• Across Canada, 15% of visits to the emergency department (ED) between April 2023 and March 2024 were for conditions that could potentially have been managed in primary care.
• 9% of visits to the ED were for conditions that could potentially have been managed virtually in primary care — suggesting an opportunity to improve health care access using virtual care.
• Those most likely to use the ED for primary care were young children, people who live in rural or remote areas, and people who reported not having access to primary care.
• The number of patients visiting the ED for conditions that could be managed in primary care may signal inadequate access to quality primary care in the community.
• Tackling primary care access alone won’t solve ED overcrowding — this is a multi-faceted issue that also reflects capacity and responsiveness concerns in other parts of the health care system.
• These findings are consistent with survey data that shows many Canadians face challenges to primary care access.

CIHI would like to acknowledge and thank the expert advisory group for this report: 

• Dr. Simon Berthelot, Emergency Physician, Associate Professor and Researcher, Département de médecine de famille et de médecine d’urgence, Université Laval 
• Dr. Nicholas Myers, Medical Director, Primary Care, Alberta Health Services
• Dr. Howard Ovens, Staff Emergency Physician and Chief Medical Strategy Officer, Sinai Health; Full Professor, Department of Family and Community Medicine and Senior Fellow, Institute of Health Policy, Management and Evaluation, University of Toronto
• Dr. Kevin Samson, Family Physician, Ontario 
• Stephen Weiss, Team Lead, Analytics, Primary Care Branch, Saskatchewan Ministry of Health

CIHI would also like to thank the many individuals and organizations across the country, including clinicians, researchers, policy experts and government representatives, who contributed to the development of these indicators. 

While CIHI gathered a wide range of feedback to inform indicator methodology and the content in this report, the content herein does not necessarily reflect the views of any individual or organization. 

If you have any questions or would like to learn more, please send us an email.

hsp@cihi.ca

Note
Emergency department statistics are based on data from Prince Edward Island, Nova Scotia, Ontario, Saskatchewan, Alberta and the Yukon.

Sources
* National Ambulatory Care Reporting System, 2023–2024, Canadian Institute for Health Information.
† Canadian Community Health Survey, 2023, Statistics Canada.
‡ Commonwealth Fund survey, 2023, Canadian Institute for Health Information.
§ Scott’s Medical Database, 2013 to 2022.

Access to primary care requires having a place to go for primary care, having this care available when it is needed, and being able to get this care without major barriers.

However, 17% of Canadians do not have a regular care provider such as a family doctor or nurse practitioner.Reference2 This proportion has been worsening over time. And Canada ranked lowest on this among 10 high-income countries in 2023.Reference3

Canadians were also the least likely, among those surveyed in 10 high-income countries, to say they could get a same- or next-day appointment (26%). Canada had one of the lowest percentages of respondents (23%) saying they found it easy to get medical care in evenings, on weekends or on holidays.Reference3 These proportions have worsened over time. 

More family medicine residency positions are going unfilled and, compared with 5 years ago, growth in family physician numbers has slowed. Family physicians also see fewer patients than they did 5 years ago. While the number of nurse practitioners is growing, that may not be enough to satisfy Canadians’ need for primary care.Reference4 Reference5

Our newest data shows that 15% of visits to the emergency department (ED) in Canada are for conditions that could potentially be managed in primary care. And over half of those are for conditions that might have been managed virtually.

Provinces and territories have different models of how primary health care is delivered, influenced by local context. Some jurisdictions are encouraging multi-provider team structures to provide more flexibility and options for care outside of regular working hours while preserving continuity of care.Reference2 Reference6 Reference7

In areas where there may be resource limitations, especially rural and remote areas, physicians often play multiple roles, including providing both primary and emergency care in one location such as the ED. This may mean that EDs are the place where people regularly access their primary care — and for many, EDs may be the only place to access care.

