How can we improve doctor and patient accountability in Ontario?

To get better quality, timely health care, patients and providers must continue to find ways to make a patient’s regular family doctor the customary first option for non-emergency care needs. As it stands, both parties could be doing more to strengthen the patient-doctor relationship, and financial incentives on providers alone likely won’t be sufficient.

Because regular family doctors know a lot about the nature or their patients’ problems and they can treat these problems more effectively than providers with little knowledge of a patient’s medical history ; by overseeing the drugs their patients use and the services they receive from labs and specialists, they can reduce wasteful duplication and ensure a more cost-effective use of public resources.

In recent decades, many Ontarians did not have a regular family doctor and struggled to access timely care. But over the last decade, with considerable public costs, some progress has been made to reduce the access problem. Ontario has reformed primary care to pay doctors more on a per-patient basis (capitation) – paying doctors a lump sum amount based on the number of patients under their care – and less via a fee for each service provided. Meanwhile, reforms emphasized patient enrollment with a family doctor or group of doctors. From 2003 to 2012, over 2.1 million Ontarians who had no family doctor were enrolled in a primary care model.

While enrollment figures suggest access to primary care has improved, high numbers of walk-in clinic and emergency department visits suggest gaps remain. However, it’s important to note that the size of these gaps are hard to determine, because these data do not account for those patients who might be visiting walk-in clinics out of convenience, rather than seeing the family doctor with whom they are enrolled (who might have been available to see them on that day).

In Ontario, when patients enroll with a family doctor, or group of doctors, they sign a written agreement to turn to these doctors, in the first instance, when they need basic care. If these enrolled patients visit outside providers, their regular doctors incur a financial penalty (a reduction in the “access bonus”). But many enrolled patients still seek care from other providers. Last year alone there were over 1.7 million visits by enrolled patients with other physicians, for services that their regular family doctor may have been able to provide in a timely manner.

The progress in ensuring access to care is likely best illustrated in survey results. In the most recent round of Commonwealth Fund results, Ontario physicians reported that roughly 60 percent of their patients were able to get same or next day care on request (the national average was 47 percent, in the United Kingdom it was 86 percent). Ontario docs also reported that 67 percent of practices have an arrangement where patients can see a doctor or nurse if needed when the practice is closed (versus 46 percent nationwide and 95 percent in the UK). And roughly 60 percent of Ontario practices shared after-hours services with other practices or groups (44 percent was the national average in Canada and 61 percent was the response in the UK).

While survey results indicate that Ontario is performing much better on primary care access measures relative to other Canadian provinces, we could be doing much better.

What does the UK do so well? For starters, UK doctors provide more advanced-access scheduling opportunities, some online appointment scheduling services, and are obliged to offer after-hours care as well as weekly walk-in hours. And walk-in clinics in the UK are organized to function primarily as complements to family practices whereby most services provided are minor in nature and clinics are largely staffed with nurses.

But primary care in the UK also has extremely high numbers of patients on their capitated rosters, allow doctors the opportunity to run parallel private practices, and charge patients fees out of pocket when they visit outside doctors for services that could have otherwise been performed by their enrolling physician. In fact, most other countries where the per-patient payment models are used require patients to seek out their primary doctor in the first instance. For example, health maintenance organizations, which are common in the US, steer patients to seek out the services of providers on the organization’s list. These policies are blunt, controversial, yet effective levers to encourage patients to get most services from their regular family doctors.

With nearly 2 million visits to outside physicians in Ontario last year – enrolled patients who seek out care elsewhere – there clearly is room for strengthening the relationship between patients and their primary-care doctors under new payment models. Patient data show that most outside use occurs on weekdays; is common among younger patients; occurs when a patient’s primary doctor was in his or her office; and, tends to be at outside doctor’s offices that were long distances from a patient’s home. Although the long distances travelled to visit an outside doctor seem puzzling, what’s likely happening in the data is that many patients are seeking care closer to their place of work or their school. Saddled with busy lives – and jobs that limit their free time – patients are sometimes seeking care by reducing the private costs of travel and time, without necessarily paying attention to their enrollment agreements. Patient convenience still plays a part in Ontario’s primary care system.

