Abstract
Background: Through medicare, residents in Canada are entitled to medically necessary physician services without paying out of pocket, but still many people struggle to access primary care. We conducted a survey to explore people’s experience with and priorities for primary care.
Methods: We conducted an online, bilingual survey of adults in Canada in fall 2022. We distributed an anonymous link through diverse channels and a closed link to 122 053 people via a national public opinion firm. We weighted completed responses to mirror Canada’s population and adjusted for sociodemographic characteristics using regression models.
Results: We analyzed 9279 completed surveys (5.9% response rate via closed link). More than one-fifth of respondents (21.8%) reported having no primary care clinician, and among those who did, 34.5% reported getting a same or next-day appointment for urgent issues. Of respondents, 89.4% expressed comfort seeing another team member if their doctor recommended it, but only 35.9%, 9.5%, and 12.4% reported that their practice had a nurse, social worker, or pharmacist, respectively. The primary care attribute that mattered most was having a clinician who “knows me as a person and considers all the factors that affect my health.” After we adjusted for respondent characteristics, people in Quebec, the Atlantic region, and British Columbia had lower odds of reporting a primary care clinician than people in Ontario (adjusted odds ratio 0.30, 0.33, and 0.39, respectively; p < 0.001). We also observed large provincial variations in timely access, interprofessional care, and walk-in clinic use.
Interpretation: More than 1 in 5 respondents did not have access to primary care, with large variation by province. Reforms should strive to expand access to relationship-based, longitudinal care in a team setting.
Research over decades has shown that health systems with strong primary care have better health outcomes, better equity in outcomes, and lower costs.1,2 Yet, worldwide, countries have struggled with reforming their primary care systems to meet the demands of a growing, aging population3 in the context of widening socioeconomic inequities,4 increasing medical complexity,5 a rising prevalence of mental health and addictions,6 and a proliferation of medical evidence and guidelines for care.7 Even before the COVID-19 pandemic, people in Canada reported some of the worst access to primary care among high-income countries. Many people do not have access to regular primary care and, among those who do, many struggle to access timely care for urgent concerns or after hours.8,9 The situation in Canada is notable, given its systems of health insurance that covers physician and hospital visits for all permanent residents.
Existing research suggests that the COVID-19 pandemic spurred early retirements10 and that many practising family physicians are contemplating closing their practices in the coming years.11 Reported rates of burnout are high.12 The situation is compounded by a backlog of care, high administrative burden, and ineffectual digital systems.13 The landscape is also complicated by the increasing reliance on urgent care and walk-in services that prioritize timely episodic care over continuity.14,15
Reforms should be co-designed with patients and the public, but little information is available on their experiences with primary care after the start of the COVID-19 pandemic and what matters most to them.16,17 We aimed to capture a snapshot of people’s experiences with primary care in Canada, what matters most to them, and how these differ by sociodemographic characteristics.
Methods
Context and setting
More than 39 million people live in Canada,18 on colonized Indigenous lands. The population is diverse,19 with almost one-quarter being first-generation immigrants.20 French is the first language of 23% of the population.21 About 18% live in rural areas.22 Through medicare — the collection of federal, provincial, and territorial single-payer insurance plans — all permanent residents have health coverage for physician and hospital services without copayments or deductibles.23 Our study represents the first phase of OurCare, an 18-month, pan-Canadian initiative to co-create a vision for better primary care with patients and the public. In addition to this work, OurCare is conducting a series of 5 provincial priority panels with demographically representative members of the public (phase 2), as well as 10 community roundtables with members of equity-deserving communities (phase 3).
Study design, population, and participant recruitment
Between Sept. 20 and Oct. 25, 2022, we conducted a national, cross-sectional survey, available online in English and French and open to people in Canada aged 18 years and older. We used the Checklist for Reporting Results of Internet E-Surveys24 for reporting.
