Diane E. Watson

Family physician workloads and access to care in Winnipeg: 1991 to 2001

Background: Current perceptions of family physician (FP) shortages in Canada have prompted policies to expand medical schools. Our objective was to assess how FP supply, workloads and access to care have changed over the past decade. Methods: We used an anonymized physician and population registry and administrative health service data from Winnipeg for the period 1991/92 to 2000/01. We calculated the following measures of supply and workload: ratios of FPs to population, of population to FPs and of FP full-time equivalents (FTEs) to population, as well as FP activity ratios (sum of FTEs/number of FPs), annual number of visits per FP and visits per FP per full-time day of work. Trends in FP remuneration were analyzed by age and sex. We also measured standardized visit rates and stratified the analysis by populations deemed at risk of needing FP services. Results: In 2000/01 FPs between 30 and 49 years of age (64% of the workforce) provided 20% fewer visits per year than their same-age peers did 10 years previously. Conversely, FPs 60 to 69 years of age (11% of the workforce) provided 33% more visits per year than the corresponding group a decade earlier. On a per capita basis, the number of FPs declined by 5%, from 97 per 100 000 population in 1991/92 to 92 per 100 000 population in 2000/01, which paralleled changes in national estimates of FP supply. Per capita visit rates among Winnipeg citizens (3.5 per year in 2000/01) and average workloads among FPs (4193 visits per year in 2000/01) were stable over the decade. Interpretation: Despite relative homeostasis in aggregate FP supply and use, there have been substantial temporal shifts in the volume of services provided by FPs of different age groups. Younger FPs are providing many fewer visits and older FPs are providing many more visits than their same-age predecessors did 10 years ago, a finding that was independent of physician sex. Given these data, the perpetual focus of policy-makers and care providers on increasing numbers of FPs will not help in diagnosing or treating issues of supply, workloads and access to care.

Toward an Understanding of High Performance Pharmaceutical Policy Systems: A "Triple-A" Framework and Example Analysis

Drawing on international examples of published policy objectives for national pharmaceutical policies, we pro- pose a framework for gauging system performance on the health-related goals of policy in the pharmaceutical sector. We review basic policy structures and performance indicators for the seven participating countries of the Commonwealth Funds 2007 International Health Policy Survey. We explore performance on three inter-related objectives that support overarching health goals: promoting the accessibility, appropriateness, and affordability of medicines. Indicators of per- formance along these dimensions are compared across countries and stratified by age, income and morbidity. Though no country appears uniformly strong in all areas, several appear to have done well to manage sometimes-difficult tensions in the pharmaceutical sector.