The number of Ontarians without a family doctor rose significantly during the first two years of the pandemic, according to the most comprehensive analysis yet of how access to primary care is deteriorating in Canada’s most populous province.
More than 2.2 million Ontarians were without a regular physician as of March, 2022, up from nearly 1.8 million in March of 2020 – a 24-per-cent increase. That means 14.7 per cent of Ontarians now rely on walk-in clinics and emergency rooms for primary care or go without it altogether, up from just over 12 per cent before COVID struck.
Children, newcomers to Ontario, and patients who live in the poorest and most racialized neighbourhoods were most likely to see their access worsen, but people from all walks of life lost their family doctors during the two-year period, the data show.
Percentage of Ontarians without a family
doctor by neighbourhood income,
2020 to 2022
2020
2022
10.1%
11.9%
Highest income
10.2
12.5
High
11.3
13.9
Middle
13.1
16.1
Low
16.1
19.4
Lowest income
8
12
16
20%
THE GLOBE AND MAIL, SOURCE: INSPIRE-PHC
Percentage of Ontarians without a family doctor by
neighbourhood income, 2020 to 2022
2020
2022
Highest income
10.1%
11.9%
High
10.2
12.5
Middle
11.3
13.9
Low
13.1
16.1
Lowest income
16.1
19.4
8
12
16
20%
THE GLOBE AND MAIL, SOURCE: INSPIRE-PHC
Percentage of Ontarians without a family doctor by neighbourhood income, 2020 to 2022
2020
2022
Highest income
10.1%
11.9%
High
10.2
12.5
Middle
11.3
13.9
Low
13.1
16.1
Lowest income
16.1
19.4
8
12
16
20%
THE GLOBE AND MAIL, SOURCE: INSPIRE-PHC
Percentage of Ontarians without a family
doctor by neighbourhood racial
composition, 2020 to 2022
2020
2022
13.2%
16.8%
Most racialized
11
15.1
High
12.4
13.6
Middle
11.4
12.5
Low
10.4
12.6
Least racialized
10
12
14
16
20%
THE GLOBE AND MAIL, SOURCE: INSPIRE-PHC
Percentage of Ontarians without a family doctor by
neighbourhood racial composition, 2020 to 2022
2020
2022
Most racialized
13.2%
16.8%
High
11
15.1
Middle
12.4
13.6
Low
11.4
12.5
Least racialized
10.4
12.6
10
12
14
16
20%
THE GLOBE AND MAIL, SOURCE: INSPIRE-PHC
Percentage of Ontarians without a family doctor by neighbourhood racial composition, 2020 to 2022
2020
2022
Most racialized
13.2%
16.8%
High
11
15.1
Middle
12.4
13.6
Low
11.4
12.5
Least racialized
10.4
12.6
10
12
14
16
20%
THE GLOBE AND MAIL, SOURCE: INSPIRE-PHC
“This shortage is not perfectly equal-opportunity,” said Michael Green, chair of the department of family medicine at Queen’s University, “but it’s certainly widespread enough that it doesn’t spare any particular group.”
Dr. Green is the co-leader of Inspire Primary Health Care, a network of family-medicine researchers whose job is to make sense of a vast array of de-identified health administrative data, including Ontario Health Insurance Plan (OHIP) billings, housed at ICES, the non-profit research organization formally known as the Institute for Clinical Evaluative Sciences in Toronto.
The group published its latest data on primary-care access in Ontario just before Prime Minister Justin Trudeau made his offer of $46.2-billion in new health funding to premiers last week. Mr. Trudeau named improving access to family-health teams and collecting better health data as two of his top priorities for fixing a system in crisis.
High-quality national data are vital, particularly when it comes to grasping the repercussions of a countrywide shortage of family doctors. It’s hard to fix the front door of the health care system if nobody in power knows how many patients are shut out in the first place, experts say.
Health administrative data are more telling than polls or surveys. By cross-referencing multiple databases that assign every Ontarian a unique code (stripped of all personal information that could identify the patient), the Inspire group was able to look at everyone with an OHIP card and determine whether they were “attached” to primary care or “uncertainly attached,” which means they don’t have a regular doctor.
When the researchers compared provincewide data for March of 2022 to two years earlier, several worrisome trends jumped out.