Innovative approaches are being adopted to address challenges relating to primary care access. While some solutions may not increase access to ideal primary care, they can help improve patients’ experiences, including reduced wait times compared with what they would encounter in the ED:

• Virtual primary care programs can support timely care of many conditions without requiring the patient to be physically near a clinician at the time of their appointment, while still maintaining the patient–provider relationship that is important in primary care.Reference7 Reference8 Reference9 Patients who live in rural and remote areas may benefit the most.
• Urgent care centres or virtual care access points within an ED are available in some jurisdictions to treat less urgent or minor conditions in a timely manner, diverting these patients from the regular flow of the ED.Reference10 Reference11
• Reorientation programs have also been implemented. In these programs, patients presenting at ED triage with minor conditions are redirected and provided an appointment with a general practitioner in the community.Reference12 Reference13
• Policies to increase the number of primary care clinicians, especially in underserved areas, can result in more access for patients.Reference6 Reference7
• Jurisdictions may also consider different models for how physicians are paid, which can affect how care is organized and practised.Reference6 Reference7
• Policies and training emphasizing equity and inclusion may be implemented to ensure that populations that currently have lower care access can receive care that is culturally safe and inclusive.Reference6

Thoughtful design is required to ensure access to care is equitable and enables continuity of care.Reference7 Reference8 Reference9

I had excruciating hip and knee pain, but there was no reason for me to go to the ER. An office visit would have been more than sufficient, but I had no choice; the pain had me very worried. Your family doctors know you; they know your history. I would really like to see these community-style clinics or integrated clinics where there’s a doctor, a nurse practitioner, a dietitian, et cetera. — Shelley Petit, Chair, New Brunswick Coalition of Persons With Disabilities

Currently, Canada uses surveys to understand accessibility and use of primary care services, along with pockets of data from local initiatives. While data from the primary care sector is growing over time, there continues to be a need for high-quality data about primary care access that can be routinely generated and compared across the country, especially at the regional level.Reference2

One way to monitor unmet needs in primary care access is by looking at how this may manifest in emergency departments. We found that 15% of ED visits were for conditions that could potentially have been managed in primary care. We also found that over half of these, or 9% of all emergency department visits, were for conditions that could potentially have been managed virtually in primary care. 

While visits for minor conditions contribute to higher volumes of patients seen in the ED, they are not a major driver of overcrowding thereReference14 — rather, such visits to the ED may signal inadequate access to timely or high-quality primary care. 

Examining the reasons why patients visit an ED can provide insights into population-level impacts of primary care access in Canada. Such insights can also support improving access, which could shape the future role of primary care in Canada. 

Read the next sections of the report to learn more about these new indicators of primary care access.

• Better access to primary care key to improving health of Canadians
• CIHI’s information on health workforce
• CIHI: Connected Care

If you have any questions or would like to learn more, please send us an email.

hsp@cihi.ca

Close to 1 in 5 Canadians do not have a regular health care provider.Reference1 And even those who do have such a provider may not be able to access care when they need it.Reference2

High-quality primary health care is a cornerstone of Canada’s health system, and improving access to this care is a priority of governments across Canada.Reference1

Canadians who need primary health care but do not have timely access often seek care at emergency departments. There, they may face long wait times, and they do not get the benefits of being able to see their own regular health care provider who specializes in family medicine.Reference3

I had severe stomach problems and didn’t have a family doctor. I went to the ER and knew there were other people there who had more intense emergencies, but I didn’t have another option. It was a full waiting room, late at night. It seems like there aren't enough doctors, or even allied health care professionals. We often go through our family doctors for everything, for any kind of referral, even to get a blood test requisition. — Melanie De Sousa, Patient Partner

Canadians would prefer not to go to the ED if they can receive care elsewhere.Reference4 Reference5 And many describe their most recent emergency department visit as one that could have been managed by their regular care provider.Reference2

Why do patients go to the ED for conditions that could be managed in primary care? There can be a variety of reasons. Here are a few examples:

• Patients don’t have a regular health care provider, or their regular health care provider is not available soon enough or at a time that works for them.
• The ED is the closest, or only, place for a patient to seek care. (This is often true in rural and remote areas.)
• Patients feel that if they go elsewhere, they can’t get the same service quality and access speed that they can get in the ED. Or the ED may be the place patients know best and/or feel safest.
• A patient’s condition has worsened — possibly due to poor access to quality primary care — to a status that necessitates an ED visit.

Having to seek primary care in the ED also has implications for the health care system. The emergency department is not an ideal place for patients to receive primary health care, and using it for primary care may lead to system inefficiencies.Reference3

Getting the right care in the right place at the right time is a challenge both for patients and for the governments that are responsible for funding and setting up appropriate health system infrastructure.

Debates about ED overcrowding often pit patients on stretchers against ambulatory patients, suggesting that only the former truly matter. However, ambulatory patients account for more than 60% of ED visits in Canada. The waiting times and lack of access to care they experience are unacceptable. A significant number of these patients should actually be seen in primary care clinics. Measurement is the first step toward real structural change. This change is more necessary than ever for the sustainability of our EDs and for the quality of care provided to the population. — Dr. Simon Berthelot, Emergency Physician, Associate Professor and Researcher, Département de médecine de famille et de médecine d’urgence, Université Laval

Our data shows that over 1 in 7 visits to emergency departments across Canada were for conditions that could potentially have been managed in primary care. Calculated for 6 provinces and territories,Footnote i this represents about 1.2 million visits to the ED each year. 

