In a universal health system like the one in Canada and New Brunswick, the primary care provider (mostly a family doctor) is the first point of access, the one who “follows” a citizen in the long run and ensures their access to other services to meet their needs. In other words, every citizen needs to have a health care professional that they can rely on, and whom they can access in a timely manner when they need care. A long wait time for an appointment with a primary care provider leads to seeking care in other settings (that can be less appropriate and lack continuity of care).1 Delays in getting necessary primary care can also lead to adverse health outcomes.2
Note: Primary health care is usually defined as the first point of contact with the health care system. Primary health care providers are essential for effective preventative medicine, health maintenance and management of chronic conditions. Although primary health care providers include a wide range of professionals, with a growing role for nurse practitioners and multi-disciplinary teams, currently 86% of New Brunswickers report that they have a personal family doctor as their primary health care professional and our health system is still family doctor oriented.
While accessing after-hours clinics and emergency rooms (ER) can help resolve an immediate healthcare need, relying on those settings as a regular place of care compromises the continuity and integration of care, two of the key pillars of an appropriate and effective primary care sector, especially for citizens with complex or multiple chronic conditions and for an aging population. Besides the implications for the quality of care, using other settings does not lead to an efficient use of resources. A visit to the emergency room is more expensive than a visit to a primary care provider.
Accessibility to a primary care provider: What is the current situation in New Brunswick?
New Brunswick has always had one of the highest percentages of citizens who have a primary care provider in Canada. In 2020, 86% of Canadians had a regular provider compared to 91% of New Brunswickers (approximately 600,000 citizens).3 As per the Primary Health Survey 2020, 86% of New Brunswickers reported having a family doctor (FD), while 4% reported having a nurse practitioner as their primary care provider.
Despite this relatively high rate, only 57% of New Brunswickers reported going to their family doctor most often when they need care. Other citizens reported using after-hours clinics and emergency rooms.
Over the past 9 years, there has been an increase in citizens reporting using after-hours clinics (from 18 to 21%) when they need care, while the use of the emergency room has remained stable at around 10%.
Timely access, or the ability to get an appointment within 5 days with a primary care provider, had been highlighted in previous cycles as a factor driving the demand for ER use and after-hours clinics.4 As per the Primary Health Survey results, timely access to family physicians has been on the decline since 2011 (from 56% to 51%) in parallel to a decrease in citizens reporting going to their family doctor when they need care (62% to 57%).
This reality varies around the province. Depending on where they live, citizens have very different pathways by which they access primary care services, different experiences of seeing their providers in a timely manner and different settings to rely on when they need care.
Having a primary care provider does not guarantee appropriate access to health care services
“Even though I have a family doctor, it’s very difficult to get an appointment when I want one, so I don’t know what they can do about that. So as a result, I end up going to an after-hours clinic, which is inconvenient because they don’t have any of my medical records” Citizen responding to Primary Health Survey 2020
Accessibility to healthcare is the “ability of citizens to obtain services at the right place and the right time, based on respective needs”. In New Brunswick, where in some regions 1 in 2 citizens go to another setting of care when they are sick, we are not achieving this goal.
In many regions of New Brunswick, the current reality is one where a primary care provider works in a solo practice, with an attached list of patients, but is also practicing in different settings, such as in the emergency room, an after-hours or walk-in clinic, a hospital setting or a long-term facility, or doing administrative tasks. A full-time practitioner ends up working only a portion of their working hours in their office. Having a clearer understanding of the daily practice of a practitioner is needed to better appreciate how timely access can be impacted.
As a result, a citizen may be attached to a particular provider, but if this provider only works 3 days a week in their practice and spends the rest of the week in other settings, the provider is actually spending their time taking care of another provider’s patient rather than their own. This then forces their own patients to seek care elsewhere as they cannot receive an appointment within 5 days. This reality creates a vicious circle where the continuity of care is disrupted. In the 12 months preceding the survey, 40% of citizens who visited an ER while having a primary care provider said that their most recent visit could have been avoided if their provider had been available. This proportion can be higher than 50% in certain health zones (Zone 4 - Madawaska and North-West Area and Zone 6 - Bathurst and Acadian Peninsula Area).
