Eliot Frymire is part of a research group that investigates and analyzes primary care in Ontario. Using OHIP billing information, the researchers painstakingly drill down into postal code-based data to find out how many people have a regular source of primary care, what type of care they're getting, and where they're getting it.
His takeaway: "We have a crisis everywhere."
As of last year, 2.5 million Ontarians — 16 per cent of the population — didn't have regular access to primary care.
In 2022, the year of the most recent data available on a geographic basis, nearly half of all residents in Sioux Lookout weren't getting regular primary care. Near both Toronto's and Ottawa's city halls, it's about one in three. The same goes for Petawawa in eastern Ontario and a portion of Mississauga near the Pearson International Airport.
About a quarter of those in Kitchener's Vanier neighbourhood, midtown London, eastern Cornwall and nearly all of Thunder Bay didn't have a primary care provider to count on.
Rates of people without primary care climb as high as 72 per cent in more rural northern areas, but Frymire warned against taking those numbers literally due to data gaps.
The data also show 12 per cent of children under 18 aren't getting regular primary care.
Near Toronto City Hall and in eastern Cornwall, the rate of children without primary care is higher than the overall population. It's lower in midtown London and Kitchener's Vanier.
"There is a crisis in primary care, not only in Ontario, but across Canada," said Frymire, who stressed that while his group, Inspire-PHC, is funded by Ontario's Ministry of Health, it's completely independent.
"If primary care isn't healthy, then the rest of the health-care system is not healthy."
Not all primary care is the same, Frymire noted. An "attached" patient, as Inspire-PHC defines them, might be getting regular primary care from a community health centre, walk-in clinic or another source.
The "most fortunate Ontarians" have what's known as team-based care — a family doctor plus a stable of specific care providers, like physiotherapists, counsellors and pharmacists, Frymire said.
The Ford government has focused on this model, tasking former federal health minister Jane Philpott with finding a way to "connect every person in Ontario to primary health care within the next five years."
In a brief interview with The Trillium, Health Minister Sylvia Jones said that means "everyone who is actively looking for a primary care practitioner will be able to have access."
She said patients will be rostered to team-based care, like Philpott's Periwinkle model, which was recently deployed in Kingston. Rostered patients are taken care of by a single family doctor or care team that's funded by the province for each patient.
"And that is multidisciplinary teams working together so that if you need to see a physician, you will see a physician," Jones said. "But you might need to see a nurse practitioner or a dietitian, a (registered nurse). Depending on what your needs are at that point in time, that is the clinician that you will see."
If that's the goal, Ontario has a long way to go.
Just 26 per cent of Ontarians had access to team-based care as of last year, Inspire-PHC found. In some places, it's far less — Scarborough has just 10 per cent team-based coverage, Frymire said.
Frymire noted that the data his group produce are complex and can tell different stories depending on what one focuses on. For instance, the Ontario Liberals pulled out the 10 worst-performing ridings held by Progressive Conservative MPPs.
The Trillium's map shows Ontario has a doctor shortage problem and a doctor allocation problem, Liberal health critic Adil Shamji said.
"We don't have doctors in the right places where patients need it most," he said.
Children need primary care for early interventions, said Shamji, a practising emergency room doctor.
"If a child has a learning disability or if they have autism, we need to diagnose those things early, because the sooner we start treating them, the bigger of a difference it makes for the rest of their lives. When children have a particular illness, there is a window of opportunity where the right treatment can have maximum impact," he said.
Family docs down, ER docs up
In 1993, there were 7.3 family doctors for every 10,000 people in Ontario. In 2022, the figure was 6.46, Frymire said.
Part of the problem is simple: many future doctors just aren't choosing family medicine.
It's a "tough gig" with long hours, lots of paperwork and low pay compared to other specialties, said Alan Drummond, a family physician in Perth, Ontario.
There are ways to convince students to become family doctors. British Columbia has added hundreds since it changed its billing model to pay physicians for administrative work — and pay them more for handling more complex patients.
But compensation isn't the only problem.
Over the past 30 years, the number of family doctors has gone down as the number of physicians working in hospitals, emergency departments and addictions medicine has gone up — a reflection of where the health system needs the most help, Frymire said.