This data includes 173 conditions or reasons for such visits. The most common are antibiotic prescriptions, colds, sore throats, ear infections and prescription refills. 

Our data cannot be used at the individual level to understand appropriateness of care. But viewed in aggregate, this proportion reflects an opportunity to better address Canadians’ unmet needs for primary care in their communities. 

The data in this report reflects an indirect system-level measure of access to primary care. These indicators evaluate broad patterns of emergency department use. They can provide health system decision-makers and planners with information to improve systems to better meet patient needs. They also add to the limited information we already have for monitoring access to primary care at the regional level. 

This data cannot speak to individual patient scenarios or to appropriateness of an ED visit. The conditions listed for consideration in the indicator can, in most cases, be managed in primary care — but some situations may be best served in the ED.

Still, at a population level, these indicators are valuable for understanding the impacts of primary care access on the broader health system. Refer to Your Health System to explore the data further and to compare indicator results across geographies and time frames.

While 15% of all emergency department visits across Canada were for conditions that could potentially be managed in primary care, this percentage varies across the country. The figure above shows how this differs by province/territory of patient residence, adjusted by age and sex. 

The percentage also varies within provinces. Refer to Your Health System to explore results at a regional level.

Due to data differences, results from Quebec and British Columbia are underestimated and not comparable with results for other jurisdictions. 

This is mainly because data from these provinces excludes most patients who left the ED without being seen by a clinician or who left it against medical advice. And this is a sizable proportion of overall emergency department visits: 12% in Quebec, 6% in British Columbia and 8% in other provinces and territories. 

Patients who leave an ED without being seen by a clinician tend to be different from those who stay on to do so. Data suggests they have lower levels of urgency based on their triage level. They are also more likely to have had a condition that could be managed in primary care. 

Additionally, data from British Columbia is incomplete. The coverage is largely limited to urban areas, where EDs are generally relied on less for primary care needs.

Data from Quebec and British Columbia can be compared across regions and over time within each province. But due to the differences listed above, data on this topic from Quebec and British Columbia cannot be compared with data from other jurisdictions across Canada. 

• Better access to primary care key to improving health of Canadians
• CIHI’s information on health workforce
• CIHI: Connected Care

If you have any questions or would like to learn more, please send us an email.

hsp@cihi.ca

Virtual care has become increasingly important to the primary care system in Canada.Reference1 Reference2 1 in 3 Canadians report having received primary care virtually in the past year.Reference3 Virtual care can include appointments over video or telephone, along with asynchronous services such as secure messaging. 

While the role of virtual primary care is still evolving, when applied appropriately it is an important part of a safe and equitable health care system and can improve primary care access.Reference2 Reference3 Reference4 Reference5
 

Over half of visits to the emergency department (ED) for conditions that could potentially be managed in primary care were for conditions that could be managed virtually. 

This represents 9% of ED visits in Canada. And it includes 97 conditions, such as colds, anxiety and repeat prescriptions, that could potentially be managed virtually. 

This data cannot be used to understand appropriateness of a virtual visit at the individual level — including whether virtual primary care is acceptable to a specific patient. And results vary locally: refer to Your Health System to explore results at the regional level.

Still, at a broad level, these findings reflect an opportunity to better address Canadians’ unmet needs for primary care using virtual services.

Note: Indicator results for Quebec and British Columbia exclude patients who left the ED without being seen by a physician or who left it against medical advice. These provincial results are therefore underestimated and are not comparable with results for other jurisdictions. For more information, refer to Understanding data from Quebec and British Columbia.

Virtual care can improve access to primary care by allowing patients to see a clinician without having to travel. This can particularly benefit patients in underserved areas. 