The OurCare survey was hosted on Qualtrics25 and distributed in 2 ways. We widely distributed an open link and promoted it through our partner networks, earned media (e.g., news reports and op-eds), social media posts, social media ads, and via the project website (Appendix 1, E-Exhibit 1, available at https://www.cmaj.ca/lookup/doi/10.1503/cmaj.231372/tab-related-content). In addition, a national public opinion firm, Vox Pop Labs, sent a closed, unique link to 122 053 people from its proprietary panel, following up with 2 personalized reminders. To help attain a representative sample of respondents, we adjusted probabilities to favour people who were underrepresented in the panel receiving an email invitation. The selection of individuals on this list of invitations itself was not intended to be representative of the population in Canada as a whole, but the resulting completed surveys were. Accordingly, we oversampled populations that Vox Pop Labs knew were less likely to participate in its surveys, and undersampled groups with higher likelihood of participation. The Durham Community Health Centre promoted the survey to people in high-priority neighbourhoods and had client-facing staff directly support survey completion, offering a $10 gift card for completion. No other incentives were offered for participation. See Appendix 1, E-Exhibit 2, for details on survey design, content, consent, and privacy.
Statistical correction and inclusion criteria
So that our sample would approximate the population of Canada, we gave each response a weight, produced by iterative proportional fitting based on marginal distributions derived from the Statistics Canada Census 2021. We weighted the responses using age, gender, education, income, language, and region, and iteratively adjusted the weighting until the survey sample distribution aligned with the broader population (Appendix 1, E-Exhibit 3). We analyzed completed surveys only (Appendix 1, E-Exhibit 4 details the exclusion criteria). Completeness meant respondents reached the end of the survey, no aberrations existed (e.g., no variation in responses within question blocks), and we obtained usable answers for all demographic questions required for weighting. We also excluded surveys that terminated in less than 550 seconds (3.3 percentile for total survey duration).
Data analysis
We calculated demographic characteristics of respondents before and after weighting; all further analysis was done using weighted data. We assessed differences in survey responses across demographic variables for the following key outcomes: who has a family doctor or nurse practitioner (primary care clinician); timeliness of care; access to interprofessional care; attending a walk-in clinic in the last 12 months; and the attributes of care that people thought were most important (Appendix 1, E-Exhibit 5). For each outcome, we calculated crude responses for each sociodemographic stratum and the odds ratio (OR) before and after adjustment for all sociodemographic variables. We conducted statistical analysis using R version 4.0.0.
Ethics approval
We obtained ethics approval from the Unity Health Toronto Research Ethics Board (Approval 22–143, 01.09.2022).
Results
A closed, unique link was distributed to 122 053 people from Vox Pop Labs’ proprietary panel. Of these, 7213 people responded (5.9% response rate). In total, 14 018 people responded to the survey and we analyzed data for 9279 (66.2%) completed surveys (Appendix 1, E-Exhibit 4); 6747 (72.7%) were completed in English and 2532 (27.3%) in French. Unweighted demographic characteristics of respondents are presented in Appendix 1, E-Exhibit 6. After weighting, the effective sample size was 3199; 50.9% of respondents were women, 49.6% were aged 50 years or older, 39.3% were from Ontario, 24.5% had a university degree, 86.2% reported their race as White, 87.8% were Canadian born, and 41.9% reported their health as very good or excellent (Table 1).
Having a regular primary care clinician
Overall, 77.0% of survey respondents reported having a primary care clinician they could see regularly for care. There were large variations by region, and differences persisted after adjustment for respondent characteristics (Ontario 87.2% [reference] v. Atlantic region 69.1% [adjusted OR 0.33, 95% confidence interval (CI) 0.22– 0.50]; Quebec 69.0% [adjusted OR 0.30, 95% CI 0.19–0.45]; and British Columbia 72.3% [adjusted OR 0.39, 95% CI 0.30–0.51]). Men, young adults, those reporting poor or fair health, and those without a disability also had significantly lower odds of reporting they had a primary care clinician (Figure 1).
Access to care for those with a regular primary care clinician
Among respondents who had a family doctor or nurse practitioner, 94.6% reported that the clinician they saw regularly was a family doctor and 5.4% said it was a nurse practitioner. Of these, 51.2% said they could always or usually get care from another primary care clinician from the same practice when their clinician was away; 35.9% said someone in the practice was available to help with urgent issues before 0900, after 1700, or on the weekend. In addition, 38.6% said they tried to book an appointment in the last 12 months with their primary care clinician or someone in their practice because they urgently needed care; when these respondents were asked how long it was between when they first tried to book the appointment until they had the appointment, 34.5% responded the same or next day, 18.5% 2–3 days, 10.8% 4–6 days, 13.9% 1–2 weeks, 13.6% more than 2 weeks, and 7.5% were never able to get an appointment.