One was a 66-per-cent increase in the number of children and teens who don’t have a family doctor or pediatrician. In 2022, there were 359,769 youth without regular access to primary care, up from 215,901 two years earlier.
The reason, Dr. Green said, is straightforward: “No one’s taking new patients.”
In Kingston, where Dr. Green also practises family medicine part time, a local community health centre has set up special outpatient clinics to provide well-baby visits and routine vaccinations for infants and toddlers whose parents can’t find a doctor. Physicians in Kingston try their best to squeeze pregnant women into their practices, he added, but demand is outstripping the supply of doctors.
Newcomers to Ontario also saw their access to primary care deteriorate over the course of the pandemic. The researchers defined newcomers as anyone with an OHIP card who moved to Ontario in the past 10 years, including Canadians from other provinces.
The number of newcomers without a family doctor rose to 511,662 in 2022 from 304,502 two years earlier – a 68-per-cent increase.
Cliff Ledwos, the associate executive director of Access Alliance, a community health centre that serves marginalized patients at three locations in Toronto, has seen first-hand how newcomers are struggling more now than in the past to find doctors.
“We have never had a waiting list before. ... We are now, for the first time ever, in a period where we are holding off for three months on taking new patients,” he said.
Mr. Ledwos said Access Alliance hopes to begin welcoming new patients again after physicians work through a glut of appointments for existing patients who postponed care during the pandemic. “But I don’t think it’s going to resolve the entire issue,” he added. “There are a large number of people who are unattached.”
In fact, the Inspire researchers say the number of Ontarians without a regular doctor is poised to grow. In a recent paper published as a preprint, which means it has not yet been peer reviewed, they found that as of 2019, about 1.7 million Ontarians had a doctor who was over the age of 65.
Those patients “have aged with their family doctor,” said Kamila Premji, an Ottawa family physician and lead author of the paper.
Her study found that the number of Ontarians attached to doctors over 65 who are themselves over 65 has ballooned from 136,394 patients in 2008 to 402,430 in 2019. The number of patients coded as the highest users of health care resources, regardless of age, with a doctor over 65, rose from 137,995 in 2008 to 350,439 in 2019.
“If I retired now, or if I dropped dead, there would be a catastrophe,” said Sudi Devanesen, a 79-year-old Mississauga doctor who said nearly 40 per cent of his patients are seniors. “I’m not trying to be egotistical. Nobody is indispensable. But right now, I have so many of these seniors who depend on me.”
Dr. Devanesen, a former chief of family medicine at St. Michael’s Hospital in Toronto, is reluctant to give up a vocation he loves and has only recently started searching for a younger colleague to take his place. But he knows many senior family physicians who can’t find replacements.
Fewer recent medical graduates are naming family medicine as a first choice, according to the Canadian Resident Matching Service, the organization that matches graduates to residency training programs. Dr. Premji’s research has also found that, in Ontario, fewer family doctors are practising full-time, office-based, cradle-to-grave primary care than in the past.
There are some bright spots in Ontario. One is that older patients with multiple chronic illnesses have high rates of attachment to primary care. Those rates held steady between 2020 and 2022, the data show.
Another is that despite the worsening situation in Ontario, it still outperforms other provinces on access to primary care, according to a survey of just over 9,000 Canadians led by Tara Kiran, a family doctor and researcher at the University of Toronto whose findings jibe with those of Statistics Canada surveys.
“Ontario is, in many ways, doing the best compared to other provinces,” Dr. Kiran said. “I can only imagine what’s happening in other parts of the country.”
Compiling and comparing detailed national data on primary-care access and other key metrics is one of the goals of the federal health funding offer, which premiers accepted on Monday, despite it falling short of their demands.
Family doctor and University of Toronto researcher Rick Glazier, the other co-leader of Inspire, the network of family medicine researchers, said that although Mr. Trudeau named access to family health teams as a priority last week, neither the Prime Minister nor his provincial counterparts seem to grasp how dire the shortage of family doctors is about to become – especially in light of population aging and the federal government’s plan to admit nearly 1.5 million new permanent residents by 2025.
“I’m honestly not seeing the sense of urgency in expanding the interprofessional teams and building the environments that new graduates would want to work in,” Dr. Glazier said. “It’s not really as much about spending the money as changing the system.”
Kelly Grant