Social Policy in Ontario

Canada has more doctors than ever — but access is worse. Why is that?

Posted on November 2, 2023 in Health Delivery System

Source: TheStar.com — Authors: Michael Rachlis

TheStar.com – Opinion/Contributors
November 2, 2023.   By Michael Rachlis, Contributor

How could more doctors make access worse? The answer, most physicians’ practices are very inefficient.

Millions of Canadians report they do not have a family doctor or a source of primary health care. Even if they do, millions still go to ERs for problems that could be handled in an office setting. And yet Canada is producing more doctors than ever. What’s wrong with this picture?

According to the Canadian Institute for Health Information’s (CIHI) annual physician report released on Oct. 26, Canada has more doctors than ever. There were almost 2,000 more doctors in Canada in 2022. The number of doctors per capita went up by 1 per cent.

COVID-19 temporarily blunted physician growth. But, from 2009 to 2019, the number of Canadian physicians grew at an annual rate almost three times that of population growth.

Now we are back on track for record increases in physicians. Provincial governments are increasing medical school enrolments and licensing ever more foreign medical graduates. Even with brisk population growth, Canada will license new physicians at a higher rate than general population growth for the foreseeable future.Fullscreen

Yet, Canadians have worse access after more than a decade of record physician growth. How could more doctors make access worse? The answer, most physicians’ practices are very inefficient. Up to 50 to 70 per cent of family doctor visits could be performed as well or better by another practitioner. And doctors spend hours a week on administration.

Family doctors in training draw salaries and benefits, and work with other providers. After graduation, they find few such models of practice. Their team may just include a receptionist. And they’re mainly paid by fees for each item service — i.e., piecework. Hence the ubiquitous waiting room signs warning patients, “One visit, one problem!”

It is impossible to provide comprehensive care in such a setting. So most new doctors don’t. New family doctors instead cobble together an income from walk-in clinics, ERs shifts, and other casual work.

And in most so-called team practices, the collaboration is worse than a last place hockey team. Imagine a hockey team where the centres, forwards, defence, and goalies were trained and managed separately. And what if they didn’t even know that they were on the same team when they hit the ice? That describes all too many health care teams.

The Indigenous-run, Anchorage-based Alaska south central Foundation (SCF)shows what medicare could be. Primary care teams of a doctor, nurse, health care aide, and receptionist co-manage 1200 patients. Same day appointments are available, and the team provides over 95 per cent of primary care visits. No need for walk-in clinics.

For every six practices there are a pharmacist, a dietitian, three mental health counsellors, a midwifery team, and a full psychiatric team. SCF’s quality metrics are all above 75th percentile, notwithstanding a population with significant health and social challenges. Thirty per cent of daily appointments are left unbooked so the clinic can see the patients who need to be seen that day. And SCF’s per capita expenditures are forty per cent less than the US national average.

What’s holding us back?

Provincial doctors’ associations think that the physicians’ money belongs to them. And the provinces tend to agree. The associations say it’s OK if doctors get salaries if the province doesn’t take money from other doctors. But by and large it’s the doctors who take time with their patients and make less money who want salaries. So, we’re talking about billions in new money for doctors.

And most doctors aren’t good team players. (Neither are most health care providers.) Governments may fund primary health care, but they don’t make the work rules. Those are made mainly by doctors.

Medicare still makes sense. Public payment reduces administrative costs while eliminating financial barriers. But because of Medicare’s policy legacies, even doubling the number of doctors would not provide the access we deserve. We need to change the way physicians do their work.

Dr. Michael Rachlis is an adjunct professor at the University of Toronto Dalla Lana School of Public Health.

https://www.thestar.com/opinion/contributors/canada-has-more-doctors-than-ever-but-access-is-worse-why-is-that/article_7ce762e4-5078-51b2-9bad-1d624fd4b004.html

Tags: Health, ideology, jurisdiction

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