Canadians like to believe that we have the best healthcare system in the world, however, a survey of primary care physicians indicates that Canadian physicians disagree. Recently, the Health Council of Canada1 released the results from the 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians entitled, How do Canadian Primary Care Physicians Rate the Health System?2 (the "Survey").3 Based on the results of the Survey, the Health Council of Canada concluded:
Canada ranks poorly compared to other countries under many factors related to access through primary care and coordination of care between primary and specialists providers. Of particular concern is the widespread lack of timely reporting by hospitals and specialists - information that primary care physicians need to provide appropriate follow-up care. Although there are large differences among some provinces, Canada shows minimal, if any, improvement in recent years in the areas where we could monitor performance over time. For example, less than half of primary care physicians regularly offer same-day or next day appointments or have arrangements for patients to see a doctor or nurse after hours except through the local hospital emergency department - and neither measure has improved since 2006. Provincial governments continue to offer that improving access to primary care is a priority. They are using a variety of approaches to achieve that goal, including support for inter-professional team-based care and new strategies to provide after-hours care. Yet, the results are not encouraging, especially when viewed against the other comparable systems.4
Level of Care
Significantly, 26% of Canadian physicians feel their patients receive too little or much too little care. This number is striking in comparison to the other countries in the Survey. For example, in Switzerland, only 2% of the physicians surveyed felt that their patients receive too little or much too little care. The only country in the Survey where the physicians expressed more concerns about the level of care was New Zealand, where 39% of the physicians said their patients received too little or much too little care.5
Access to Specialized Diagnostic Tests
Overall, 38% of primary care physicians in Canada report that their patients often have difficulty getting specialized diagnostic tests such as CT scans or MRI. Only New Zealand and France ranked lower. In some provinces, such as Quebec and Newfoundland and Labrador, more than 50% of the primary care physicians report that their patients have trouble getting specialized diagnostic tests. Physicians in the top-ranked countries responded that relatively few patients have such trouble. For example, only 3% of Swiss physicians and only 7% of Dutch physicians reported that their patients have difficulty in accessing specialized diagnostic tests.6
Same Day or Next Day Appointments
Canada ranks last and significantly behind the other countries surveyed when it comes to arranging same-day or next-day appointments. According to the Survey, only 47% of Canadians are able to get a same-day or next-day appointment with a primary care physician. In contrast, physicians in France report that 95% of their patients can easily get a same-day or next-day appointment (France is the top ranked country). The second lowest ranked is Australia, where fully 63% of physicians report that their patients can easily get a same-day or next-day appointment.7
It is clear from the Survey that Canada is relying on hospital emergency departments for after-hours care and it is doing so in substantially higher incidences than the other countries surveyed. In fact, the only country that ranks lower than Canada when it comes to the ability of patients to see a physician or nurse when a practice is closed, other than at a hospital emergency department, is the United States. Comparatively, 90% or more of patients in Denmark, New Zealand, the Netherlands and the United Kingdom are able to see a physician or nurse, other than in a hospital emergency department, when the practice is closed.8
House Calls
In France, the United Kingdom, Norway and the Netherlands, house calls are the norm (between 96% and 100% of physicians in these countries say they make house calls), and are a usual practice in all other countries in the Survey except Canada and the United States. In Canada, 58% of primary care physicians surveyed reported making house calls.9
Interestingly, 54% of Canadian physicians said they have the potential to receive or currently receive extra financial support, such as special payments, higher fees or reimbursements, for making home visits. This result ranks Canada second within the 10 countries surveyed; with Australia coming first at 57% and the United States coming in last at 10%.10
Coordination of Care
Coordination between health care providers, including primary care physicians, specialists and hospitals, are a key indicator of patient treatment. Unfortunately, only 30% of Canadian physicians surveyed say they are always notified when their patients go to an emergency department. This statistic falls in the middle of the other countries surveyed, where 60% of physicians in the Netherlands (the highest result) and 21% of physicians in France (the lowest result) said they received notification when their patients go to an emergency department. That said, there is great disparity across Canada. Fully 69% of physicians in New Brunswick said they received such notification, compared to only 8% of Quebec physicians who said they received such notification.11
Canada ranks third from last with respect to the continued management of patients within 48 hours of hospital discharge. In Canada, 16% of physicians surveyed said they received information about their patients within 2 days of hospital discharge. Germany leads the countries with 69% of their primary care physicians saying they received information about their patients within 2 days of hospital discharge.12
