Family physician workloads and access to care in Winnipeg: 1991 to 2001

Background

Current perceptions of family physician (FP) shortages in Canada have prompted policies to expand medical schools. Our objective was to assess how FP supply, workloads and access to care have changed over the past decade.

Methods

We used an anonymized physician and population registry and administrative health service data from Winnipeg for the period 1991/92 to 2000/01. We calculated the following measures of supply and workload: ratios of FPs to population, of population to FPs and of FP full-time equivalents (FTEs) to population, as well as FP activity ratios (sum of FTEs/number of FPs), annual number of visits per FP and visits per FP per full-time day of work. Trends in FP remuneration were analyzed by age and sex. We also measured standardized visit rates and stratified the analysis by populations deemed at risk of needing FP services.

Results

In 2000/01 FPs between 30 and 49 years of age (64% of the workforce) provided 20% fewer visits per year than their same-age peers did 10 years previously. Conversely, FPs 60 to 69 years of age (11% of the workforce) provided 33% more visits per year than the corresponding group a decade earlier. On a per capita basis, the number of FPs declined by 5%, from 97 per 100 000 population in 1991/92 to 92 per 100 000 population in 2000/01, which paralleled changes in national estimates of FP supply. Per capita visit rates among Winnipeg citizens (3.5 per year in 2000/01) and average workloads among FPs (4193 visits per year in 2000/01) were stable over the decade.

Interpretation

Despite relative homeostasis in aggregate FP supply and use, there have been substantial temporal shifts in the volume of services provided by FPs of different age groups. Younger FPs are providing many fewer visits and older FPs are providing many more visits than their same-age predecessors did 10 years ago, a finding that was independent of physician sex. Given these data, the perpetual focus of policy-makers and care providers on increasing numbers of FPs will not help in diagnosing or treating issues of supply, workloads and access to care.In 2002, 80% of Canadians believed that there was a shortage of “family doctors,” and 97% of these people believed that the shortage was serious.¹ These perceptions are amplified within the physician workforce itself, with 93% of physicians surveyed in the same year believing that shortages among their ranks were widespread.² Paradoxically, current perceptions of shortages and suggestions to fast-track increases in supply^3,4 come close on the heels of widespread perceptions of surpluses, at least in urban centres, and reductions in medical school enrolment only 10 years ago. For example, in 1993, a Canadian Medical Association survey found that half of the doctors in the country believed enrolment in medical schools should be reduced.⁵ Such relatively quick shifts from perceptions of surpluses to ones of shortages are at odds with recent national data indicating that the per capita number of FPs has remained relatively stable over the last decade.^6,7Unfortunately, temporal patterns of FP workloads over the past decade have not been documented in national supply-side analyses.^6,8 Furthermore, analyses have not been conducted to understand temporal patterns in the relation between FP age or sex and workloads. Yet this type of information is vital to understanding (and projecting) the impact of demographic shifts in the workforce⁸ on current (and future) supply of services. When the supply of FPs is inadequate, the workloads of both FPs and specialists could be affected and access to care compromised. There is evidence that FPs work long hours,⁹ that many are unhappy with their workloads^9,10 and that those who report heavy workloads are more likely than others to stop accepting new patients.⁶The purposes of this study were to evaluate whether FP workloads, on average or for certain cohorts of practitioners, have changed over a period of relatively stable FP-to-population ratios; to simultaneously examine the population''s use of FPs; and to consider the potential impact of any change in workloads or service utilization on perceptions of adequacy of FP supply and access to care. This population-based study, which formed part of a larger project,¹¹ was based on data from Winnipeg, a city (like others in Canada) where FPs report unhappiness with workloads, where citizens express frustration regarding access to FPs and where journalists document widely held views that many FP practices are “restricted” in accepting new patients.¹² We hypothesized that average workloads increased, that population rates of use declined, and that age- and sex-specific workloads remained constant.