Immigration is another driver of the shortage, he said. Premier Doug Ford has often boasted that Ontario is the fastest-growing jurisdiction in North America.
"Comprehensive family physicians, the numbers per capita have not kept up with population growth," Frymire said.
However, Frymire stressed that some people without primary care simply aren't seeking it.
Of the 2.5 million "uncertainly attached" patients, over 700,000 have had at least one primary care visit in the past two years, meaning they're getting looked after wherever they can.
That group "would love to have a family physician," Frymire said.
Almost 1.8 million Ontarians in that group aren't receiving any kind of primary care — not even for a walk-in visit for a sore throat. That group also has the lowest rate of ER visits.
"So these people do not have a family (doctor), but they're not looking for one ... and they're not going to the (emergency) department either," Frymire said.
This group of healthy marvels should still be getting preventive screening checks and immunizations, he said.
"But these people are not desperately seeking care," he said.
The lack of primary care is still a crisis — "but there is nuance to the data, and you really need to closely look at that nuance," Frymire said.
1.7 million have family doc nearing retirement: report
Things might get worse, according to data released by the Ontario Liberals on Wednesday.
A report, which the Liberals said was leaked to them by a concerned health-sector source, details the number of people in each Ontario municipality who are rostered to a family doctor and the number of rostering physicians who are close to retirement age. The data came from the Ministry of Health, the party said.
There are 2,336 family physicians aged 60 and up in Ontario, per the report. Their three million patients could be without a stable source of primary care in the near future, Liberal Leader Bonnie Crombie said on Wednesday.
Family doctors tend to retire later, at age 70.5 on average, according to one recent Ontario study.
There are 1.7 million Ontarians whose doctors are aged 65 and up.
The following map shows where the problem is most intense.
"So let me be clear: access to a family doctor is not a privilege in Ontario, it's a basic right," Crombie said. "Today's report sheds light on a health-care system that is in crisis and shows a provincial government completely unprepared and uninterested in responding."
Jones noted that her government has expanded medical school seats and residency spots, allowed internationally educated nurses to more easily practice in Ontario, and is overseeing the opening of two new medical schools.
"So we're doing all of this work, whether it's in the short term, the long term or the medium term, to make sure that we have access and continue to have access," she told reporters Wednesday.
Several aging family doctors have spoken about the challenges of finding successors. Wanting to retire but unwilling to leave their hundreds of patients without primary care, some work well into old age.
"It's totally an issue," said Drummond, who is 70.
Drummond said he'd be happy to work until he's 80 but is planning to retire next year to appease his wife. The process of turning over his 1,500 patients to other practices is going smoothly — Perth, a charming town between Kingston and Ottawa, doesn’t have issues attracting doctors, he said.
But the same can't be said for every town, as some have resorted to offering financial incentives to attract physicians.
Family doctors in rural areas often have to take shifts at the hospital — "an unforgiving mistress," Drummond said.
"Being a new graduate, getting out of the university and saying, 'Well, do I really want to go to a rural community where, you know, I'm going to be busting it 365, there'll be some kind of expectation that I will be working the emergency department, that I'll be covering in-patients, that my life is never really my own?'" he said.
Millions of Ontarians without care
The Liberal-released report also shows that 4.1 million Ontarians are not on a family doctor's roster. There are 205 municipalities where no family physicians are signing up patients to their roster.
The report does not include physicians practising under the traditional "fee-for-service" model, which exclusively pays doctors for each time they see patients. It also doesn't include children seen by pediatricians or people who regularly see nurse practitioners or community health clinics.
"The bottom line is that this group is at risk. Many of them don't have a stable, predictable, secure relationship with their own family doctor," Shamji said.
There could be 4.4 million Ontarians without a family doctor by 2026, the Ontario College of Family Physicians has said.
NDP Leader Marit Stiles said the issues raised by the Liberals are old news.
"I've been asking the legislature about it for months. I'm glad the Liberals are finally figuring it out, frankly," she said.
Stiles said the Ford government "poured gasoline" on the health-care fire set by the Liberals.
"We have a Liberal leader who has actually gone on record saying she thought the Liberal government before us actually ended up spending too much money on health care. I mean, we need to make a real change here in the province of Ontario," she said.
—With files from Jessica Smith Cross