Graphics by Murat Yükselir/The Globe and Mail

Canada lags behind other well-off nations when it comes to timely access to health care, according to an influential survey of patients in 11 countries, including the United States.

Canadian patients reported more trouble scoring same-day or next-day appointments with their family doctors than patients in any country but Norway, which tied Canada for last place.

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Canada also placed second-last on the availability of doctors on nights and weekends, which contributed to making patients in this country the most frequent users of emergency departments and the most likely to wait four hours or more for emergency care.

However, the report found that once Canadians get in to see their physicians, they rate the care they receive from their regular doctors as among the best in the world.

The wide-ranging survey of adults in 11 countries was conducted by the Commonwealth Fund, a New York-based private foundation whose reports are frequently cited by Canadian politicians and policy makers looking to see how the country's health-care system stacks up against its peers in Europe, Australia and the U.S.

CIHI oversaw the Canadian portion of the Commonwealth Fund study, which surveyed 4,547 Canadians from March to June of last year. The Commonwealth Fund asked the same questions about timely access, cost barriers to medical care and quality of care during the same time period in Germany, France, Norway, New Zealand, Sweden, Australia, the Netherlands, Switzerland, the U.S. and the United Kingdom.

"Over all, Canadians were the most likely to rate the quality of care they receive [from their own doctors] as excellent of all the countries," said Robin Osborn, vice-president of the international program in health policy and practice innovations at the Commonwealth Fund. "Where it stands out in terms of having room to do better is on the access."

An overview of the 2016 survey's results was published in the journal Health Affairs in November, but on Thursday, the Canadian Institute for Health Information (CIHI) released a deeper dive into the Canadian findings, including breakdowns by province.



Access to health care, by the numbers

0,2013,2016 Canada,38,43 CMWF average,55,57

0,2013,2016 Canada,36,34 CMWF average,45,43

0,2013,2016 Canada,60,59 CMWF average,68,72

0,2013,2016 Canada,40,41 CMWF average,29,27

0,2013,2016 Canada,46,41 CMWF average,33,34

0,2013,2016 Canada,57,56 CMWF average,32,36

2013 vs. 2016

Canada CMWF average

2013 vs. 2016

Canada CMWF average

2013 vs. 2016

Canada CMWF average

2013 vs. 2016

Canada CMWF average

2013 vs. 2016

Canada CMWF average

2013 vs. 2016

Canada CMWF average

What the numbers mean

"The overall message is that on timely access to care, we still have a fair amount of work to do," said Tracy Johnson, the director of health system analysis and emerging issues at CIHI, the country's official agency for health-care statistics.

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"We're below the international average in seven out of the eight areas that were measured. For person-centred care, though, we appear to be doing better, generally, than the international average."

The survey also found that waiting times to see a specialist were longer in Canada than in any of the other countries, as were waiting times for all elective surgeries.

Survey results should always be taken with a grain of salt, Ms. Johnson warned, because they rely on patients' memories of their experience with the health-care system, unlike data directly from hospitals or clinics.

But in cases where CIHI has hard data – as it does for emergency-department waiting times, for instance – the Commonwealth Fund survey findings tend to track roughly with the other evidence, she added.

The survey found that only 43 per cent of Canadians were able to secure same-day or next-day appointments with their primary-care physicians, a tie for last place. Still, that figure was an improvement over the last time the Commonwealth Fund asked the question in 2013, when only 38 per cent of Canadian patients said they could see their doctors right away.

In top-performing Netherlands, 77 per cent of respondents reported snagging a same-day or next-day appointment the last time they were sick, followed by New Zealand (76 per cent) and Australia (67 per cent).

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Only 34 per cent of Canadians said it was easy or somewhat easy to get medical care outside the emergency department on evening or weekends. Only Sweden fared worse.

Colleen Flood, the director of the University of Ottawa's Centre for Health Law, Policy and Ethics, said part of the explanation is that Canada has fewer physicians per capita than any of the other countries surveyed, except the United States – 2.6 doctors for every 1,000 Canadians, according to the Organization for Economic Co-operation and Development.

The United States also has 2.6 doctors for every 1,000 people, the OECD says. Norway, by contrast, has 4.4, Germany has 4.1 and the U.K. has 2.8.

Canada has 2.6 doctors for every 1,000 people, according to the OECD. JENNIFER ROBERTS/FOR THE GLOBE AND MAIL

The role the provinces play

But the deeper reason that Canadians struggle to access primary care, Prof. Flood said, is that provincial governments here exert less control over when and how doctors work than do the public and private payers in the other countries surveyed.

"Our physicians are relatively autonomous," she said. "They still decide, largely, what they do and when they do it. They decide their work hours and how many days a week they want to work."

Some provinces are trying to rectify this by encouraging family doctors to join group practices, where they can share the burden of night and weekend shifts. In Ontario and Alberta, where provincial governments have made an especially strong push for team practices, survey respondents reported better access to night and weekend appointments.

However, in December, Ontario's Auditor-General criticized the Ministry of Health and Long-Term Care for failing to set and enforce clear requirements for night and weekend work for doctors who had joined group practice models.

The challenge of cost

The Commonwealth Fund survey also asked about financial barriers to medical care.

For services covered by the Canada Health Act, Canada received high marks, above the average for the 11 countries.

Only 6 per cent of Canadian respondents said they did not visit a doctor or skipped a medical test or treatment because they could not afford it. In the United States, 22 per cent said they declined to visit a doctor because of the cost.

But when it comes to prescription drugs and dental work – which fall outside the universal coverage guarantee of the Canada Health Act – Canada is second-last to the United States.

Ten per cent of Canadians said they failed to fill prescriptions or skipped doses of medications because they could not afford the out-of-pocket price.

"In all of the countries in this international survey, with the exception of the United States and Canada, you have universal health insurance that includes universal coverage of medicines, regardless of your age or income," said Steve Morgan, a health economist who teaches in the department of population and public health at the University of British Columbia.

Where Canada did well

Canada's best results came in a part of the survey dubbed patient-centred care.

Seventy-four per cent of Canadians rated the care they received from their own doctor in the last year as very good or excellent, second only to New Zealand.

Canadian patients said their doctors were more likely than the survey average to know their medical history, spend enough time with them, involve them in decisions about medical care and explain things in a way they could understand.

Yet that did not lead patients to bestow high marks on the system over all. Only 45 per cent of Canadians rated the overall quality of medical care as very good or excellent, the third-worst result in the report.

In 2014, Canada spent $5,543 per person on health care, well above the OECD average of $4,463.

Follow Kelly Grant on Twitter: @kellygrant1



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