Given this reality, the assumption that a citizen who has a primary care provider is privileged in comparison to a fellow citizen on the NB Patient Connect list, and waiting to be assigned to a provider, might not hold true. Although not having a primary care provider is clearly an issue, practically, about 1 in 3 citizens who have a provider has no other option but to seek other settings like an after-hours clinic or an emergency room when in need of care.
“My concern is with wait times, especially with the primary physicians. […]. Going to a clinic, there is no continuity and no understanding of background and the care is just not the same. a lot of it is a prescription and out the door. A lot of clinics have criteria and if you don’t fit the criteria you are out the door. and if that happens you have to go to emerg[…].” Citizen responding to Primary Health Survey 2020
Do we have a good idea about the resources we have?
“I do know that the doctor per capita is higher than in some provinces that have much better health care …. I believe that problems lie with management of the system. Problems addressed with small incremental change, but bigger changes are needed …” Citizen responding to Primary Health Survey 2020
The existing crisis in accessing primary care in New Brunswick has been traditionally linked to a shortage in primary care providers, despite national data reporting that the number of family doctors by capita is among the highest in Canada (14 family medicine doctors per 10,000 citizens compared to 12 for the Canadian average).5
According to data from the Department of Health, when we look at the profile of primary care physicians in the province, there are on average 11 primary care physicians per 10,000 citizens who provide some type of work every week in any setting (office, emergency room, hospital, after-hours clinic, etc.).
On average, a primary care physician sees 1,000 patients in a year (ranging from 600 in Zone 4 - Madawaska and North-West Area, to 1,200 in Zone 2 - Fundy Shore and Saint John Area, and Zone 6 - Bathurst and Acadian Peninsula Area), which amounts to around 3,100 visits per year.
If we look at this data by zones, we notice the following:
Zone 2 (Fundy Shore and Saint John Area) has the lowest number of family doctors per population, whereas Zone 5 (Restigouche Area) has the highest. Despite the fact that the population in Zone 2 and Zone 5 have similar level of chronic health conditions (at least 1 in 4 citizens have 3 or more chronic health conditions), a family doctor in Zone 2 does an average of 4,000 visits per year, compared to their colleague in Zone 5 who does 2,000.
This difference may be linked to the way that they practice, with some providers working in multiple settings besides their offices.
The wide variabilities observed around the province in how primary care providers are distributed, how they practice, and how citizens use their services, demonstrate an absence of an agreed upon model of care, and that the supply of services (and various practice approaches/arrangements) highly dictate the quality and outcomes of primary care in each zone.
Due to the differences in terms of demographics, healthcare needs and the rural-urban differences, a “one size fits all” approach is not the solution, but there are different practices that can be implemented, to some extent, to improve both timely access and continuity of care.
Various studies have shown that a team-based practice is among the best types of practices to promote a patient-centered approach with favorable outcomes in terms of achieving the right care, at the right time, by the right team and in the right place.6 Even when a patients provider is not available, they have the option to see another provider who has access to their medical file, thereby ensuring some level of continuity of care. Citizens who receive team-based services are usually highly satisfied with the services.
“My family doctor works with other family doctors in a same building. they have a built- in clinic and other services. although its new, it works very well.” Citizen responding to Primary Health Survey 2020
Although Regional Health Authorities encourage practice settings that leverage a team-based approach, there is currently no system in place to promote or enforce a particular type of practice. New Brunswick still reports the highest percentage of solo practices in the country, with 55% of physicians working on their own, compared to the Canadian average of 15%.7
“I believe it would benefit the province […] if we had clinics and a group of 4-5 doctors working in a clinic. It would be easier to see a doctor since there are more than one doctor. It’s better for the doctors because they are working as a team and can consult with each other. Also it reduces the work load for any one doctor. If a doctor leaves, there is little to no interruption […]” Citizen responding to Primary Health Survey 2020
Besides the opportunity to improve access to services, group/team-based practices, accompanied with better information technology and sharing of data, and the use of non-physicians, can mitigate the risk of physician shortages in certain areas of New Brunswick (due to retirement, unexpected leaves, etc.). Non-physicians, like case managers or dieticians, among other primary care providers, could also provide continuity of care for citizens with higher needs who require frequent monitoring at a lesser cost, which would also free up the schedule of physicians.8 The most appropriate combination of services for a particular community or region depends on the needs of the population.
