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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.

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9 comments

  1. Alexander Bardon

    It’s great that you brought up electronic medical records. I frequently have patients in my ER from all across the province that are shocked to find out I don’t have access to their medical records from their family doc, imaging clinics and even other hospitals. I use this fact to highlight how underfunding and mismanaged the healthcare system is: I can watch a YouTube video, on my phone, that was posted halfway across the world 7 minutes ago…. but I can’t get access to your echocardiogram report and bloodwork that was done 3 weeks ago at a clinic just around the corner.
    More and more pressure is being placed on physicians to order less test via the government and the Choosing Wisely Campaign. Their logic is that these tests are often redundant and unnecessary. That may in fact be true, but it would be helpful to have the information sharing tools in place to verify, the tests in question are in fact redundant.
    Providing doctors with a province wide, electronic health records database is a relatively simple and isolated task compared to a systemic overhaul of the primary care system. Many years and billions of dollars later, we still don’t have proper electronic records. Is this government capable of the relatively complex task of transforming primary care for the better? When they can’t even get us proper medical records? At a time when doctors frustrated and hurt by the government’s funding cuts and condescending rhetoric? The government will need the cooperation and support of doctors. They don’t have that now, nor do they have the competence to make this work.

  2. Yan xu

    I agree with Dr. Premji that discussion on primary care access is much-needed. I would submit, however, that a proportion of patients who seek walk-in care out of convenience does not fully account for access issue faced by patients who are willing to but unable to see their physicians. The Commonwealth Fund comparisons consistently point out that Canada continues to perform poorly in provision of same-day appointment and has the highest percentage of patients who had to wait >6 days for see a physician or nurse.

    In the Auditor General report cited by Dr. Premji, it is indeed the case that 36% of patients used walk-in clinics out of convenience; however, it should not escape our attention that 47% of patients had to use the clinics not out of convenience, but due to unavailaibility of their primary care providers.

    At the same time that we make primary care more geographically flexible and advocate for the notion of “move knowledge, not people” (http://www.ihi.org/Engage/collaboratives/LeadershipAlliance/Documents/Leadership%20Prospectus%20Year%202-Final.pdf), we still need to be cognizant of the need to improve our health system redesign so that patients who seek to get help from their routine primary care physician has every opportunity to do so.

    • Kamila Premji

      Thank you for your comment and the link. I fully agree that many patients truly face difficulties accessing their family doctor. I think the issue needs to be teased out much more in depth, and from all sides – patients, doctors, and government. The self-reported patient access metric cited by the Commonwealth Study is just one of many that can be used to better understand where access can be improved.

  3. Dale Wiebe

    Provinding access to quality care while keeping costs down relies on clinicians having access to relevant patient information. As a physician in Toronto I am still waiting for Ontario to catch up to the electronic health record system that Alberta was using over a decade ago. This wait is not for lack of trying but is certainly related to lack of quality governance in the eHealth file. What metrics can we use to hold our government to the standards we expect in order to provide better access to quality care? The following article details $51.3 million wasted on the failed diabetes registry and that doesn’t include the amount of money spent on years of litigation.

    http://canadafreepress.com/article/73581

  4. Kyle Pearce

    Thank you – this is a great article, and summarizes nicely the conundrum between attachment (which means something economic to the system and something relational to the patient and clinician), and convenience (which is central to our culture in everything except healthcare).

    When I led a big engagement process in Vancouver to improve primary care capacity, we found similar results – that patients who have a family doctor and go to a walk-in or emergency department, do so because of convenience – 36%because they can’t book a convenient appointment, 17% because it’s outside of regular office hours, and 18% because they think it can be handled more quickly elsewhere.

    I think the solution will come from outside the system – people who look at the business model of primary care from the perspective of the patient. There’s a group in BC doing that – Vancouver Citizens Health Initiative – which looks at how healthcare can be co-designed by clinicians and citizens to meet the needs of both.

  5. Alex Bardon

    Yan Xu unfortunately is correct in stating that not all patients seek care at Walk-in clinics for convenience. Many do out of necessity as they don’t have a family doctor, or their family doctor is under-accessible.
    I would caution against adopting our Minister of Health’s attitude regarding this however. Dr Hoskins has stated that poor access to family doctors in the province is due to doctors “dragging their feet” to see patients. The poor doctor-to-patient ratio in this province would suggest the opposite. Family doctors are “running off their feet” to see patients. There are simply too-many patients, and far too-few doctors.
    There are doctors in my community who openly admit they have too many patients to handle. There are several who have 4000+ patients rostered to their care. They took on these extra patients at the request of Health Care Connect, the government’s own service to connect orphan patients with a family doctor. They did this to help. They did this to be supportive.
    Now these doctors that took on extra patients at the request of the government have just been scolded by their very own Minister of Health for “dragging their feet”. This is not leadership.
    Dr Hoskins’ rhetoric is neither informed nor productive much less professional. His “transformational reform” is just a scheme to force family doctors to take on even more patients than they can already handle. Dr Hoskins needs the support of his doctors. He has lost that. Health care reform will have to wait for a new Government and a new Minister of Health.

  6. Laura Muldoon

    Great post, Kamila.
    Sometimes same day access is over-rated.
    Our grandmothers knew how to deal with many issues, and self-limited conditions will not be treated with un-necessary antibiotics if there’s no doctor visit.

  7. Tom Freeman

    Not much has changed since the Pickering report: availability; affability; ability, in that order.

  8. Ruth

    Access should be based on priority. not on convenience. If the matter is less urgent, it shouldn’t clog the system up so that more urgent cases wait. But how do we determine priority? Or how does the individual booking the appointment assess that? This is likely a controversial statement, but in this environment of diminishing resources and increased demand, we need to put in MORE barriers to health care. Slow down access to the ‘worried well’ and increase access to people who really need health care. Is it time to have another look at user fees or is that off the table?

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