No-appointment clinics can ease ER overcrowding—but only somewhat. The answer to the problem lies elsewhere, in addressing the lack of family doctors in the Montreal urban agglomeration.

Every year at this time we see headlines about overcrowded emergency rooms in city hospitals. Unless you are unconscious, having a heart attack, bleeding or in excruciating pain, you will wait many hours before being seen. For seniors who have paid hefty taxes to maintain the health-care system, this is depressing and humiliating.

The Jewish General Hospital, which faces criticism from the Montreal Health and Social Services Agency because it has an accumulated deficit this year of $17.5 million, has pioneered a walk-in clinic that relieves some of the ER burden. The agency’s idea was implemented at the Jewish in 2010, tailored to fit patient needs. Last year it treated 40,000 ambulatory patients compared with 50,000 at its busy ER.

But ER overcrowding statistics compiled by the agency for January 25—a date chosen at random—make it clear this widely praised initiative is not enough. The Jewish was among four city hospitals of 17 that day where patient capacity was over 150 per cent. Almost one-third, or 58 of 172 ER patients, had been parked on guerneys for at least 24 hours. Not good.

A study by the Canadian Institute for Health Information, based on 2005 figures and cited by Dr. F.P. Gladu in Canadian Family Physician, reveals that Quebec had more family physicians per 100,000 than in the rest of Canada, yet more than twice as many Quebecers, or 25 per cent, had no regular doctor.

The situation was worse in Montreal, where one-third of patients had no physician, Gladu found.

These ER visits cost taxpayers five to 10 times more than the same consultation in family-physician offices. Under their own doctor’s care, these patients have better survival rates, are less expensive to care for, spend less time in hospitals, and consume fewer drugs than other patients, Gladu said. It adds up to “the biggest waste of public funds of our generation.”

Walk-in clinics are helping by, for example, accepting patients from the ER who need follow-up care, sometimes providing call-back services at a small cost so patients don’t have to sit in the waiting room. Last year, the clinic saw 550 patients in that category, who had made 2,600 ER visits over the past five years, reported hospital chief of family medicine Michael Malus.

But the real culprits are Quebec policies that doctors say are contributing to the brain drain, as graduates leave the province for the rest of Canada, where rules are seen as less punitive.

Under the PREM, Plans régionaux d’effectifs médicaux, the government awards a certain number of permits for new doctors per region based on the physician-population ratio of each region. The formula favours outlying regions because Montreal doctors also treat many patients from Laval and the north and south shores.

To remedy the problem, the Montreal Health and Social Services Agency last fall said it would grant about 60 permits in 2013. According to Mark Roper, director of primary care the McGill University Health Centre, that will still leave the city under-served because it fails to account for retirements and the increasing needs of an aging population.

Montreal’s central districts are most affected, compared with areas like Ahuntsic and Rivière des Prairies, where there are fewer seniors and many residents work and get their medical care downtown.

The other major factor that drives away young graduates is the requirement to take on special medical activities (SMAs) in hospitals during the first 20 years of practice. If they do not, they are fined 30 per cent of their income. These activities, such as 24-hour on-call shifts, elder care, obstetric and emergency services, are paid at a lower rate or performed at less attractive times of day. Few hospitals allow physicians to work less than 25 hours a week. Gladu reported. Other provinces offer targeted incentives for these activities.

Walk-in clinics can help because with intra-disciplinary care and seven-day-a-week operations, they offer what is beyond the scope of a family doctor. As Malus points out, one of its physicians can care for 3,000 patients rather than the standard 1,800.

“It’s not a substitute for family physicians, but it is a good idea for overflow and sophisticated chronic care problems that require a team approach,” Malus says.

As for the $17.5-million deficit, the Jewish is not alone. (The MUHC is anticipating a deficit of $115 million by March.) Up to $7 million could be because people from beyond its catchment area seek care at the Jewish. The hospital attributes the deficit to an increase in the number of patients who are referred to it or seek care “due to its reputation and areas of expertise” in geriatrics, cardiology and oncology, including 14 areas of cancer treatment not available in all areas of Quebec.

It has seen a 30-per-cent increase in the number of patient-days requiring acute care, and added eight beds requiring 24-hour monitoring. It has made $6.9 million in cuts in non-clinical areas.

“Quality of care and safety of our patients remain our top priority,” the hospital said, as it pledged to balance quality of and access to care with funding limits.

We urge Quebec to revise its permit restrictions to take into account Montreal’s situation, so more family-practice physicians can work here. We ask that it increase budgets for major city hospitals which, because of their reputations and areas of expertise, attract patients beyond their catchment areas.