Conclusions: Moving forward - removing the element of luck in accessing primary care services
In the absence of a clear understanding of the distribution of human resources in the primary health sector by zones, and how these resources are allocated or managed, services seem to have evolved in a random approach leading to wide variabilities around the province. Citizens have started to perceive an element of luck when it comes to accessing primary care providers in a timely manner.
“My husband and I have had good health care services so far, we can’t complain, I think we have been very lucky” Citizen responding to Primary Health Survey 2020
“I believe I’m an anomaly and not the normal story, as my doctor is exceptional and takes a personal interest in her patients and makes sure her patients have access to the services they need. My physician is also accessible to her patients through text, phone or her office, but that is not the norm” Citizen responding to Primary Health Survey 2020
Within the existing context, the accessibility crisis New Brunswickers struggle with will not simply be solved by increasing an already relatively high attachment rate to primary care providers.
Immediate intervention is necessary to clearly define what combination of services meets the needs of New Brunswick citizens. In 2017-2018, the New Brunswick Health Council recommended that an effective and clear accountability framework be developed to clarify responsibility for the state of primary health services, to improve the planning, operation and performance management of primary health services.
The successful implementation of a primary care system that favors citizens being able to see their primary care provider in a timely manner will require a clear accountability framework, and a proactive management approach to ensure a citizens-centered, rather than supply driven approach, to the organization of service provision.
Virtual care: new players? When New Brunswickers started to receive the phone calls to participate in the Primary Health Survey in January 2020, virtual care was not a service widely offered by providers or used by a large number of citizens. Accordingly, the survey did not include questions related to virtual care. With the onset of the COVID-19 pandemic in March 2020, virtual care went from being a marginal service to taking the centre stage as the only means of access to primary care providers while respecting physical distancing measures. 18 months into the pandemic, and with the perceived value by both providers and users, virtual care is here to stay. However, it is also becoming clearer that virtual care should not replace all face to face visits and it is now necessary to better define where and when virtual care is appropriate.
References
- Oliver D et al. Patient trade-offs between continuity and access in primary care interprofessional teachings clinics in Canada: a cross-sectional survey using discrete choice experiment. BMJ Open 2019; 9: e023578; Jeyaraman et al. Interventions and strategies involving primary healthcare professionals to manage emergency department overcrowding: a scoping review. BMJ Open 2021; 11: e048613
- Ansell, D et al. Interventions to reduce wait times for primary care appointments: a systematic review. BMC Health Serv Res 2017;17(1):295; Wong ST, et al. What do people think is important about primary healthcare? Healthcare Policy 2008; 3(3):89-104
- Statistics Canada. Table 13-10-0096-01 Health characteristics, annual estimates
- New Brunswick Health Council, New Brunswickers’ Experiences with Primary Health Services, Results from the New Brunswick Health Council’s 2014 Primary Health Survey (NBHC 2014). https://nbhc.ca/sites/default/files/publications-attachments/primary_health_survey_-_complete_report.pdf
- Canadian Institute for Health Information, Scott's Medical Database, Supply, Distribution and Migration of Physicians in Canada, 2020. (this data includes physicians in clinical and non-clinical practices).
- Ansell, D et al. Interventions to reduce wait times for primary care appointments: a systematic review. BMC Health Serv. 2017;17(1):295
- Canadian Institute for Health Information. How Canada Compares: Results From the Commonwealth Fund’s 2019 International Health Policy Survey of Primary Care Physicians — Accessible Report. Ottawa, ON: CIHI; 2020
- Green, L.V., Savin, S., and Lu, Y. (2013) Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication. Health Affairs. VOL. 32, NO. 1 : https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2012.1086