Our findings show that 13% of ED visits for patients living in rural or remote areas could potentially have been managed virtually, compared with 7% for patients living in urban areas. Applied thoughtfully, virtual care can increase equity in primary care access, reduce the carbon footprint of health care systems, and provide resources in rural and remote communities.Reference4 Reference5 Reference6

I visited the emergency department because a minor medical condition was worsening, and my primary care physician wasn’t available during the time period that I needed care. It would have been helpful to have more accessible urgent care options through my physician’s clinic. A virtual visit would have saved time and streamlined the coordination of care. — Lucksini Raveendran, Patient Partner

Implementation of virtual care solutions must be done carefully.Reference1 Reference4 Reference5 Reference7 Reference8 There are many aspects to consider: 

• Support for clinicians to implement virtual care in their primary care practices.Reference4 Reference5 Reference7 Half of clinicians using virtual care report it has increased their workload.Reference9 Common challenges include administrative and technical barriers, as well as poor integration with other systems such as electronic medical records.Reference9
• Clinician training for best practices on conducting virtual assessments and on which modality is most suited to different scenarios.
• Patient comfort with technology, cognition and ease of virtual communication.
• Patients having a choice in how to access their care, since individual needs and situations vary.
• Patients’ access to appropriate technological infrastructure. Patients living in rural and remote areas often do not have access to robust internet services due to lack of local infrastructure; however, this group could benefit the most from access to good virtual care.Reference10 Reference11 For this reason, it may be within the purview of governments to provide appropriate technological infrastructure so that access to reliable internet services is available to all Canadians regardless of where they live.Reference10 Reference11
• Continuity of care is essential for safe and efficient care. For example, patients who use “virtual walk-in” services may be more likely to visit the ED compared with those who use virtual care with their regular provider.Reference12
• Integration of virtual care into the larger health system. If success factors are not in place, virtual care services could result in increased health inequities, financial barriers for patients and inadvertent impacts on other sectors of the health care system.Reference8 Reference13

Despite challenges, many clinicians report virtual care technology enables them to provide more efficient care.Reference9 For example, clinicians and patients may communicate asynchronously, such as through secure messaging to answer patient questions or for simple follow-up care.Reference7 Additionally, clinicians can offer virtual visits to investigate whether a more thorough visit is required.Reference7

When implemented equitably and well, virtual care programs can improve access to care for Canadians in a way that also provides efficient, quality care.

In many situations, virtual care can provide access to primary care for people who might otherwise seek care in emergency rooms or even go without the care that they need. We need to continue to focus on technological improvements, provider engagement and patient awareness to enable the optimal use of virtual care across the country. — Dr. Kevin Samson, Family Physician, Ontario

This data provides an indirect system-level measure of access to virtual primary care that can be used to assess the impact of virtual care access on broader health systems. 

While visits for minor conditions contribute to higher volumes of patients seen in emergency departments, these visits are not a major driver of overcrowding there.Reference14 Rather, data about these visits provides key information for improving health systems to better meet patient needs. This data is available publicly at the regional level via Your Health System, allowing more detailed investigation of how virtual care access affects health systems. 

Additionally, these indicators cannot speak to individual patient scenarios, nor to the appropriateness of any individual ED visit. Furthermore, while virtual care is often convenient, patients should have a choice in how they visit their primary care provider. 

Overall, at a system level, we can compare these indicator results over time and/or across populations to investigate broad patterns. We can also use them to investigate potential impacts of virtual care access.

• CIHI: Virtual care in Canada
• The expansion of virtual care in Canada: New data and information
• CIHI: Connected Care

If you have any questions or would like to learn more, please send us an email.

hsp@cihi.ca

In children age 2 to 9, 26% of visits to the emergency department were for conditions that could potentially be managed in primary care — higher than in other age groups. Similar trends exist in the subset of conditions that may be helped by virtual primary care. 

These findings suggest that parents of young children may face barriers in getting timely access to care for those children. This aligns with previous research showing that parents seek care in emergency departments for children’s minor medical conditions when barriers exist to timely primary care access.Reference1 Reference2

For older patients, there is a slight trend downward in the proportion of ED visits for conditions that could potentially be managed in primary care. Older adults are more likely to have a regular health care provider than younger adults.Reference3 Therefore, older adults may be more likely to have their primary health care needs addressed by a regular provider.

Rural and remote areas have more than twice the proportion of ED visits for conditions that could be managed in primary care than urban areas do. 24% of ED visits in rural and remote areas are for such conditions, compared with 11% in urban areas.

A similar trend exists for conditions that could be managed virtually. 13% of ED visits in rural and remote areas are for conditions that could potentially be managed in virtual primary care. In urban areas, that figure is 7%.

Patients in rural areas have less access to health care, including primary health care.Reference4 This may explain the trends in these findings.