In respondents reporting that they were able to see a primary care clinician on the same or next day for an urgent problem, we saw large differences by region, education, and self-reported health (Figure 2).
Interprofessional care
Those with a primary care clinician reported having the following health professionals working in their practice (multiple selections allowed): 68.9% family doctor, 35.9% nurse, 30.9% nurse practitioner, 12.8% dietitian, 12.4% pharmacist, 9.5% social worker, and 9.4% other health professionals. Overall, 60.8% reported having 1 or more of a nurse, social worker, pharmacist, dietitian, or Indigenous cultural service provider; however, odds were significantly lower for those living outside Ontario or Quebec, even after adjustment. Before but not after adjustment, odds were also lower for men, people without a university degree and those who were racialized (Figure 3). Notably, 89.4% of respondents were comfortable or very comfortable with getting support from another member of the team, if their primary care clinician recommended it.
Walk-in clinics
Among all respondents, 47.3% reported visiting a walk-in clinic 1 or more times in the last 12 months. After adjustment, women, young adults, those living in BC, people not living in rural areas, and those reporting poor or fair health had higher odds of visiting a walk-in clinic (Figure 4). The biggest difference in walk-in clinic use was between those who did and those who did not have a primary care clinician (“yes” 41.2% [reference] v. “no” 71.7% [adjusted OR 3.15, 95% CI 2.56–3.87]). Overall, 76.2%, 32.2%, and 12.0% reported having the walk-in clinic visit in person, by phone, and by video, respectively (multiple selections allowed). Common reasons for attending a walk-in clinic are summarized in Appendix 1, E-Exhibit 7.
Virtual care and access to medical information
Among respondents with a primary care clinician, the most common appointment types were scheduled in-person (73.8%) and phone calls (70.7%). All respondents were asked about how they would like to get care; respondents listed scheduled in-person (92.5%), phone (66.1%), and drop-in in-person (54.4%) as the 3 most important modes.
Most respondents (59.1%) reported using an app or website to see their medical information, with laboratory test results (90.0%) and vaccination history (59.4%) being the most commonly reported information viewed online. Of respondents, 93.5% said it was fairly or very important to have 1 personal health record that all health professionals working in the province could see and use.
Most important attributes of primary care
Of respondents, 97.2% said that it was very or fairly important that every person living in Canada have a relationship with a family doctor, nurse practitioner, or team of health care professionals they could see regularly if they needed to. Figure 5 summarizes how respondents ranked various attributes of primary care. The attribute selected as very important by the largest percentage of respondents (65.0%) was that their primary care clinician “know me as a person and consider all the factors that affect my health.” However, after adjustment, we saw significant variation in the percentage who selected it as very important, by gender, age, region, place of birth, and self-reported disability (Figure 6). The attribute ranked second highest as very important was that their clinician and practice “stand up for me”; attributes related to timely access, care coordination, and comprehensiveness all ranked highly.
Reimagining care
Respondents were open to new ways of organizing care. Nearly three-quarters (72.7%) somewhat or strongly agreed with reorganizing care similarly to the public school model, where teams of family doctors and nurse practitioners would have to accept as a patient any person who lived in the neighbourhood near their office, and 65.9% somewhat or strongly agreed with this type of neighbourhood care guarantee, even if it meant patients would be encouraged to change providers if they moved. Of respondents, 90.8% were somewhat or very willing to see the same nurse practitioner consistently for most things, except when the nurse practitioner felt a doctor was needed; 75.7% were somewhat or very willing to see any primary care clinician in the practice in a situation where everyone in the practice had access to their health record.