The data do not show if patients who sought outside care tried to get same or next-day access to their regular doctor but were unsuccessful. However, it’s fair to conclude that many of them simply wanted to save their time and resources by visiting the local walk-in clinic nearby. The key lesson for policymakers is that financial reductions in payments to doctors – a key part of the current payment model (the access bonus) – is insufficient as a means of promoting the family doctor-patient relationship.

Both parties must do more. Enrolling physicians should make great efforts to show available after-hours care, and perhaps offer a block of hours when their office is available on a walk-in basis, like in the UK. We could also consider making the services available at walk-in clinics more complementary – meaning staffed mainly by nurses and intended only for minor health needs – to those offered by family practices, something which could also be driving the strong UK access results. Another option would be for the government to impose a maximum amount of time within which a patient must be seen. The government could also track access to care and after-hours availability, for example.

To the extent that patients might be ill-informed about their enrollment agreements, doctors should clarify to patients that, upon signing the enrollment agreement, they are agreeing to only seek care from another provider as a last resort.

A bolder proposal would ask patients with a pattern of frequent outside use to pay a nominal charge if they visit outside providers for basic services. Patients who work long distances from home could be permitted one or two outside visits per year before charges begin. Or better, such a charge could be contingent upon their regular doctor’s ability to provide an appointment within 24 hours of a request. Patients with regular outside use patterns can also be encouraged to enroll with family doctor closer to their place of work or be notified when a space becomes available.

Ontarians value a high level of patient flexibility and convenience. But frequent visits to outside doctors weaken the family doctor-patient relationship and lead to wasted public resources and multiple treatments.

The comments section is closed.

  • Hanssen Tulia says:

    I really loved this article! It gave me some new insights I never really thought about before.

  • Marie says:

    Well, what do you do when your primary doctor doesn’t take your health seriously? Should we not be allowed to get a second opinion? It is our health after all.

  • Tanja says:

    There needs to be major changes in the training of doctors in medical schools. First; pharmaceutical companies fund/train in many of the medical school programs. If this is not a conflict of interest, I don’t know what is. Second; doctors are only given between 8 and 25 hours of nutritional training within their 7-8 year medical school program. The public is realizing that pharmaceuticals are not the only way to stay healthy and understand that doctors have no training in alternatives. Question; why is there such a disjunct system when the best and most expensive cancer hospitals in the world tell their patients that they should eat only a plant-based diet to fight cancer and others cancer hospitals say that it is ok to eat meat and dairy? There is an injustice in the system. The public deserves better. Doctors also need to step up, find ways to fight through the system or get out and run their own practice privately so they have more control, allowing their patients to thrive.

  • Clare says:

    This post makes some very good points. I liked the comparison with the UK, and as I have lived both in Ontario and the U.K, I can understand your points even better than most. I think every FP in Ontario should have at least two half days a week for walk in patients, depending on the volume of the practise. At the present, it takes my two to three weeks to get an appointment with my doctor. I have even offered to see a nurse practitioner, but was told I had to choose whether to see the doctor or the nurse- I could not be enrolled with both! Waiting three weeks if you have something like pneumonia could be fatal. When I was in the UK, the waiting rooms were full with thirty or so people. Here there are two or three. So why the long wait for an appointment? There is no evening or weekend cover. The phone message says “Go to the emergency department of your nearest hospital”.
    As someone else commented, the support staff, receptionists etc. are often rude and unpleasant, and talk down to you like a small child. I can hardly ever get through to the receptionist to book an appointment. The voice mail comes on and she never phones me back. If you are not feeling well, this is very frustrating.
    Another point: Why does every prescription have to be faxed to the pharmacy? Why not a direct computer link? Same with the lab. My clinic is always faxing lab requisitions and prescriptions to the wrong lab or the wrong pharmacy!

