The British Columbia government has only a vague idea of how many people in the province lack access to a family doctor or other primary care provider, Health Minster Adrian Dix has acknowledged.
Dix shared that assessment during legislature debate on his ministry’s $25.3 billion budget this month. But it’s also clear in records the ministry released to The Tyee in response to a freedom of information request.
“Over a period of years, we have seen an increase in what's called unattachment, but it's not well measured in our system,” Dix said. “This was true of the previous government, it was true of the government before that, and it's true of this government.”
The admission comes at a time when anecdotes about people’s difficulties getting primary care have become common and the government has been under heavy political pressure to fix the problem.
Opposition MLAs have raised the issue repeatedly in the legislature and “Everyone Deserves a Family Doctor” lawn signs have sprouted around the province as part of a campaign organized by BC Health Care Matters, a patient advocacy group that has adopted the slogan from the BC Family Doctors, the group representing the profession in the province.**
BC Liberal health critic Shirley Bond said during the budget debate that many people are concerned about the state of health care in the province. She and her colleagues hear from British Columbians every day who are concerned about the cracks in the system, she said.
“The doctor situation in British Columbia is being described by doctors, by patients, by families, as a crisis,” said Bond, MLA for Prince George-Valemount. “Transformation is important, but we actually need to manage the system we have now so people can get the care they need. Part of the core of that issue is that they cannot get a family doctor.”
Family doctors act as gatekeepers to the health-care system, referring patients to other specialists, but they also get to know the people they serve over time, allowing them to deliver higher quality care than a walk-in clinic or other episodic care without the ongoing relationship.
There are roughly 900,000 people in the province — about one person in five — who are unattached to a family doctor or other primary care provider. That number, like most on attachment, comes from the annual Canadian Community Health Survey.
“While that survey is valuable... it isn't sufficient to what we need in health care at this moment in the 21st century,” said Dix.
“It doesn't give us enough sensitivity,” he said. “It doesn't describe how you're feeling at 73, which might be different than if you're a healthy 26-year-old without children. Your need for a family practice doctor is different and your response to that survey is different.”
The government does know that people who lack access to primary care are often people with other challenges, including housing instability and economic disadvantage, he added.
Across Canada, according to the most recent figures available, males are more likely than females to lack a regular health-care provider. So are people aged 18 to 34, when compared to other age groups.
The survey figures do, however, show a clear trend. As Dix outlined in the debate, in 2003 there were 437,000 people, or 10.6 per cent of the B.C. population, without a family doctor. By 2017 it was up to 18.2 per cent, or 897,000 people.
“In fact, other than 2018 and 2019, that percentage basically went up every year over that period,” Dix said. “That tells us a little bit about the challenge, that there's a momentum to this challenge over time.”
The current crisis may be attributable in part to the COVID-19 pandemic, when there have been shifts in primary care, including a major increase in the number of virtual visits and a rise in the provision of services by large corporations.
The government has also been expanding a system of new urgent primary care centres. Intended as a way to take the pressure off hospital emergency departments, some also see them as taking away physicians who otherwise would be providing primary care in other settings.
But even before the pandemic it had been clear that the number of people unattached to primary care was growing and that attempts to solve it had been unsuccessful.
The Tyee tried to get more clarity on what the government was doing about the problem in November 2019, filing a freedom of information request for “Any and all records of any assessment produced regarding access to primary care in B.C., including but not limited to any records tracking or estimating the number of people who lack access to a family doctor or other primary care provider.” The request asked for documents going back to May 2018.
In total the ministry has so far released 766 pages of records in two phases. The first batch came in the fall of 2021, nearly two years after The Tyee asked for them. The ministry released the second set earlier this year and says there is still more to come in a third instalment.
Large portions of the released records were withheld under sections of the Freedom of Information and Protection of Privacy Act allowing the censoring of policy advice or recommendations, information harmful to the financial or economic interests of a public body, information harmful to intergovernmental relations or negotiations, and information harmful to personal privacy.
They included a 130-page discussion paper from 2015, "Primary and Community Care in BC: A Strategic Policy Framework," that was already publicly available.
Various records cite the federal Canadian Community Health Survey, but they also include documents on the ministry’s own attempts to get a handle on the problem through billing information and other methods of estimating the gap.
One table shows that in fiscal 2017-2018 there were 778,773 British Columbians known to be unattached, about 15.4 per cent of the population.
To determine “attachment,” the table used an algorithm that counted someone as attached to a primary care provider if they’d made at least five visits to a primary care provider in the last fiscal year and the majority of them were with the same provider.
It could also go back up to a decade to find five visits to determine if someone was attached to a particular provider. And someone who hadn’t had five visits in the last decade would be considered “attached” if they had been to the same provider three times in the last year.
Using that approach, the ministry said there were another 443,752 people, or nearly nine per cent of British Columbians, whose attachment status to a primary care provider was unknown.
