access” to primary care really mean?
In the early 2000s, government reforms in Ontario mandated that family physicians provide greater after-hours services for their patients. Family doctors were also incentivized to ensure patients obtained the majority of their primary care from their own family doctor.
In some ways, the reforms were successful. Today, more primary care clinics are open evenings and weekends than prior to the reforms. Increased payments to family physicians has led to improved work satisfaction and has in turn attracted more graduating medical students to the speciality. This has resulted in significant growth of the primary care workforce. In Ontario, 96% of patients now report being registered to a family physician.
Yet, Ontarian patients continue to rate access to primary care as poor. The province’s Health Minister recently made headlines for “scolding” family physicians over a Health Quality Ontario report that again demonstrated this issue. Today, as the government is implementing new primary care reforms and considering others, let’s take a step back and ask: Why does better access to primary care continue to elude us?
What does access mean to patients?
For a start, it would help to understand what exactly access means to patients. Does it mean that your doctor or someone from your doctor’s office is available to see you on the day you’re sick? Or does access mean being able to choose to be seen at a time and place that’s most convenient to you – whether or not the provider is connected to your family doctor’s office? From my experience, many patients prioritize convenience over access to a specific provider.
I used to work in a large, urban family practice. Although I was only in the clinic part-time, the clinic offered my patients appointments with someone on our team if I was not available. Also, if a patient simply showed up at our clinic during operating hours they were guaranteed to be seen by someone that same day. The clinic offered extended hours as well, including weekday evenings until 8pm and weekends from 10am to 2pm.
We expected this arrangement to result in our patients feeling confident they could access care at our clinic almost anytime they needed it. But when we conducted a patient satisfaction survey, only a minority reported being able to see a health care provider when needed. It’s possible our patients didn’t know about their access options at our clinic. However, given that many of our patients worked in the area but lived elsewhere (or vice versa), it’s also quite likely that our clinic was not always the most convenient choice.
As a society, we are increasingly demanding that we get not only what we want, but when we want it and where we want it. The 2011 Ontario Auditor General Report found that 36% of patients who visited a walk-in clinic did so not because they couldn’t see their own family physician, but because it was easier or more convenient than seeing their family physician. Similarly, in its review of OHIP data, the C.D. Howe Institute found that walk-in clinic use by patients with a family doctor did not seem to be due to urgency but rather was “largely due to patient choice based on convenience of care.” Dr. Rick Glazier’s group at the Institute for Clinical and Evaluative Sciences has recently done work around access that seems to confirm this finding.
Ontario’s primary care reform strategies have encouraged patients to be “attached” to a family doctor and to seek as much of their primary care as possible from that doctor. The continuity of care that results from this strategy is an important quality measure, with prominent research demonstrating the many health and cost benefits. But the reality is, continuity is not always convenient, and convenience is important in a culture where many of us live hectic lifestyles.
The Ontario government is now considering a new strategy, also aimed at primary care access, where patients will be attached to primary care providers based on postal code. The authors of the report recognize that such a model may not work for the patient who lives in Brampton but works in downtown Toronto five days a week, but the report doesn’t suggest any solutions for these patients. Is it rational to ask already busy, stressed out patients not to prioritize convenience?
Rather than restricting access to primary care according to neighbourhood or one’s regular family physician, perhaps we should champion a more innovative, integrated health care system. For example, many of my patients are shocked to learn that I cannot access the details of their visit to a walk-in clinic via my Electronic Health Record. Some jurisdictions, such as Alberta, appear to be working on this integration issue, leveraging technology to improve access for both physicians and patients to important health information regardless of where that information was generated. It will be important to understand just how successful this initiative has been from the perspective of the average Alberta patient and physician, and where improvements can be made.
As a society, we need to have this collective discussion around access. Otherwise, primary care reforms run the risk of trying to address what doctors and governments think patients should want, rather than what patients actually want. And that would be a waste.
Kamila Premji is a practicing family physician in Ottawa who is currently collaborating with INSPIRE-PHC’s Primary Care Reform team.