The Primary Care Problem

The 2005 Chaoulli Supreme Court decision – which said that forbidding us to use private insurance contravened our Charter rights – clarified an important problem in the Canadian experience of monopoly healthcare: access to a waiting list is not the same thing as access to healthcare. Lengthy waits for diagnostic procedures, consultations with specialists and therapy are now the rule in this country, and widely accepted. Health administrators and politicians have given up on eliminating waiting lists, and now merely talk about reducing them. But many Canadians lack the most basic form of primary care: a family physician.

Due to poor planning, most cities have very few General Practitioners who will take new patients, and rural areas frequently have none at all. A family doctor is the front line for health. Frequent check-ups and the continuity of care GPs provide are two crucial tools in preventing many diseases, and in diagnosing and treating small problems before they become big ones.

Those without a GP often end up using the local emergency room for their medical care. This is a losing proposition all round. Nobody enjoys spending hours in an urban ER and waiting to be seen only after priority cases are under control. And the costs to our system for ER visits are significantly higher than treating the same problem through a family doctor.

Even those with a family doctor often resort to using emergency care for problems that aren’t really emergencies. The number of GPs in Canada who provide evening and weekend coverage, either themselves or by rotating calls with colleagues, is very low and still dropping. If you can find acceptance as a patient by a family practice, that means little when one’s doctor is only available from 9:00 a.m. until 4:00 p.m. on weekdays, and when appointments must be booked weeks in advance.

Many healthcare providers in Europe and the U.S. have standards of care that ensure a superior level of service. A requirement that family doctors provide some form of coverage outside of office hours would do much to reduce unnecessary use of emergency rooms, and would improve the quality of Canadian care. Further, all primary-care providers should commit to seeing urgent cases on a same-day basis, and less urgent problems within days, not weeks. Many regions of Europe have already implemented these standards.

Patients and their needs are the engines that drive all medical care. But Canadian primary care is still structured around the convenience of doctors, rather than the needs of consumers. Canadians have been banking on-line for several years now, and many parents of school-aged children keep in touch with their kids’ teachers by e-mail. Dentistry and veterinary practices, sensitive to the increasingly busy pace of modern life, offer early-morning or evening appointments for the convenience of their clients. Only in healthcare is the trend moving in the other direction, with house calls a thing of the past, telephone access to physicians increasingly rare and online access unusual.

Is the technology that serves us so well in other areas – much less important areas than health – not applied to primary care? If we can go on-line to see whether a certain DVD is in stock at the video store, why can’t we do that to see what slots our GP has free? All kinds of routine tasks can now be transacted without ever leaving one’s house or putting pen to paper. We can apply for mortgages and order clothing or books that are delivered to the front door within days. But to renew a prescription for a chronic, stable condition, a patient must still go to the doctor’s office, wait to see the doctor and then carry the written prescription to a pharmacy. Why do Canadians tolerate this inconvenience?

Access to information is another essential component of health. In a country where so many lack family doctors and most have family doctors who can’t talk to them after hours, an alternative source of information that is available around the clock is especially crucial. Canadians have very inconsistent access to this sort of resource, athough some provinces do better than others. Alberta, for instance, has a 24-hour line staffed by registered nurses to help consumers decide if they need urgent treatment or if they can wait a day or two to see a doctor, and what they can do in the meantime to improve their condition. Other provinces provide only “health advice”, a rudimentary service that does not increase access to real medical care.

In the first half of the 20th century, the medical industry was structured around doctors who provided and directed almost everything. More recently, massive systems that financed and organized healthcare – insurance companies and HMOs in some countries, ministries and health authorities elsewhere – became the driving force, setting priorities, allocating care and deciding who gets what treatment and when. It’s high time that consumers, the patients who are the raison d’etre of the entire system, to move to the centre of attention.