The government could only say for sure that about 76 per cent of the population, or 3.8 million people, were attached to a primary care provider.
Other documents suggest that almost half the people who are unattached are not in fact looking for a primary care provider. In other words, about 7.4 per cent is the “natural rate” of unattachment that should be expected.
In 2019 the Canadian Community Health Survey also found that among British Columbians who lacked a primary care provider, 36.5 per cent said it was because no one was available in their area or no one in their area was taking new patients.
The B.C. Health Ministry’s analysis showed notable differences among local health areas. Greater Victoria, where much of the attention on the issue has been focused in recent months, had 16 per cent who were unattached and another nine per cent for whom the status was unknown.
Unattachment rates were higher in Alberni (20 per cent), Smithers (20 per cent), Chilliwack (25 per cent), Howe Sound (25 per cent), Peace River South (25 per cent), Grand Forks (29 per cent), Peace River North (31 per cent) and Hope (33 per cent).
Each of those also had at least five per cent and as much as 12 per cent of the population for whom the attachment status was unknown.
The highest level of attachment was in Upper Skeena at 88 per cent. Some of the other health areas with relatively high levels of attachment included Fort Nelson, Burns Lake, Kitimat, Queen Charlotte, Central Coast, Lillooet, Revelstoke and Golden.
While the data predates the pandemic, it is the most recent that’s available publicly. The Tyee sought updated information from the Health Ministry over the past few weeks, but it has yet to be provided.
Strains on health care in B.C. have been a hot topic for opposition parties in the legislature.
The BC Green Party has been raising concerns about increasing corporate involvement and lack of access to primary care. The BC Liberals have been criticizing long wait times and the lack of capacity in a system where doctors have better employment options than running clinics.
“It’s about results and the results are getting worse everywhere in the health-care system,” recently elected BC Liberal Leader Kevin Falcon said. “The issue isn’t what you’re putting into the system, it’s what you’re getting out of the system.... It’s not working well for patients.”
Falcon pointed to the amount of paperwork required from doctors, high housing prices and high personal income tax rates as contributing to the problem.
“Part of it is understanding the challenges doctors face,” he said, “and I think the problem with the NDP is they don’t realize doctors, especially family physicians, are really small business people and they’re struggling with all the challenges the government has imposed on them as small businesses.”
In theory B.C. has plenty of family doctors. There are more than 6,000 family physicians, residents and medical students registered with the BC College of Family Physicians. If each had a panel of 1,000 patients, which is fewer than many family doctors serve, there would be plenty to care for everyone in the province.
Having already had a turn wrestling with these issues as a previous health and finance minister, Falcon argued the solution isn’t as simple as putting more money into the system, noting the ministry’s budget has consistently grown. “If it was just about more money, all the health-care problems would have been solved by now.”
He did not, however, have solutions to offer. Asked for a vision of what he would do differently, he said he needed to have a discussion with his caucus and would have more to say in the months ahead.
The direction that Dix laid out during debate of his ministry’s budget was in line with the strategy he announced in 2018 that included training more doctors and nurse practitioners and creating primary care networks that would have doctors and nurses working as part of teams with other health professionals.
It includes moving away from a fee-for-service system where physicians bill for each patient they see and adopting other payment models such as providing salaries to look after a population of patients. The majority of new doctors coming out of medical school say they don’t want to work in the fee-for-service model, he said.
Still, about 80 per cent of billings in B.C. are based on fee-for-service, Dix said, almost double the amount in Ontario. It’s a model that doesn’t work as the population ages and the care individuals need becomes more complex, he added, meaning there are fewer “easy” appointments to balance out the ones that take more time.
“We need to build out team-based care,” he said. “That's what progressive health care is doing everywhere. Some of this work began under the previous government, and we've really worked at it hard since 2018.”
Training more providers takes time and changes need to be done in consultation with doctors and other professionals, including through contract negotiations, Dix said.
The transformation is complicated by the fact it has to happen while the system continues to function to serve patients every day, he said. “We can't shut it down and start anew. We've got to continue to function while we're bringing that change.”
But fixing the problem will also require gaining a better understanding of just how extensive it is.
On Tuesday, Premier John Horgan issued a statement after he and Dix met with Doctors of BC, a voluntary association of 14,000 physicians, residents and medical students in British Columbia.
“The number of British Columbians without access to an in-person family physician is a real problem. They are left waiting hours for medical attention that, for many, could have been addressed with a visit to a family doctor,” Horgan’s statement reads in part.
“While this is a problem across Canada, it is very acute here in B.C.”
The statement said the government is committed to working with Doctors of BC to find “solutions to provide transformational change.”*
* Story updated on May 18 at 9:22 a.m. to include information from a statement by John Horgan issued after deadline.
** Story updated on May 18 at 11:46 a.m. to correct the sponsors of the "Everyone Deserves a Family Doctor" campaign.