To: Canadians Concerned About Primary Care Access
From: Tingting Zhang and Rosalie Wyonch
Date: April 26, 2023
Re: Improving Primary Care Access
Too many people don’t have a family doctor, a longstanding and worsening problem in Canada while primary care is the foundation of our healthcare system.
Health systems with strong primary care have better outcomes, lower emergency use, lower mortality, lower costs, better chronic disease management, and greater equity. But there were about 4.6 million Canadians 12 and older who did not have a regular health care provider in 2019. And, equally troubling, about 6.6 million Canadians had a family doctor aged 65 and over.
And the situation has worsened. By 2022, one in five survey respondents had no family doctor or nurse practitioner. With no family physician, emergency departments become a default option for those seeking care. In 2020, 40 percent of Canadians reported they went to the emergency department for a condition that could have been treated at a regular place of care. And only 41 percent of Canadians with a family physician said they could get an appointment on the same or next day when they were sick or needed medical attention – the second lowest reported percentage among the 11 developed countries included in a Commonwealth Fund study.
The pandemic has made things worse. Younger physicians under age 55 were more likely to experience stress, emotional distress, and burnout. Half or more of older physicians reported that they would stop seeing patients within the next three years (and 24.5 percent of family physicians are over 60). In the first six months of COVID, twice as many family physicians stopped practicing in Ontario, compared to previous years.
Though the current and future demand for family physicians is high, the supply has been growing slowly, merely 1.3 percent between 2019 and 2021. By 2031, occupational projections suggest Canada will be short about 19,500 family physicians and general practitioners.
To make matters worse, fewer graduating medical students are interested in family medicine, compared to other specialties. The 2022 Canadian Resident Matching Service (CaRMS) showed that 7 percent of family medicine spots in Canada were unfilled (99 positions, mostly in Quebec). No other medical discipline had more than three unfilled residency positions in 2022. Meanwhile, there are hundreds of internationally trained physicians interested in family medicine but do not have residency positions available to them. Fully 979 international medical graduates applied for family residencies last year. Just 324 were matched, a match rate of just 33.1 percent compared to 97.4 percent for Canadian medical graduates.
One big reason is lower incomes. Family physicians made about $70,000 less than medical specialists and $179,000 less than surgical specialists in 2020-21. And those lower incomes are not take-home pay, they are business revenues. Most family physicians are independent small business owners, responsible for all staffing and infrastructure costs. Running a business also includes administrative burdens that results in time and productivity losses. Physicians across Canada spend 18.5 million hours a year on unnecessary administrative work – equivalent to 55.6 million patient visits.
There are a number of actions that could help. Some are relatively simple, such as increasing the number of residencies for international medical graduates, or reallocating unfilled residency slots from the domestic stream to the international one. Others require more significant government intervention and coordination. Those include:
- Reorienting care delivery around a team-based model. In the team-based model, each health professional in the team can leverage their expertise, making the most of their profession’s scope of practice. Having family physicians work with nurses, nurse practitioners, pharmacists, social workers, and other health professionals also increases the coordination of care and provides better care for complex patients. Larger practices create economies of scale and greater administrative efficiency. Younger medical graduates also prefer shifting from the traditional small-business model of family medicine to being employees with paid vacation and parental leave. Team-based care can accommodate vacations, without leaving patients without a primary care provider.
- Review and reduce regulatory and administrative burdens. This might involve multiple government departments and private sector insurance (for which family physicians provide medical authorization for patients to be able to access various public and private benefits).
- Reduce barriers for licencing and expand scopes of practice for other medical professions such as nurse practitioners and pharmacists. For example, Ontario is making it easier for physicians in other provinces to temporarily practice in Ontario. Nova Scotia is in the process of piloting pharmacist-delivered primary care for 31 minor ailments and providing treatment for people with common chronic conditions like diabetes and asthma.
Tingting Zhang is a Junior Policy Analyst at the C.D. Howe Institute, where Rosalie Wyonch is a Senior Policy Analyst.
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The views expressed here are those of the authors. The C.D. Howe Institute does not take corporate positions on policy matters.