  • Pamela Zätterberg says:

    What if you don’t trust your FP? Mine doesn’t listen, rarely takes the time to do a thorough exam or investigation of a problem and is away from the office more than he is present. He is always too rushed to take the time to understand and it feels like we aren’t welcome.

    I was only able to find a family doctor once I was pregnant 20 years ago. Doctors were simply not taking on patients. I had no choice in who I was seen by and ‘lucked’ into having this FP take me on because he would deliver babies.

    For the past 19 years I have only gone or taken the children when it was absolutely necessary and yet I’ve felt like I was wasting his time each and every time!

    When a very scary set of symptoms presented themselves I tried to get him to listen but he quickly gave up and suggested I see a naturopath (not covered by Ontario’s health care). I did and though it has cost me a great deal financially; I feel listened to, understood and am on my way to feeling better.

    The holistic approach that the naturopathic Doctor takes has restored my health and I respect and trust this approach. I feel this type of medicine aught to be covered in Ontario so that we may have choices for our healthcare.

  • John MacIntosh says:

    Not mentioned is that it is very tempting for doctors to take on a too-large patient roster. Docs get paid in part based on the size of their roster, whether or not they ever see the patient. My doctor has been impossible to get in to see, frequently her office is closed, or the wait to get a regular appointment is over a month. In five attempts in the past year and a half, no luck at all, and we always have wound up obediently going to a far away partner walk-in (others are much closer) on the days (weeks, really) when she is closed and we’ve needed care. The only time we’ve ever met her was for our new patient interview. Frankly, I think the sole purpose of that was to make sure we would be ‘low maintenance’ patients, and just generate that passive income for her of having a large roster.

  • i would prefer not says:

    I visit an other doctor because my present doctor attitude is impossible to digest

  • Elizabeth Rankin BScN says:

    Interesting article which raises issues that still seem to pose problems for patients: uneven access to getting or seeing a doctor, patients choosing other service providers over the one they are rostered with and the list is endless BUT one problem that both patients and physicians and other health care workers want is personal recognition and satisfaction with their doctor-patient experience. To achieve this, the model for health care must be unified using a model that provides a service that is actually beneficial to both patients and practitioners.

    Patients want to be listened to which requires both time and a mix of the right professional practitioners to provide the right service at the right time for the right needs of the patient. The largest problem facing patients is having access to this type of care. Patients seeing one physician in a single practice is the weakest and poorest way to practice medicine and it should not be allowed. If OHIP refused to pay this type of practitioner it could solve the issue for that type of practitioner who feels”burned” by their patients selecting other service providers who work together to provide the service that patients both want and need. Weeding out this type of practice is step one if we are to engage the right type of interdisciplinary team to provide the type of care patients need so they aren not required to go elsewhere to see various professionals who can properly service a variety of needs within any population group of patients. It is well documented that the matched team approach provides better care and achieves better patient health outcomes.

    The fact that “frequent visits to outside doctors weakens the family-doctor relationship” is something that is not the patient’s fault IF AND WHEN the patient doesn’t have access to a model that services patients the way they want and need to be serviced. Patients today are far more savvy. They want the technology used in doctor’s practices they use everyday for themselves and in business, using email to set appointments etc. Many doctors and other practitioners would too. For example, patients should have access to practitioners using Skype of Face Time for those patients that can be serviced promptly and more easily when an office visit isn’t necessary. Patients should be able to share their data readily and easily and should be able to access their data equally as easily so they have copies of all relevant data about them which is essential since the EHR system is known for not serving either doctors or patients well. The patient having control over “their data” permits health care providers to access what the patient has on file for themselves AND they verify if the data is correct, something doctors don’t necessarily know. [Upcoming on a project I’m currently working on and bringing to market.]

