The Fixing Health Care series presents 10 common problems faced by patients in Canada, along with 10 solutions that the authors argue can be achieved within our existing publicly funded health system. While the ‘problem’ scenarios in the series are fictional, the authors offer these examples to echo the patient experiences they have encountered through their work in health care and social services
The Problem: It’s very hard to book a timely appointment to see a family doctor
Larysa is a single mother with a three-year-old daughter, Elena. Recently, Elena was sent home from daycare with a fever. At home, Larysa measured the child’s temperature; it was 39.5 C. She gave Elena an Advil, but Elena got more irritable and started crying, then vomited. It was 3:30 p.m. Larysa called her family doctor’s office.
An answering machine told Larysa that the office was closed and, if necessary, she could go to the emergency room. She called a government medical advice line, and a nurse told her to give Elena lots of fluids and to try Tylenol. Larysa put her daughter to bed and she seemed better for a bit, but at 9:30 p.m., she woke up, vomited again and would not stop crying.
They went to the nearest hospital, but Elena wasn’t seen until 1 a.m. The doctor said she had a virus, that Larysa should keep giving her fluids and see her family doctor. Larysa rang the doctor the next morning, but the answering machine had the same message.
Elena’s temperature remained high throughout the day, and she kept vomiting. She was miserable, and Larysa was nervous that something was really wrong, so she took her back to the ER, where she waited another four hours. She was glad she went – the ER physician said Elena had an ear infection and needed antibiotics. He told Larysa to follow up with the family doctor within 48 hours to make sure her ear was improving.
Larysa finally got through to the family doctor’s office the next day. The receptionist offered an appointment in 2½ weeks. When she told the receptionist that the ER physician had told her to have the ear checked within 48 hours, the receptionist said she should go back to the ER.
This is not the first time Larysa had to go to the ER when her daughter was sick. She likes her family doctor and he is nice when they go in for checkups. But whenever Elena gets sick, a timely appointment seems impossible.
The Fix: Canada needs more primary-care nurse practitioners
In response to the common problem described above, medical associations in Canada have suggested that the country needs more family doctors (FDs) to improve timely access to care for sick patients. The Ontario Medical Association has identified “fixing doctor shortages” as a key issue that the province’s health care system needs to address, and it’s a growing problem from coast to coast. Newfoundland and Labrador has around 98,000 residents in need of a doctor, for example, while 900,000 British Columbians currently don’t have an FD. This is especially taxing for urgent-care systems, as more patients are turning to walk-in clinics and emergency departments for matters that could be attended to by an FD.
According to a 2019 report from the Canadian Institute for Health Information (CIHI), however, Canada’s growth rate for its number of physicians over the previous decade has either kept pace or outpaced the growth rate of the general population, even doubling the general population’s rate of increase between 2015 and 2019. In 2020, half of Canada’s physicians (46,797 of 92,173) were family doctors, according to CIHI. Still, nearly 15 per cent of Canadians aged 12 or older indicated to Statistics Canada in 2019 that they do not have “a regular health care provider they see or talk to when they need care or advice for their health.” An uneven distribution of family doctors between urban and rural regions also exacerbates the problem for Canadians living outside of major city centres.
Data from Ontario might explain why a rise in the number of doctors in Canada has not necessarily translated into an increase in family-doctor availability. In a 2016 report, the Auditor-General of Ontario found that the average FD working in a family health organization (or FHO, a common primary-care model used by about half the province’s FDs) sees patients in their office fewer than 3½ days a week.
The Auditor-General also reported that despite the number of family doctors in Ontario increasing by 31 per cent from 2006 to 2016, the wait time to see an FD had increased. The report noted that in a survey of Ontario Ministry of Health data from October, 2014, to September, 2015, 60 per cent of FHOs “did not work the number of weeknight or weekend hours” mandated by the contracts FHOs must sign with the ministry, a requirement that is meant to reduce the number of patients with acute-care needs making unnecessary visits to the emergency room. In addition, the report found that around 30 per cent of Ontarians had visited a walk-in clinic during the survey period “for care that could normally be provided by family physicians.”