Only 26% of Canadian physicians responded that when their patients have been seen by a specialist they always receive a report back with all the information they need, compared to 59% of physicians in the top ranked country, Switzerland.13 Further, only 11% of the Canadian primary care physicians surveyed say the information they receive from specialists who have seen their patients is timely and available when needed. Swiss physicians ranked their country the highest at 27% and the physicians in the Netherlands ranked that country the lowest with only 1% of their physicians responding that they receive this type of information.14
Finally, 81% of Canadian physicians responded that they help manage and coordinate care after hospital discharge. Although this number is high, it still puts Canadian physicians in last place out of the countries surveyed, with the United Kingdom at the highest (97%) and Norway the second to last (82%).15 In response to the question: "Do you contact patients between visits to monitor their conditions?" Canada scored second to last with a positive response of 62%, only ahead of the Netherlands (which scored 48%). The top scoring results came from the United Kingdom where fully 98% of primary care physicians contact their patients between visits to monitor their conditions.16
Use of Electronic Medical Records
Barely half (57%) of the Canadian physicians reported using electronic medical records. This ranks Canadian physicians second to last out of the 10 countries surveyed. This is in sharp contrast to Norwegian physicians all of whom responded that they use electronic medical records. Within Canada, 74% of Alberta's physicians reported using electronic medical records; New Brunswick reported the lowest use of electronic medical records at 26%. The good news is that the use of electronic medical records in Canada more than doubled between the 2006 Survey and the 2012 Survey (only 23% of Canadian physicians reported using medical records in 2006).17
When asked how many physicians routinely use electronic prescribing for medications, 98% of physicians in the Netherlands answered in the positive compared to only 43% of Canadian physicians. Although this ranks Canada 7th out of the 10 countries, in the past six years, the use of e-prescribing in primary care in Canada has increased almost four times (11% in 2006 compared to 43% in 2012).18
Incentive-based Payment
Despite the fact that overall Canada ranked among the lowest in most categories in the Survey, Canada was ranked among the highest countries when it came to offering extra pay to physicians to enhance various aspects of their practice (although there is a wide variation among the provinces).19Canada has nearly doubled its use of incentives for chronic/complex diseases in the last 6 years. 71% of Canadian physicians reported receiving incentives for managing patients with chronic conditions or complex needs. Canada is tied for first with Australia in this category.20 Additionally, 42% of Canadian primary care physicians reported receiving extra pay to provide enhanced preventative care through activities like individual counselling or group visits. However, the range within Canada is wide, from a low of 4% in Newfoundland and a high of 78% in British Columbia.
Even with these incentives, Canadian physicians were among the least likely to work in a practice where clinical performance is reviewed at least annually against improvement targets. Specifically, Canada was the third lowest in the use of clinical performance monitoring in primary care. The highest ranked countries scored considerably higher: 96% of physicians in the United Kingdom, 83% of physicians in New Zealand and 69% of the physicians in the United States reported that their practice reviews aspects of its clinical performance against targets at least annually.21
Conclusion
Overall, Canadian primary care physicians ranked Canada's health care system poorly in comparison to other countries on most of factors related to primary care and the coordination of care between primary and specialist providers. Canada continues to rank low in arranging for same-day or next day appointments, utilizing electronic medical records, or other communication methods, and for informing primary care physicians about their patients' care. Perhaps what is most striking in these results is the contrast between Canadian's perception that Canada has the best healthcare system in the world compared to the perception of the primary care physicians delivering healthcare in Canada.
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Footnotes
1.The Health Council of Canada is an independent national agency that reports on the progress of healthcare renewal.
2.Health Council of Canada. (2013). How do Canadian Primary Care Physicians Rate the Health System? Results from the 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians. Canadian Health Care Matters, Bulletin 7. Toronto: Health Council of Canada. healthcouncilcanada.ca
3.The results of the Survey are based on responses from 2,124 primary care physicians in Canada and 8,642 primary care physicians from Australia, France, Germany, the Netherlands, New Zealand, Norway, Switzerland, the United Kingdom and the United States. The Survey was conducted between March 2012 and July 2012: Similar surveys were also conducted in 2006 and 2009. The Survey includes comparative results over the three surveys.
4.The Survey at page 46.
5.The Survey at page 15.
6.The Survey at page 19.
7.The Survey at page 20.
8.The Survey at page 21.
9.The Survey at page 23.
10.The Survey at page 45.
11.The Survey at page 25.
12.The Survey at page 26.
13.The Survey at page 27.
14.The Survey at page 28.
15.The Survey at page 29.
16.The Survey at page 31.
17.The Survey at page 33.
18.The Survey at page 34.
19.The Survey at page 43.
20.The Survey at page 44.
21.The Survey at page 42.
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