Accessibility and Continuity of Primary Care in Quebec

by Jeannie Haggerty | Feb 01, 2004

Key Implications for Decision Makers

  • Clinics with acceptable accessibility and continuity of care have key features in common: evening walk-in and scheduled care; fewer than 10 physicians; and established operational links with other healthcare organizations. Their physicians have effective ways of meeting the urgent care needs for their patients and they see approximately four patients per hour.
  • Patients with good, ongoing relationships with their physician experience benefits from that "continuity of care" - better co-ordination of care between their primary care physicians and specialists and more complete advice on preventing illness and maximizing health.
  • Primary care clinics in Quebec and individual physicians tend to offer either continuity (the doctor knows the patient well and spends time on each visit) or accessibility (it is easy to get in when illness strikes), but patients need both.
  • More than one in five people in Montreal don't have a regular family physician; overall 16 percent of patients surveyed had no family doctor, and the number is probably higher in the general population. People without family doctors don't get good continuity of care - they receive less preventive care and are more likely to use the emergency room.
  • The average wait for Quebeckers who want an appointment with their family physician is 24 days; only 20 percent of 3,441 patients interviewed thought they could see a doctor quickly if they suddenly became ill.

Executive Summary

Provincial and national commissions looking into healthcare say every citizen should have a primary care physician who assumes principal responsibility for the majority of a patient's healthcare needs. There are repeated calls for reforms that would turn the primary care system into a clinical environment that ensures accessible, continuous, comprehensive care, and efficiently and effectively co-ordinates a patient's dealings with other levels of care.

We studied the state of accessibility, continuity, and co-ordination of primary medical care in Quebec in 2002 as the province embarked on a reorganization of its primary care system. We wanted to identify the elements in clinics and physician practices that are associated with better primary care.

In total, 3,441 patients were interviewed at 100 randomly selected community and private primary care clinics in urban, suburban, rural, and remote areas of Quebec.

Results and implications

We found that although patients like and trust their doctors, overall primary care barely meets their minimum expectations. Patients without a regular physician have less access to care and experience poorer continuity and co-ordination of care. In the region of Montreal, 22 percent of those we surveyed did not have a regular physician; that rose to 34 percent among those interviewed in walk-in clinics. Things were little better outside the city. Those patients receive less preventive care and are more likely to have used the emergency room in the last year. Overall, 16 percent of patients surveyed did not have a regular personal physician; that percentage is likely higher in the general population.

We found that "first-contact accessibility" - the ease with which people can initiate contact with their healthcare provider for a new problem - was considerably below minimum expectations. The chance of being seen was better if patients got sick during the clinic's opening hours, but were almost nil if they needed help at night or on the weekend.

The survey also showed that co-ordination of care and preventive care were barely at minimum acceptable levels. Nevertheless, patients felt a strong affiliation to their doctors and trusted them to provide care in keeping with their medical needs and personal context ("relational continuity").

Walk-in clinics tend to perform poorly on continuity and preventive care, but they are the regular source of care for 60 percent of the patients we interviewed in them, and we found that some walk-in doctors strive to provide continuity of care. Clearly, walk-in clinics meet the needs of patients without regular doctors, and are the only source of continuity of care for a significant proportion of patients.

A policy of assigning a roster of patients to a physician will probably ensure better access and continuity, but the plight of those who do not have a responsible physician should be an enormous concern for policy makers.

Patients with a regular physician expressed high levels of confidence that their doctor knew their medical history and personal context and would manage their comprehensive care needs. We found that strong affiliation to a physician and good relational continuity translated into better co-ordination with specialists and more complete preventive services and health promotion.

Patients expressed deep frustration with access when they were given the opportunity to make comments. Their greatest dissatisfaction is with waiting for appointments and their ability to reach their physician by phone. The average waiting time until the next available appointment with physicians was 24 days.

Opinions on accessibility were not uniformly bad. Twenty percent of patients expressed clear confidence that they could be seen within a day by their own regular provider. CLSCs in remote regions - community health centres that have emergency rooms integrated with the primary care clinics and at least one physician on site at all times - provided almost optimum accessibility.

We found that clinics and individual physicians tend to focus either on accessibility or on continuity of care. Most provide continuity at the expense of accessibility, although there is a minority which does both - and a depressingly large number who are weak on both. Some elements in our models speak to a trade-off between continuity and accessibility. For instance, if patient volume drops below the average of 3.4 patients per hour, then accessibility suffers; if it increases, continuity suffers. About four patients an hour seems to be the best balance of accessibility and continuity. Likewise, there is a need to offer a mix of both walk-in and scheduled care.

Our analysis found several common elements in clinics that achieve the best mix of accessibility and continuity. The feature most strongly related to patients having a better sense of accessibility and co-ordination was round-the-clock access to telephone advice (other than the province's Info-Santé line). It can be as simple as voice mail that's checked regularly during the day and refers patients to the on-call network at night. Our model suggests 24/7 telephone access would move patients' sense of accessibility from unacceptably low to at least the minimum-expected threshold.

Contrary to a common assumption, we did not find that solo practitioners offered worse accessibility than group practices, and in the case of rural practices it was better. But when clinics had more than 10 physicians, accessibility and continuity began to decrease. This supports the current policy that suggests that family medicine groups should have between six and eight physicians.

Each additional hour of service above 55 hours per week translated into higher accessibility, especially when offered as evening hours of both scheduled and walk-in care (extra weekend hours were not felt to improve accessibility). Clinics that can't stay open longer should at least consider shifting some working hours to evenings.

The more operational links that a clinic has with other healthcare establishments, the better its accessibility, continuity, and co-ordination of care. This bodes well for the new policy that encourages more links among clinics and hospitals.

Conclusion

There is a perception, among the public and policy makers, that primary care is unresponsive, fragmented, and unco-ordinated with other healthcare. Our study confirms that it is generally unresponsive, but we also find important exceptions that provide guidance for future policies. The core features of the Quebec policy of family medicine groups, such as increasing clinic hours, working in nurse-physician teams, and providing more comprehensive care through operational links with other healthcare establishments, should improve the situation.