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Question: Although I like my family doctor, I find it takes a very long time to get an appointment, even when I am not feeling well. A friend of mine has another family doctor and this doesn’t seem to be a problem. We both live in Ontario. Why the difference?
Answer: That sounds very frustrating. If it’s any consolation, a lot of other patients also have trouble seeing their doctors in a timely fashion.
In recent years, provincial governments and medical associations have introduced various measures to speed up the time it takes for patients to see their primary health-care providers. But relatively prompt access is still not available to a majority of Canadians.
Only 41 per cent of Canadians can get an appointment the same day or the next day with their own doctors, according to a report released earlier this year by the Health Council of Canada. When patients can’t see their family physicians, they often head to the nearest hospital – and that contributes to longer emergency department wait times. So the issue of access has wide ramifications for the health-care system.
The Health Council report is based on data from the Commonwealth Fund, which conducts annual surveys of people who live in 11 affluent nations including the United States, United Kingdom, Canada, Australia, New Zealand and several European countries.
Canada was at the bottom of the heap in terms of how quickly people can get an appointment with their physician. (Germany came out on top – with 76 per cent of those polled reporting swift access to a primary care provider.)
Still, some Canadians are served better than others. You noted that your friend doesn’t have trouble getting an appointment and wondered why you do.
There are several reasons that might account for the difference in response time. But it often hinges on one thing – how well your doctor’s office is organized, says Joshua Tepper, president of Health Quality Ontario, an arms-length agency of the provincial government.
For a better understanding of the issue, it’s worthwhile reviewing a bit of recent health-care history in your province.
About 15 years ago, Ontario began to encourage physicians to work in groups, rather than in solo practices.
“If you have 10 doctors working together, you are just going to have more flexibility during the day and after hours than a one-doctor shop,” explains Dr. Tepper.
There are a number of different models including family-health teams, family-health groups and family-health networks. Essentially, if your own doctor is busy or away, you can see another member of the group including other professionals like Nurse Practitioners and Physician Assistants. The team can also take turns providing care after regular business hours.
As part of the move to group practices, Ontario also offered doctors a new way to get paid. Physicians have traditionally worked on a fee-for-service basis, in which the province pays them a set fee for each service they provide to a patient.
Under the alternative arrangement called capitation, doctors receive a lump sum based on the individual patient. The amount is adjusted to take into account the age, gender and medical complexity of a patient. “You get paid less for a healthy 23-year-old male than you would for an 85-year-old male with several chronic conditions,” notes Dr. Tepper. In most models, doctors can also charge the province separately for additional services not considered part of their regular duties, such as home visits.
Overall, physicians’ incomes have been on the rise. “There was a deliberate plan to increase the incomes of family physicians so they didn’t lag behind other specialists,” says Dr. Rick Glazier, a health services researcher at the Institute for Clinical Evaluative Sciences located at Sunnybrook Health Sciences Centre in Toronto.
The added financial incentive helped to boost the number of physicians entering family medicine – reversing an earlier trend in which new doctors were choosing other specialties.
In theory at least, group practices should be improving the quality of health care and making it faster for patients to see their doctors. But unfortunately the teams don’t always produce the intended results.
Although we now have more family doctors in the province than ever before, many are working only part-time – devoting some of their attention to other professional duties or personal matters. Those other activities “take away from clinical care and make it much harder to fully utilize your resources within the team,” says Dr. Tepper. So a relatively large group practice may have only a limited number of physicians who can take same-day or next-day cases.
Another problem is that it can be hard to co-ordinate the doctors’ schedules so they function effectively in teams that can deal with urgent cases.
“Even when you are really committed, it is not entirely clear what is the best way to do it. A few options have been tried,” says Dr. Tepper.
One scheduling approach is called Advanced Access, in which a doctor leaves open a significant number of appointments each day for those last-minute calls from patients who need immediate attention.
“It’s actually very difficult to change your scheduling system,” says Dr. Glazier, who works in a group practice at St. Michael’s Hospital in Toronto.
“You have to be kind of brave and bite the bullet to leave most of your slots open for a day. What if nobody shows up?”
Some group practices put doctors on a rotation system, in which one of them handles the bulk of urgent cases that need to be seen on a given day.
However, this approach has drawbacks, too, because it doesn’t provide for continuity of care. “Its works for treating things like coughs and sprains. But if you have diabetes or a chronic problem like hypertension, you want to see your own doctor – not a different doctor, ” says Dr. Glazier.
Patients also have had to adjust to the new system. At some clinics, patients were initially told they couldn’t book an appointment more than a few weeks in advance. But many patients need extra lead-time in order to book off work or arrange childcare. The clinics eventually loosened up their schedules to better meet the needs of their patients.
“Every practice handles booking and appointments differently,” says Dr. Glazier. “Some have done well and others have really struggled.”
So what are the options for patients like you who might be in one of the struggling practices?
In an ideal world, the health-care system would be patient-driven. You would simply move your business to another group practice that provides services that best meet your needs, says Dr. Tepper. But that’s not going to happen any time soon. Also, he points out that “same day access is only one element of what might draw you to a practice.”
Dr. Glazier suggests you should have a discussion with your doctor about access and availability. Some physicians may be quite open to having patients show up at their clinic, and then they will try to squeeze them in between existing bookings, says Dr. Glazier. If a same-day or next-day appointment isn’t possible, there may be other ways to communicate. Some doctors are willing to talk to their patients on the phone or correspond by email.
From my own personal experience, I know that being a patient in a group practice can have its advantages. My doctor is in a well-organized family-health team and I can unusually get a same-day or next-day appointment. In fact, I recently had a skin infection that was rapidly getting worse. Because I work at Sunnybrook, I could have popped down to the emergency department and waited my turn to see a doctor. It would have been very convenient. But I realized that was not the right thing to do.
So I called my family-health team at Toronto Western Hospital and was offered an appointment within the hour. When I arrived, I was assessed by a nurse who concluded I needed to be seen by one of the team doctors. Within a few minutes a physician reviewed my case, wrote a prescription for antibiotics, and I was on my way. And lucky for me, my infection was brought under control without resorting to a potentially lengthy wait in an ER.
“One of the things we’ve done is to focus on the full scope of the practice of the inter-professional team,” says Teri Arany, the acting executive director of my family health team. “Access to care is integral to our processes.” Nurses, she explains, triage and screen to determine what kind of care the patient needs. “We also have strong receptionist who assist in triage,” making sure urgent cases are seen promptly.
Group practices can work in an extremely efficient manner. Let’s hope more doctors learn how to master the system.
Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog Personal Health Navigator is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to AskPaul@sunnybrook.ca and follow Paul on Twitter @epaultaylor