Interpretation
Primary care is the front door to the health care system — the first point of access to address acute concerns, manage chronic disease, prevent illness, and support people to navigate other parts of the system. Yet we found that among more than 9000 respondents to a national survey of adults in Canada conducted in fall 2022, more than 1 in 5 did not have a primary care clinician they could see regularly for care. In our survey, the largest variation in primary care access was regional, with almost 1 in 3 reporting not having a primary care clinician in Quebec and the Atlantic region, a 70% reduced odds compared with Ontario even after accounting for demographic differences in respondents. Men, people younger than 65 years, and people with poor self-reported health also had lower odds of reporting they had a primary care clinician. When asked about the ideal state, respondents noted the most important attribute of primary care was having a primary care clinician who knew them as a person and considered all the factors that affected their health. This attribute was more important for women, people older than 65 years, people born outside of Canada, and people with a disability.
In 2019, before the COVID-19 pandemic, surveys estimated that 15% of people in Canada aged 12 years and older did not have a regular health care provider.26 Our results are consistent with other research showing a decrease in primary care attachment since the start of the pandemic.27 Our findings suggest that provincial policies strongly influence access to primary care in Canada. Ontario respondents had the highest odds of reporting having access to a primary care clinician even after accounting for other factors, a finding consistent with the results from the Canadian Community Health Survey 2015 and 2019.26 Underlying reasons are unclear but could include increases in physician payment, a shift from fee-for-service to capitation, and investment in interprofessional teams in Ontario over the last 2 decades, which made primary care careers in Ontario more attractive to physicians. 28,29 More research is needed to understand why respondents with poor or fair self-reported health have lower odds of having a primary care clinician.
Even respondents with a primary care clinician reported challenges in accessing timely care. A minority of respondents reported that their practice offered care outside 0900 to 1700, Monday to Friday, and more than half said they were not able to get an urgent appointment within 3 days of trying to book one. These findings are consistent with results from the 2020 Commonwealth survey.9 We found timely access for urgent concerns was worse for people with lower educational attainment, those with poorer self-reported health, or people who lived in a province with lower primary care attachment. Given challenges with timely access, it is not surprising that we also found that almost half of all respondents had received care at a walk-in clinic in the last year, an episodic care model that does not provide ongoing care continuity. These types of episodic care models have grown over the course of the pandemic30 but are not in line with what respondents said they valued most in primary care: an ongoing relationship with a clinician. Numerous studies have shown that relational continuity positively affects patient outcomes, health care use, and costs,31–36 and our findings clearly show it is also what respondents most desire — particularly people with more complex care needs.
Investment in interprofessional primary care teams is suggested internationally by clinicians, researchers, and professional associations as part of the solution to the current primary care crisis16,37–42 and our findings indicate the public would be supportive of such a shift. Of respondents, 90% said they would be comfortable getting care from another team member if their primary care clinician recommended it. However, less than 15% reported that their primary care clinician worked with a social worker or pharmacist or dietitian, and the odds of working with any health professional were lower for people living outside Ontario and Quebec. Evidence suggests teams have the potential to improve patient outcomes and clinician joy in work, and increase clinician capacity to take on more patients.43–46 That attachment to a primary care clinician was relatively low in Quebec despite investment in teams speaks to the complexity of implementation and the importance of designing teams to enhance capacity and the influence of other health system factors.47
Limitations
Our biggest study limitation is response bias. The survey was offered only in English and French, was Internet based, and required 15 minutes to complete. Respondents may have been driven by strong interest or opinions on health care. We excluded almost 5000 incomplete surveys. We had a low response rate to the closed link and in particular observed a low number of responses from people new to Canada, those who are racialized, and those who identify as Indigenous — groups we know are less likely to receive high-quality primary care. We also had no complete responses from people residing in the territories, a geographic area with unique challenges regarding primary care access. Further, data were collected at one point in time, some questions may have been unclear, and multiple-choice responses inherently limit depth of understanding. The next phases of the OurCare initiative include citizen dialogues in multiple regions to better understand values, key issues, and potential recommendations for improving Canada’s health care systems.
Conclusion
We found that more than 1 in 5 people who responded to our survey did not have access to primary care, and the situation was worse in some regions. Among those who did have a family doctor, most struggled to get timely care. Regardless of whether they had a family doctor, many were turning to walk-in clinics; however, the episodic walk-in clinic model is not aligned with what respondents reported being most important to them: having a primary care clinician who knows them as a person and takes into account all the factors that affect their health. Respondents were supportive of interprofessional care, one of many potential reforms that could alleviate the primary care crisis. Our results should be interpreted in the context of a low response rate and response bias. More research is needed to understand which policies, regulations, and contextual factors have influenced the observed regional variation in attachment, timely access, and availability of interprofessional teams. Future reforms should be co-designed with patients and the public and preferentially support the creation and expansion of relationship-based, longitudinal models of primary care.