There are a few reasons why we’ve encountered this gap in our continuum of care, and the first cause is not unique to physicians. As society places a greater emphasis on work-life balance, family doctors, like many other professionals, may not be willing to provide as many hours in-office as previous generations did. Family doctors operate their practices as small businesses (similar to independent contractors) and must ensure that they generate sufficient income for their needs. Many FDs may seek out additional sources of revenue by working in other settings (for example, providing care in emergency rooms, walk-in clinics, hospitals, nursing homes or via telemedicine), as opposed to solely seeing patients in-office.
Since FDs are technically independent contractors and not employees of the government, they also generally have no legislative or contractual commitment to the number of patients they treat, which makes human-resource planning for primary care difficult for provincial ministries of health. FDs are their own bosses and decide what services they will provide and when – the fact that there are many who do prioritize timely access to care is a credit to their professionalism. A variety of incentives have been offered to lure physicians to rural Canada, but we still haven’t managed to resolve the doctor deficit in remote communities – 19 per cent of Canadians live in rural regions, whereas only 8 per cent of Canada’s physicians practise in these areas.
So how can we solve this problem?
We propose that Canada has an inadequately utilized primary health care human resource in both our nurse and nurse practitioner populations.
There are currently 300,000 nurses employed in provinces across the country, 7,100 of whom are qualified as nurse practitioners. Once they earn their designation, NPs can provide many of the same services to patients as family doctors can, and for certification they require just two additional years of training after completing their undergraduate nursing degree (as opposed to the minimum six years of additional training required for a family doctor after their undergraduate degree). Nurse practitioners working for provincial health ministries or organizations receiving provincial funding are required to provide regular office hours, after-hours care, and clinic hours on weekends, often for rosters of about 800 patients each (NPs also work collaboratively with physicians when more complex care is required).
If provinces were to prioritize primary-care training streams at institutions that certify NPs, employ these graduates and draw from the existing population of nurses to train more NPs, this could work to fill Canada’s gaps for timely access to primary care much more quickly than relying solely on the training of new doctors. We believe this could be achieved by a concerted effort on the part of governments to employ nurse practitioners in regions where there are gaps in primary care. Of course, in addition to training more nurses as NPs, provincial governments also need to attract more students to the nursing profession.
With shorter training times, hiring nurse practitioners to work in smaller, rural communities is also more straightforward than trying to convince doctors that they should open offices in sparsely populated areas. Governments could even support nurses who already live in rural communities to train as nurse practitioners, a more effective solution than trying to convince doctors to move to more remote locations.
For decades, studies have shown that patient health outcomes and satisfaction with the care provided by independent nurse practitioners is as good as patient satisfaction with family doctors. The authoritative Cochrane Library evaluated 18 randomized trials comparing nurse practitioner and physician outcomes and concluded that nurse practitioners “probably provide equal or possibly even better quality of care compared to primary care doctors.” And, according to a 2015 review of 11 scientific studies, the NP care model is “potentially cost-saving.” Currently, 25 nurse practitioner-led clinics are successfully operating in Ontario.
Ministries of health across the country should augment and improve access to primary care by training and hiring more primary-care nurse practitioners instead of solely trying to fill primary-care gaps using only doctors.
About the authors:
Dr. Robert Bell is professor emeritus in the Department of Surgery at the University of Toronto, former deputy minister of health for Ontario, and former chief executive officer of the University Health Network. Anne Golden is past president of the United Way of Greater Toronto and the Conference Board of Canada. Paul Alofs is former CEO of the Princess Margaret Cancer Foundation. Lionel Robins is past chair of the Princess Margaret Cancer Foundation, and a board member for the United Jewish Appeal Federation and the Betel Senior Centre.
More from the Fixing Health Care series:
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