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David Clinton

Are We Winning the Patient-to-Doctor Ratio War?

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7 minute read

By David Clinton

The fact that millions of Canadians lack primary healthcare providers is a big deal. The grand promise of universal healthcare rings hollow for families forced to spend six hours waiting in a hospital emergency room for a simple ear infection diagnosis.

Just how big a deal is it? Statistics Canada data from 2021 ranks provinces by their ability to provide primary health providers. As you can see from the chart, New Brunswick and Ontario were doing the best, with doctors for nearly 90 percent of their residents. Quebec, able to find providers for just 78.4 percent of their population, landed at the bottom. But even just 10-15 percent without proper coverage is a serious systemic failure.

Since healthcare is administered by the provinces, it makes sense to assume that provincial policies will influence results. So comparing access to primary care practice results over time might help us understand what’s working and what isn’t.

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To that end, I pulled Statistics Canada data tracking total employment in offices of physicians (NAICS code 621111) by province. The data covers all employees (including nurses, office managers, and receptionists) in all non-hospital medical offices providing services that don’t include mental health.

I originally searched unsuccessfully for usable data specific to doctors. But as it turns out, such data would have included surgeons and other hospital-based specialties when I’m really looking for general (family) care providers. So I think what we got will actually act as a better proxy for primary care access.

Do keep in mind that staffing levels in the sector represent just one of many statistical signals we could use to understand the healthcare universe. And it’s just a proxy that’s not necessarily a perfect map to reality.

In any case, I adjusted the numbers by provincial populations so they’d make statistical sense. The chart below contains ratios representing how many residents there are per worker between 2010 and 2023:

You might notice that PEI is missing from that chart. That’s because the reported numbers fell below Statistics Canada’s privacy threshold for most of the covered years.

Alberta, with a ratio of just 282:1 is the current champion, while Newfoundland (438:1) has the worst record. But changes over time are where things get interesting. BC’s performance declined by more than 11 percent. And Quebec improved by more than 40 percent!

As you can see for yourself in that chart, Quebec’s most dramatic growth took place between 2016 and 2019. What was going on around that time? Well, both Bill 10 and Bill 20 were introduced in 2015.

  • Bill 10 restructured the healthcare system by reducing the number of administrative regions and centralizing governance to streamline services and improve efficiency.
  • Bill 20 established patient quotas for doctors, mandating a minimum number of patients they were required to see. Physicians who did not meet these quotas faced penalties, such as reduced compensation.

I don’t need to speak French to assume that those measures must have inspired an awful lot of anger and push back from within the medical profession. But the results speak for themselves.

Or do they? You see there’s something else about Quebec we can’t ignore: Chaoulli v. Quebec (2005). That’s the Supreme Court of Canada case where the Canada Health Act’s ban on private delivery of healthcare was ruled unconstitutional (for Quebec, at any rate).

As a direct result of that decision, there are now more than 50 procedures that can be performed in private surgical clinics in the province. The number of private clinics nearly doubled between 2014 and 2023.

Predictably, wait times for surgeries fell significantly over that time. But the numbers of non-hospital employees would probably have climbed at the same rate. That could possibly go further to explain Quebec’s steady and consistent improvements in our data.

What about the other provinces? There have been structural changes to delivery policies in recent years, but they’re mostly too new to have produced a measurable impact. But here’s a brief overview of what’s being tried:

  • This Toronto Star piece describes efforts in both Ontario and BC involving plans among some smaller municipalities to build and manage family health practices and pay their doctors as employees. The idea is that many doctors will prefer to avoid the headaches of starting and running their own businesses and would prefer instead to work for someone else. The obvious goal is to attract new doctors to underserved communities. It’s still way too soon to know whether they’ll be successful in the desperate race for the shrinking pool of family physicians.
  • Both Ontario and Alberta have championed Family Health Groups (FHGs), where physicians receive additional incentives for providing comprehensive care. Ontario’s Family Health Networks (FHN) and Family Health Organizations (FHO) also compensate physicians based on the number and demographics of enrolled patients.
  • British Columbia and Nova Scotia have implemented variations of a Longitudinal Family Physician (LFP) Payment Model. LFPs compensate family physicians based on factors like time spent with patients, patient panel size, and the complexity of care. They claim to promote team-based, patient-partnered care.

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David Clinton

You’re Actually Voting for THEM? But why?

Published on

  By David Clinton

Putting the “dialog” back in dialog

I hate it when public figures suggest that serious issues require a “dialog” or a “conversation”. That’s because real dialog and real conversation involve bi-directional communication, which is something very few public figures seem ready to undertake. Still, it would be nice is there was some practical mechanism through which a conversation could happen.

It should be obvious – and I’m sure you’ll agree – that no intelligent individual will be voting in the coming federal election for any party besides the one I’ve chosen. And yet I’ve got a nagging sense that, inexplicably, many of you have other plans. Which, since only intelligent people read The Audit, leads me directly to an epistemological conflict.

I have my doubts about the prospects for meaningful leadership debates. Even if such events are being planned, they’ll probably produce more shouting and slogans than a useful comparison of policy positions.

And I have remarkably little patience for opinion polls. Even if they turn out to have been accurate, they tell us absolutely nothing about what Canadians actually want. Poll numbers may be valuable to party campaign planners, but there’s very little there for me.

