Getting deliberate about access

Dear Colleagues,

Your College is a member of the Wait Times Alliance (WTA). I had the privilege of representing you at a recent event on Parliament Hill to mark the 10th anniversary of the 2004 Health Accord. The most recent data show positive change by the provinces in wait times for 4 of the 5 procedures singled out as opportunities for improvement (radiation therapy, coronary artery bypass graft surgery, hip and knee replacement, and cataract surgery). Not surprisingly, considerable gaps still exist, and Canada ranks the lowest among Organisation for Economic Co-operation and Development countries with regard to wait times.

Emergency departments are often viewed as the laboratory of what ails our health system. The most recent Nanos poll of 1000 Canadians revealed that 27% reported waiting more than 4 hours to be seen, compared with 1% in the Netherlands and 5% in the United Kingdom.¹ The same poll reminds us that opportunities for improvement remain regarding access in family practice. When asked if patients are waiting too long to see their family doctors, 33% were concerned, 36% were somewhat concerned, 19% were somewhat unconcerned, and 12% were unconcerned.¹ We could say that family practices are overwhelmed with patients with chronic illnesses and comorbidities, and that scheduling appointments appropriately has become increasingly difficult; that an important bottleneck is the referral process to other specialists; and that payment models do not encourage innovation. Yet, when it comes to service (and, let’s face it, we provide a service), perception can be reality. We can no longer ignore this and must offer and be engaged in the solutions.

According to Dr Chris Simpson of the WTA, 3 factors emerge to explain the sustained improvement in access by other nations: leadership by the medical profession; a clear vision and action plan for sustainable change; and leadership and engagement of government (oral communication, October 2014).²

Considerable innovation is taking place in parts of the country in terms of access to primary care: shared care models (first started for mental health, now expanding in other areas), mentoring programs, group visits, electronic communication (e-mail, texting where and when appropriate), telemedicine consultations, and same-day or advanced access are all examples of such innovation.

For the first time since its inception, the WTA has included advanced access as a performance indicator in primary care. Advanced access is well described in a CFPC paper supporting the timely access pillar of the Patient’s Medical Home.² Key elements include doing today’s work today; eliminating the backlog of patients before implementation; keeping at least 50% of appointments unscheduled to accommodate those who need to be seen the same day or who wish to choose when to be seen; and maximizing each appointment. Good evidence demonstrates that advanced access improves patient, provider, and clinical team satisfaction with care; reassures patients that their doctors and care team will be available when needed; builds trust and enhances the patient experience; substantially decreases the number of “no-shows”; eliminates backlogs and time-consuming tasks related to triaging patients; minimizes inappropriate use of emergency services; and decreases the need for walk-in clinics.

Although the scheduling system is clearly a part of advanced access, its implementation requires engagement in organizational aspects of practice by all clinicians and support staff. It is essential to eliminate the backlog of patients at the start, to carefully plan time off (vacation, statutory holidays), and to have contingency plans in place for when demand exceeds predictions. The practice needs to be prepared for potential increases in urgent or acute visits, and there is also the potential for continuity of care to be negatively affected if patients are seen by different providers too often in order to foster same-day access.

Appropriate support infrastructure and mentoring are required to implement advanced access, and it can be difficult to maintain even with support. But it results in better care, efficiently delivered, with an enhanced patient experience. We cannot afford not to do this. It is estimated that family practices need to invest 5% of their time in continuous quality improvement (written communication with Drs Rob Wedel and Lee Green, October 2014). In our conversations with Chapters and provincial medical associations, we get the clear sense that our profession is keen to be engaged in improving timely access. However, clinicians cannot implement this by themselves. They need guidance and support. Provincial governments have shown interest in improving access to family practices. With an action plan, political will, and sustained leadership from both the medical profession and governments, we can improve our patients’ access to care. By seeing patients when they want to be seen, often the same day they seek care, we can greatly improve their experience and the quality of compassionate care provided by Canada’s family doctors.

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