More than one in five Canadians — an estimated 6.5 million people — do not have a family physician or nurse practitioner they see regularly, according to a national survey. That’s a dramatic increase since 2019 when Statistics Canada estimated only 4.5 million people did not have a regular health care provider.
The OurCare initiative, led by Tara Kiran at Unity Health Toronto, surveyed more than 9000 people across Canada last fall about their access to primary care and preferences for the future.
“One thing that was striking to me was just how much variation there is in access to a family doctor or nurse practitioners across the country,” Kiran said. “I live and work in Ontario, and I think there’s a big problem with access here, but Ontario fared the best with just 13% of people saying they didn’t have a primary care provider they see regularly.”
By contrast, more than double that number in British Columbia (27%), Atlantic Canada (31%), and Quebec (31%) said they lacked a primary care provider.
“The fact that almost a third of people [in some provinces] don’t have a family doctor or nurse practitioner is heartbreaking,” Kiran said.
Racialized people, those with lower incomes, and those in poor health were among those least likely to report having a regular primary care provider.
“People who most need access to primary care are struggling to find it,” said Ruth Lavergne, an associate professor in the department of family medicine at Dalhousie University in Halifax.
According to Kiran, these findings are in keeping with recent reports of worsening access during the COVID-19 pandemic.
One recent analysis of administrative data showed the number of Ontarians without a primary care provider rose from 1.8 million in March 2020 to 2.2 million in March 2022. Meanwhile, roughly 3% of family physicians in the province stopped working in the first six months of the pandemic — twice as many as in previous years.
People without a regular primary care provider told OurCare they sought treatment for nonurgent health issues at in-person and virtual walk-in clinics (50% and 27%, respectively) or emergency departments (24%) instead.
Some turned to other health professionals, including pharmacists (14%), chiropractors (5%), specialist physicians (3%), and naturopaths (3%).
Notably, more than one in five people without a regular primary care provider (21%) reported paying a fee the last time they sought care. This was most common in Quebec, where 37% reported paying such fees.
Relationships matter most
Overall, survey respondents were less concerned about the type of professional providing them care than their relationship with that provider.
Sixty-five percent ranked having a provider who knew them as a person and considered all the factors affecting their health as very important.
“Often, I think, we hear about struggles with timely access but don’t focus enough on the fact that people want this relationship with their provider, so that was really heartening to hear,” Kiran said.
Meanwhile, 90% of people said they would be comfortable or very comfortable receiving care from other types of professionals in a team if their family doctor or nurse practitioner recommended it.
“Interprofessional, team-based care is something that pretty much all family doctors have been advocating for for a long time because we know the benefits,” Kiran said. “It can improve outcomes and increase the capacity and joy of providers at work… and now, we see from these results that patients are ready to embrace it.”
Still, only a minority of respondents reported receiving team-based care currently.
“Most people said their family doctor didn’t have other team members as part of their practice, especially when it came to professionals that are not nurses or nurse practitioners,” Kiran noted.
And even where team-based care has been implemented, “we’re not always keeping that issue of improving provider capacity at front and centre,” she said. “Often, it’s been add-on care.”
Early failures to make the most of teams to ease pressure on family doctors may partly explain why provinces like Ontario refocused on quicker fixes like urgent care centres and walk-in clinics in the 2010s, Kiran said. Now, the pendulum appears to be swinging back again, with recent investments to create 18 new interprofessional teams in the province.
Virtual care disconnect
The rise of virtual care during the pandemic has been touted as another boon for access, but survey respondents expressed mixed feelings about it.
When asked how they would like to access primary care, 92% ranked scheduled in-person visits as important, followed by phone calls (66%) and in-person drop-in appointments (54%).
Less than half the respondents ranked email or secure messaging (42%) or video (41%) as important. Fewer still actually used these services in the past year (18% and 5%, respectively).
And despite more than a quarter of respondents saying they used virtual walk-in clinics the last time they sought care, they expressed strong opposition to using such services owned by for-profit companies, pharmaceutical companies, or companies that sold their deidentified health data.
Kiran said this disconnect between patients’ preferences and their use of virtual services suggests that some patients may have nowhere else to turn while others “probably don’t know how their data [are] being used.”
Research also suggests virtual walk-in clinics may be adding more churn to the system, driving more visits to emergency departments, and diverting human resources from the ongoing, relationship-based primary care that people want.
Ensuring everyone has access to a regular primary care provider is “multifactorial,” Kiran said, and will partly depend on reforms to recruit and retain more professionals. “That includes payment reform, meaning shifting from fee-for-service to capitation or salaried models, team-based care, and even going further than the models we have now.”
“We need to rethink how we fundamentally organize the system because so many new grads are not even interested in starting up their own businesses,” she explained. “So can we have more employment-based models, be more geographic in nature, and shift to a model kind of like a public-school catchment, where ideally, if you move into a certain neighbourhood, you’re guaranteed access to a local primary care team?”
Governments may also have to impose checks on how family physicians use their licences — for example, restricting focused practices in psychotherapy or sports medicine that take away from comprehensive, longitudinal care. “The more focused practice opportunities and freedoms we have in that respect, the less the likelihood of people setting up shop to provide the type of care that’s most needed,” Kiran said.
Radical change to support more people having long-term relationships with team-based primary care providers can’t happen “magically for everyone everywhere,” Kiran acknowledged. “But we certainly can take an incremental approach… in areas that we know are most in need.”
Digging deeper
For the next phase of the OurCare initiative, Kiran’s team is conducting in-depth discussions about primary care priorities with small, demographically representative groups in five regions across Canada. The team will also work with community groups to reach marginalized people who may have been missed by the initial surveys.
OurCare recently published the results of the first of these in-depth discussions with 35 Ontarians.
The Ontario panellists reaffirmed that primary care should be public, universal, accessible, patient-centred, holistic, intersectional, and culturally responsive. To this end, they recommended expanding Medicare to include mental health, eye care, dental care, and medications.
Among their top frustrations, the panellists cited difficulties accessing health records and recommended the government legislate interoperability among all electronic medical records systems to create a patient portal that serves as a single point of entry.
They also called for the automatic rostering of patients to local primary care teams while preserving some patient choice, as well as better links between primary care and community agencies to address social determinants of health like poverty and housing.
“Canadians know and feel that access to relationship-based family medicine and team-based primary care are the foundation of their health care,” said Danielle Martin, chair of the department of family and community medicine at the University of Toronto. “This is consistent with all the international evidence. We now need to act on what the residents of Canada are telling us.”
Footnotes
Posted on cmajnews.com on April 6, 2023
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