Dr. Tara Kiran is a family physician and researcher at St. Michael's Hospital. She also works part-time as a Primary Care Advisor for the Toronto Central Local Health Integration Network.
Canadians are proud of Medicare and consistently report being satisfied with the health care services they receive. But, perhaps they should be demanding better.
The most recent Health Council of Canada report highlights findings from the 2012 Commonwealth Fund survey of primary care physicians in ten high-income countries. In almost all areas – from access to care coordination to use of information technology – Canada ranks at or near the bottom.
Canada’s poor performance relative to other countries shouldn’t be too surprising. After all, Canada ranked at or near the bottom in a similar survey from 2009. What did surprise me, though, was the considerable variation in quality of primary care among provinces.
Results from Quebec were consistently far below the Canadian national average. Only 22% of Quebec primary care physicians report that their patients can get same or next day appointments compared to the Canadian average of 47% (the lowest national average among all countries). Only 8% of Quebec physicians said they are notified when their patients go the emergency department compared to the Canadian average of 30%. And only 26% of Quebec physicians said they use electronic medical records compared to the Canadian average of 57% (the second lowest national average among all countries).
In contrast, physicians in Ontario, BC, and Nova Scotia all reported better same or next day access than the Canadian average. Ontario physicians were far more likely to report providing patients with after-hours coverage and sharing this responsibility with other practices. Physicians in Ontario, BC, and Nova Scotia were also consistently more likely to use information technology in their practice, review their performance against targets, and receive financial incentives for certain areas of care.
Ontario and BC are two provinces that have invested heavily in improving their primary care system. Over the last decade, most primary care physicians in Ontario have joined new practice models, signing contractual agreements with government which require or incentivize them to formally enroll patients and mandate after hours care provision. Ontario physicians in some practice models are financially penalized if their patient goes to a walk-in clinic and financially rewarded if their patients meet certain quality of care targets. Adoption of electronic medical records is subsidized in most models and required in some. And, a province-wide quality improvement program has helped hundreds of physicians improve access in their clinics.
BC took a different but similarly ambitious approach to reform. Since 2002, the General Practices Services Committee– a partnership between the BC Medical Association and BC Ministry of Health – has championed several initiatives ranging from new financial incentives for chronic illness management, changes to billing codes to encourage telephone and email consultation with patients, and a comprehensive practice support program that includes training on improving access for patients.
Other provinces have also dabbled in primary care reforms but as pointed out by the Health Council of Canada years ago, we have not systematically studied the results of reform efforts across the country or spread successful approaches.
The wide range in quality of care measures between provinces should make us question the notion of a “Canadian” health care system. The federal government has defended its hands off approach to health care but without its influence, Canadians living in different provinces will continue to have very different health care experiences – to the detriment of some of our citizens.
It was fantastic to see the British celebrate their pride in their National Health Service at the opening ceremonies of the recent Summer Olympics. We need continued investment and thoughtful oversight of health care from our federal government to ensure we can maintain similar pride in Canadian Medicare.