A key factor missing from discussions of population aging and health care is the declining access of older people to primary care.
The aging of the population is a catch-all explanation for many social challenges: labor market challenges, for example. But the aging of the population is particularly cited in connection with health care.
Seniors are portrayed as a tsunami that will overwhelm the Canadian health care system or as “bed blockers” filling up spaces in hospitals. What the health care system does to keep older people healthy longer and out of acute care has received less attention.
A key factor missing from discussions of population aging and health care is the declining access of older people to primary care. Older people may outlive their family doctor, or their doctor retires or leaves practice, leaving patients stranded.
When looking for a new GP, seniors face doctor shortages (severe in southern Vancouver Island) or are turned away due to age or complex health issues.
New family physicians, according to surveys, prefer not to work in private practices with heavy administrative and capital burdens, but to devote more time to patient care.
This can leave older people without primary care at the very time of their lives where it can be essential to prevent serious health problems requiring hospitalization later. Without proactive “health care”, much more expensive “sick care” occurs (e.g. visits, hospitalization, long-term care).
The demographic gloom over health care with an aging population lingers on like a walking zombie, while the best evidence shows there is no need to panic.
Canada’s population is indeed aging and has been since before Confederation. The pacing is icy – no elderly people pop out of the carpentry to demand health care unexpectedly. These are us, all of us, aging one year at a time, and aging quite well for the most part.
The overlooked element in discussions of population aging and health care are the primary care practitioners who can help keep people healthy as they age, and out of emergency rooms and hospitals. That is, if the system works as it should.
So what about the system now? Is there a shortage of doctors or is something else getting in the way of keeping people healthy as they age?
Clearly, something is wrong: Statistics Canada notes that in 2019 there were 4.6 million Canadians (700,000 in British Columbia in 2021; 100,000 in southern Vancouver Island) without primary care physician. Statistics Canada finds that people aged 65 and over have higher unmet needs than other age groups, with the exception of 25 to 34 year olds.
And older men as well as people with disabilities or low incomes have the greatest unmet health needs. Internationally, Canada ranks third from the bottom in terms of seniors have access to family doctors.
Is there really a shortage of family doctors? In short, no. In fact, the number of physicians in Canada has grown in recent years at twice the rate of the population — 12.5% for physicians, 4.6% for population. This rate of growth is also true for family physicians, who remain at approximately 50-53% of the medical workforce.
Are new physicians choosing specialty practice in urban centres? The best evidence shows that they are not. Is Canada bringing in too few foreign-trained doctors? Again, evidence shows that the proportion has remained around 25% for decades.
So what’s the deal with so many older Canadians without primary care when there’s no doctor shortage? In short, the fee-for-service approach where physicians charge for each service provided, resulting in a huge administrative burden, is intimidating for new family physicians. In addition, they face significant costs to set up and maintain practices.
Family physicians do not practice medicine because of these barriers. Add to that difficult access to childcare services for new doctors with young families, and the scene is set for mismatches between the needs of the elderly and the doctors available.
Family physicians want to practice in real team environments in clinics where colleagues can replace each other, where they are employed by the clinic rather than independent billers to Medicare.
If policy makers are truly interested in addressing the health care challenges as the population ages, serious action needs to be taken now, action that could mitigate the health care costs later caused not by the aging of the population per se, but by the insufficiencies of the system which push the doctors to leave. And the quality of life of older Canadians could be improved as well as life expectancy.
Professor Emeritus Emeritus at the University of Alberta, Dr. Susan McDaniel is Adjunct Professor of Sociology and Research Affiliate at the Institute of Aging and Lifespan Health at the University of Victoria. She is an aging population specialist and one of 100,000 people on southern Vancouver Island without a family doctor.