Acknowledgements
The authors thank their collaborators in the OurCare National Health Policy and Health System Governance Group and OurCare Primary Care Leaders Circle, members of the Canadian Medical Association’s Patient Voice Advisory Group, and the Improving Primary Care Public Advisors Council at Unity Health Toronto, for their help informing the study design and survey questions, interpreting results and promoting the survey. They also thank Amy Craig-Neil for her support early in the project, Katrina Grieve for help simplifying the survey language, and Paul Krueger for feedback on survey design.
Footnotes
Competing interests: Tara Kiran reports receiving support for the present manuscript from Health Canada, Staples Canada, the Max Bell Foundation, and the FDC Foundation. Dr. Kiran has also received grants or contracts from the Ministry of Health and Long-Term Care and the St. Michael’s Hospital Foundation, and grants and consulting fees from Ontario Health. Dr. Kiran has received payment or honoraria from the Canadian Medical Association, the College of Family Physicians of Canada (CFPC), the Association of Family Health Teams of Ontario, the Ontario Medical Association, and the Ontario College of Family Physicians. Dr. Kiran is the Fidani Chair in Improvement and Innovation at the University of Toronto and is also supported as a clinician scientist by the Department of Family and Community Medicine at the University of Toronto and at St. Michael’s Hospital. Amanda Condon reports receiving honoraria as the Manitoba co-lead for OurCare, in support of the present manuscript. Dr. Condon is also the Manitoba co-lead for Health Canada and the Canadian Institutes of Health Research CanTreatCOVID adaptive platform trial, and reports receiving funding for travel related to this trial. Dr. Condon is a director of the board of the CFPC. Michael Green is president and board chair of the CFPC, and board member and chair of the Fellowship Committee of AMS Healthcare Inc. Alan Katz reports receiving support for the current manuscript from the University of Manitoba. Maggie Keresteci reports receiving a grant from the Canadian Association for Health Services and Policy Research, consulting fees from Healthcare Excellence Canada and the Canadian Agency for Drugs and Technologies in Health (CADTH), and payment or honoraria from Healthcare Excellence Canada, CADTH, the Ontario College of Family Physicians, and the University of Ottawa. Dr. Keresteci also reports holding a leadership role with Emily’s House Children’s Hospice. Sarah Newbery reports receiving travel support from the PSI Foundation for attending a meeting, and from the Northern Ontario School of Medicine University for attending the CFPC’s Family Medicine Forum. Dr. Newbery is also a member of the CMAJ Editorial Advisory Board. Goldis Mitra reports holding roles with BC Family Doctors (Executive Treasurer), the Statutory Negotiations Committee of Doctors of BC, and OurCare (BC Physician Lead). Katherine Stringer reports receiving an honorarium as the Nova Scotia co-lead for the OurCare initative (paid to Dalhousie Department of Family Medicine) and support from the CFPC and Dalhousie University to travel to and attend meetings or conferences. Dr. Stringer reports holding the roles of chair of the CFPC Family Medicine Specialty Committee and chair of the Association of Academic Chairs of Family Medicine (both unpaid). No other competing interests were declared.
This article has been peer reviewed.
Contributors: Tara Kiran, Peter MacLeod, and Clifton van der Linden conceived of the work. All of the authors contributed to the design of the work. Alexander Beyer and Clifton van der Linden contributed to the acquisition of data. Maryam Daneshvarfard, Ri Wang, and Alex Beyer contributed to the analysis of data. All of the authors contributed to the interpretation of data. Tara Kiran and Maryam Daneshvarfard drafted the manuscript. All of the authors revised the manuscript critically for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.
Funding: This study received funding from Staples Canada Even the Odds Campaign and Max Bell Foundation. The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources.
Data sharing: Data are publicly available at https://data.ourcare.ca/all-questions.
- Accepted March 8, 2024.
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