    Changes are in the works and the model of care that has existed for ages is archaic and those that currently are moving or have moved to offer better service need to report here to let us know how they experience the difference.[both patients and practitioners]. Making a better and safer patient experience is rewarding for all.

  • Graham Scott says:

    Excellent assessment. The two primary goals should be to enhance access to the family group practices while placing greater constraints on Walk-in clinics. A sound system of electronic appointments would improve access and lower the patient temptation to use walk-ins and the latter should be held to a much higher standard of patient care and accountability thus discouraging the attractiveness of superficial well paying services provided by most walk-ins.

  • Elizabeth Doyle says:

    Thank you for a very interesting and thoughtful article, Ake Blomqvist and Colin Busby.

    In my experience, accessibility and time-constraints are, more often than not, what dictates the average person’s day-to-day activities in heavily populated urban areas. If someone has to go out of their way for a service (even health care related), it’s just not going to happen, unless there is a financial (dis)incentive imposed. I suspect this is one of the reasons why so many patients, who do not have family doctors, don’t access health care unless it’s urgent. They simply do not feel that they have the time to wait, and/or they can access resources online that can help them self-diagnose (with greater or lesser success and efficiency). Sadly, the loyalty and trust is to the dollar and the clock, not the system. With that in mind, I think making office hours and bookings available online would be a welcome time-save that would go a long way in improving the face-to-face time between family doctor and patient, and thereby lessen redundancies and gaps in care.

    Elizabeth Doyle

    • MyraMaines58 says:

      Amen Elizabeth.

      Why not use the model as they do in places which ARE inaccessible and have a PRIVATE “chat” as it were where patient could sit in front of their screen (with doctor present on the other end) and show doc problem there?

      It would save an ENORMOUS amount of time, not to mention cost overhead!!

      Personally, I DO have a strong connection with my family doctor. Unfortunately, he is the SECOND GP I have had to go on sick leave.

      I have MULTIPLE chronic conditions which require medicine often and sometimes I cannot reach doctor AT ALL. Or he is NOT there. It is happened MORE times than I care to count …

      Now, I am at my wit’s end with it all. After almost 14 YEARS, yes, I said YEARS, I have NO resolution. NOTHING is even on the radar and unfortunately for me, NO WAY for medical science to do surgery YET.

      What am I to do?

      Sit here and stay at home and live like the hermit I am becoming? Of course, I have withdrawn from most of society and friends and am becoming estranged from my family …

      I am NOT depressed, as I LOVE life … BUT … there is a LIMIT to what a human can endure …

      As someone who applauded when Dr. Low finally made his heart-wrenching video … (I had admired Dr. Kevorkian for decades and what he was doing), I yet again had hope that MAYBE just MAYBE doctors would listen and learn AND politicians … Sigh.

      There ARE things WORSE than death … I am a living example …

      I haven’t given up hope but sometimes I ENVY people who have now passed — at least they had an end to their suffering.

  • Dr. Poland says:

    I am of the minority opinion that the days of the family doctor are numbered, and that family doctors serve no real purpose in heavily populated urban areas.

    In rural areas, a jack-of-all-trades general practitioner still holds value and is a required element of the health care spectrum since specialist access is limited.

    In cities, family doctors exist to refer patients to the appropriate specialist, one problem at a time (competition is fierce and one-problem-per-visit ensures that offices do not go bankrupt). This is a needless redundancy.

    I believe that patients should have access to specialists from the get go, and that specialist would deem, just as a family doc does at present, which other specialist to send the patient to should that patient’s problem not be of that specialist’s bailiwick.

    The value of the family doctor can be seen in their incomes. Those that do old-fashioned Marcus Welby medicine barely make ends meet. Those that practice everything except “family medicine” do not have this problem. If OHIP billings are a direct reflection of the value of services provided, then true family medicine is not worth much. We should just stop doing it.