If I can’t even visualize the thinking taking place in other camps, I’m missing a big part of Canada’s biggest story. And I really don’t like being left out.

So I decided to ask you for your thoughts. I’d love for each of you to take a super-simple, one question survey. I’m not really interested in how you’re planning to vote, but why. I’m asked for open-ended explanations that justify your choice. Will your vote be a protest against something you don’t like or an expression of your confidence in one particular party? Is it just one issue that’s pushing you to the polling station or a whole set?

I’d do this as a Substack survey, but the Substack platform associates way too much of your private information with the results. I really, really want this one to be truly anonymous.

And when I say this is a “super simple” survey, I mean it. To make sure that absolutely no personal data accompanies your answers (and to save me having to work harder), the survey page is a charming throwback to PHP code in all its 1996 glory.

So please do take the survey: theaudit.ca/voting.

If there are enough responses, I plan to share my analysis of patterns and trends through The Audit.

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We’re paying the bills, why shouldn’t we have a say?

Published on

  By David Clinton

Shaping Government Spending Choices to Reflect Taxpayer Preferences

Technically, the word “democracy” means “rule of the people”. But we all know that the ability to throw the bums out every few years is a poor substitute for “rule”. And as I’ve already demonstrated, the last set of bums you sent to Ottawa are 19 times more likely than not to simply vote along party lines. So who they are as individuals barely even matters.

This story isn’t new, and it hasn’t even got a decent villain. But it is about a universal weakness inherent in all modern, nation-scale democracies. After all, complex societies governed by hundreds of thousands of public servants who are responsible for spending trillions of dollars can’t realistically account for millions of individual voices. How could you even meaningfully process so many opinions?

Hang on. It’s 2025. These days, meaningfully processing lots of data is what we do. And the challenge of reliably collecting and administrating those opinions is trivial. I’m not suggesting we descend into some hellish form of governance by opinion poll. But I do wonder why we haven’t tried something that’s far more focused, measured, and verifiable: directed revenue spending.

Self-directed income tax payments? Crazy, no? Except that we’ve been doing it in Ontario for at least 60 years. We (sometimes) get to choose which of five school boards – English public, French public, English separate (Catholic), French separate (Catholic), or Protestant separate (Penetanguishene only) – will receive the education portion of our property tax.

Here’s how it could work. A set amount – perhaps 20 percent of the total federal tax you owe – would be considered discretionary. The T1 tax form could include the names of, say, ten spending programs next to numeric boxes. You would enter the percentage of the total discretionary portion of your income tax that you’d like directed to each program with the total of all ten boxes adding up to 100.

The specific programs made available might change from one year to the next. Some might appear only once every few years. That way, the departments responsible for executing the programs wouldn’t have to deal with unpredictable funding. But what’s more important, governments would have ongoing insights into what their constituents actually wanted them to be doing. If they disagreed, a government could up their game and do a better job explaining their preferences. Or it could just give up and follow the will of their taxpayers.

Since there would only be a limited number of pre-set options available, you wouldn’t have to worry about crackpot suggestions (“Nuke Amurika!”) or even reasoned and well-meaning protest campaigns (“Nuke Ottawa!”) taking over. And since everyone who files a tax form has to participate, you won’t have to worry about a small number of squeaky wheels dominating the public discourse.

Why would any governing party go along with such a plan? Well, they almost certainly won’t if that’s any comfort. Nevertheless, in theory at least, they could gain significant political legitimacy were their program preferences to receive overwhelming public support. And if politicians and civil servants truly believed they toil in the service of the people of Canada, they should be curious about what the people of Canada actually want.

What could go wrong?

Well the complexity involved with adding a new layer of constraints to spending planning can’t be lightly dismissed. And there’s always the risk that activists could learn to game the system by shaping mass movements through manipulative online messaging. The fact that wealthy taxpayers will have a disproportionate impact on spending also shouldn’t be ignored. Although, having said that, I’m not convinced that the voices of high-end taxpayers are less valuable than those of the paid lobbyists and PMO influencers who currently get all the attention.

Those are serious considerations. I’m decidedly less concerned about some other possible objections:

  • The risk that taxpayers might demonstrate a preference for short term fixes or glamour projects over important long term wonkish needs (like debt servicing) rings hollow. Couldn’t those words just as easily describe the way many government departments already behave?
  • Couldn’t taxpayer choices be influenced by dangerous misinformation campaigns? Allowing for the fact the words “misinformation campaign” make me nervous, that’s certainly possible. But I’m aware of no research demonstrating that, as a class, politicians and civil servants are somehow less susceptible to such influences.
  • Won’t such a program allow governments to deflect responsibility for their actions? Hah! I spit in your face in rueful disdain! When was the last time any government official actually took responsibility (or even lost a job) over stupid decisions?
  • Won’t restricting access to a large segment of funds make it harder to respond to time-sensitive emergencies? There are already plenty of political and policy-based constraints on emergency spending choices. There’s no reason this program couldn’t be structured intelligently enough to prevent appropriate responses to a genuine emergency.

This idea has no more chance of being applied as some of the crazy zero-tax ideas from my previous post. But things certainly aren’t perfect right now, and throwing some fresh ideas into the mix can’t hurt.

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