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

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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2025 Federal Election
Highly touted policies the Liberal government didn’t actually implement

From The Audit
State capacity is the measure of a government’s ability to get stuff done that benefits its population. There are many ways to quantify state capacity, including GDP per capita spent on health, education, and infrastructure versus outcomes; the tax-to-GDP ratio; judicial independence; enforcement of contracts; and crime rates.
But a government’s ability to actually implement its own policies has got to rank pretty high here, too. All the best intentions are worthless if, as I wrote in the context of the Liberal’s 2023 national action plan to end gender-based violence, your legislation just won’t work in the real world.
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So I thought I’d take a look at some examples of federal legislation from the past ten years that passed through Parliament but, for one reason or another, failed to do its job. We may agree or disagree with goals driving the various initiatives, but government’s failure to get the work done over and over again speaks to a striking lack of state capacity.
The 2018 Cannabis Act (Bill C-45). C-45 legalized recreational cannabis in Canada, with a larger goal of regulating production, distribution, and consumption while reducing illegal markets and protecting public health. However, research has shown that illegal sales persisted post-legalization due to high legal prices and taxation. Studies have also shown continued use among children despite regulations. And there are troubling indicators about the overall impact on public health.
The 2021 Canadian Net-Zero Emissions Accountability Act (Bill C-12). The legislation aimed to ensure Canada achieves net-zero greenhouse gas emissions by 2050 by setting five-year targets and requiring emissions reduction plans. However, critics argue it lacks enforceable mechanisms to guarantee results. A much-delayed progress report highlighted a lack of action and actual emissions reductions lagging far behind projections.
The First Nations Clean Water Act (Bill C-61) was introduced in late 2024 but, as of the recent dissolution of Parliament, not yet passed. This should be seen in the context of the Safe Drinking Water for First Nations Act (2013), which was repealed in 2021 after failing to deliver promised improvements in water quality due to inadequate funding and enforcement. The new bill aimed to address these shortcomings, but a decade and a half of inaction speaks to a special level of public impotence.
The 2019 Impact Assessment Act (Bill C-69). Passed in 2019, this legislation reformed environmental assessment processes for major projects. Many argue it failed to achieve its dual goals of streamlining approvals while enhancing environmental protection. Industry groups claim it created regulatory uncertainty (to put it mildly), while environmental groups argue it hasn’t adequately protected ecosystems. No one seems happy with this one.
The 2019 Firearms Act (Bill C-71). Parts of this firearms legislation were delayed in implementation, particularly the point-of-sale record keeping requirements for non-restricted firearms. Some provisions weren’t fully implemented until years after passage.
The 2013 First Nations Financial Transparency Act. – This legislation, while technically implemented, was not fully enforced after 2015 when the Liberal government stopped penalizing First Nations that didn’t comply with its financial disclosure requirements.
The 2019 National Housing Strategy Act. From the historical perspective of six years of hindsight, the law has manifestly failed to meaningfully address Canada’s housing affordability crisis. Housing prices and homelessness have continued their rise in major urban centers.
The 2019 Indigenous Languages Act (Bill C-91). Many Indigenous advocates have argued the funding and mechanisms have been insufficient to achieve its goal of revitalizing endangered Indigenous languages.
The 2007 Public Servants Disclosure Protection Act (PSDPA). Designed to protect whistleblowers within the federal public service, the PSDPA has been criticized for its ineffectiveness. During its first three years, the Office of the Public Sector Integrity Commissioner (OPSIC) astonishingly reported no findings of wrongdoing or reprisal, despite numerous submissions. A 2017 review by the Standing Committee on Government Operations and Estimates recommended significant reforms, but there’s been no visible progress.
There were, of course, many bills from the past ten years that were fully implemented.¹ But the failure rate is high enough that I’d argue it should be taken into account when measuring our state capacity.
Still, as a friend once noted, there’s a silver lining to all this: the one thing more frightening than an inefficient and ineffective government is an efficient and effective government. So there’s that.
The fact that we’re still living through the tail end of a massive bout of inflation provides clear testimony that Bill C-13 (COVID-19 Emergency Response Act) had an impact.
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David Clinton
You’re Actually Voting for THEM? But why?

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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