    • Ed says:

      %featured%I wholeheartedly disagree with your opinion re: urban family medicine. Having grown up in the US, I am quite used to the approach of visiting specialists without referral. The result? Going to an ENT for an earache, and having my ears flushed out to remove wax. Such a system would be annoying to specialists, as well as a massive cost to the public for all the specialist consultations for things that could’ve been dealt with more simply and directly. In addition, without a central hub to coordinate all these various specialists, how are patients to make sense of conflicting recommendations or prescriptions that might pose interactions? The role of the primary care professional is invaluable despite the setting, in my opinion.%featured%

      I’m a family medicine resident planning to practice in an urban area, and if spending more time with patients means less take-home pay, I’m fine with that. I would challenge you to find me an urban family doctor who’s struggling to put food on the table.

  • David Daien says:

    There is no doubt that FP are not always easily accessible. However, there must be partnership with patients taking some accountability. I have 7 same spots available today and one of my patients just registered in the ER with “foot pain”. One wonders if I had a patient portal if the patient would have used the channel to contact our office prior to going to ER.

    • Donna Clare says:

      An integrated system would have the ER contacting your office to see if you could see your patient with the un-emergency (triaged by a nurse). If you did in fact have time/room, then the patient is refused care at the ER and directed to your office.
      It takes a village.

  • Shawn Whatley says:

    Great post.

    Accountability presupposes freedom. We need freedom to choose between meaningful options in order to be held accountable for our decisions. Physicians have little freedom to design creative solutions to attract patients to behave in ways that benefit patients and the system, and have almost no reward for doing so. Patients have limited options to seek care beyond one physician’s office, walk-in clinics, and the emergency department.

    When we arbitrarily assign the price of bread and limit the number of bread makers, grocery stores will rarely have the supply or variety of bread that customers want.

    We waffle between seeing physicians as civil servants vs. small businesses. If they are civil servants, we can put them on salary, give pension and benefits, and mandate office hours. Or, physicians are small business that adjust their behaviour, and prices, in response to market conditions. Currently, we have a strange blend of the two pretending that docs have freedom, but with prices fixed.

    Thank you for a great post!

    Shawn Whatley


    • MyraMaines58 says:

      Thanks for your post. As a patient, and someone who has lived in Ontario all my life it appears to those outside the profession doctors strictly work on THEIR terms and THEIR terms only. The more letters after their name – I don’t want to deal with them AT ALL.

      Primadonas NOT wanted.

      What patients REALLY want and I am sure, doctors are occasionally patients themselves, is for their doctor to LISTEN to them. Most don’t.

      It appears you are ALL taught NOT to think. This new method of “scientific-based medicine” is SO asinine and should be ABOLISHED. When a patient tells you SYMPTOMS you MIGHT listen and look for something – odds are you WON’T doctor.

      What you WILL do however is go to insane lengths to prove a horse is a horse is a horse when it fact, MOST these days are NOT horses but Zebras.

      Also, stuffing 10 patients into the time allotted for ONE, is truly suicidal. Both for the patient AND the doctor – with the latter usually going on SICK leave for stress, which THEY created themselves because they don’t want to hire the PROPER staff to deal with the public – someone who is paid an actual DECENT wage, instead of the $10 an hour, vacuous employees you now have …

      On second thought … most doctors advice is often vacuous …

      If you want to CHARGE for patients, GLADLY you should go to the States :-) BUT please BEFORE you leave, repay the ENORMOUS grants, you have received from Canada and whichever province, and pay what it REALLY costs … only THEN can you have what you call “pretend” freedom ;-)

      Most are back here now who left when they realized how THAT system doesn’t work!

      ALL MEDICAL TRAINING NEEDS TO BE THROWN OUT. What we need is a walk-in clinic AT the emergency room – SHARING the space and ONLY being paid the $50 and not the almost $300 they charge at a hospital!



Åke Blomqvist


Åke Blomqvist is an Adjunct Research Professor at Carleton University and a Health Policy Scholar at the C.D. Howe Institute.

Colin Busby


Colin Busby is a Senior Policy Analyst at the C.D. Howe Institute.

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