Trend differences may also be due to primary care infrastructure. In rural or remote areas, a person’s primary care clinician may also be the emergency department physician, so the ED may be the place where people regularly access their primary care. Or, in some areas, the ED may be the only place to access care. 

In some provinces and territories, patients registering at the emergency department are asked whether they have access to primary health care through a family physician, family health team, walk-in clinic or other settings. 

• Patients who report having no access to primary health care have a higher percentage of ED visits for conditions that could potentially be managed in primary care — and the highest proportion of these visits take place on weekdays. 
• Patients who report having access to primary health care have a slightly higher percentage of these types of visits on weekends. 
• Similar trends exist for ED visits for conditions that could potentially be managed virtually.

Patients who report having access to primary care may not be able to get an appointment when they need it. 3 out of 4 Canadians report not being able to get a same- or next-day appointment.Reference5 A similar proportion do not find it easy to receive care after hours, on holidays or on weekends.Reference5 And 42% of Canadians report waiting more than 3 days to see their health care provider for a minor problem.Reference6

Our newest finding that 13% of ED visits by patients who report having access to primary care are visits for conditions that could potentially have been managed in that primary care setting. These findings suggest that even patients who are rostered to a family clinician or who have walk-in clinics nearby may have unmet needs for care in the community.
 

These indicator results supplement existing information on equity in accessing primary care.

We did not find that neighbourhood income was linked to marked differences in the percentage of visits to the emergency department for conditions that could be managed in primary care. But other robust research has shown that Canadians with lower incomes are less likely to have a regular health care provider than those with higher incomes.Reference5 Reference6

Other equity considerations have also been shown to be important factors for primary care access. But some of these were not included in our analyses because related information is not consistently available in the databases we used. Established research does show that people in certain racialized groups,Reference6 as well as First Nations, Inuit and Métis Peoples,Reference7 report lower access to primary care. 

• Taking the pulse: Measuring shared priorities for Canadian health care, 2024 
• The Expansion of Virtual Care in Canada: New Data and Information
• Health equity and population health at CIHI
• Promising Practices for Strengthening Primary Care in Northern, Rural, and Remote Communities from Healthcare Excellence Canada

If you have any questions or would like to learn more, please send us an email.

hsp@cihi.ca

Emergency departments are at capacity and are understaffed. ED crowding has led to longer wait times, higher proportions of patients leaving without receiving care and increased demands on staff.Reference1 Reference2 Reference3

The causes of ED crowding are multi-faceted and go beyond primary care access. Increased access to primary care may be one factor that could reduce ED visits. But this access is not enough, on its own, to improve the situation in crowded emergency departments. Primary care access issues are not a major driver of overcrowding.Reference2 Reference4

A recent review by Canada’s Drug Agency summarized the complex issue of emergency department overcrowding as “a problem of hospital overcrowding and strained resources in the broader social and health care systems.”Reference2 The situation in emergency departments reflects larger system challenges: patient flow in acute care hospitals and long-term care, staffing shortages, increasing complexity of patient needs, and lack of community social supports.Reference3

• Patient flow, especially for patients who need to be admitted, is a major challenge: CIHI data shows that half of patients who were admitted to hospital spent more than 16 hours in the emergency department, and 1 in 10 spent more than 48 hours there.Reference5
• Other indicators of health care access point toward strained resources leading to broader systemic challenges. For example,
  • 1 in 10 patients in hospital have their stay extended until home care services or supports are ready for their discharge.Reference6 Reference7
  • Almost 1 in 10 patients who visit the emergency department for help with mental health or substance use have done so at least 4 times a year.Reference8
  • People who frequently visit the ED show signs suggesting that their needs for the care in the community are not being met.Reference9

Interventions aimed at relieving overcrowding need to address not just processes and resource capacities in emergency departments. They also need to address broader issues influencing the types of patients who visit the ED; the flow of patients out of the ED; and the social contexts influencing population needs for services.Reference2

The Canadian Association of Emergency Physicians recommends a comprehensive approach to addressing ED overcrowding. This approach includes policies that give patients options outside the emergency department to address their primary health needs. It also includes frameworks for addressing issues in hospital capacity and the role of emergency departments in broader health care systems.Reference3

The indicators in this report measure unmet needs for access to primary care through the lens of emergency departments. 

Improving access to primary care may reduce ED visits for conditions that could be managed in primary care. This would also improve patient experiences and continuity of care, as well as reduce some demand on staff. 

However, tackling primary care access alone will not solve emergency department overcrowding. For this, we need an approach that addresses hospital capacity and capacity in other sectors of care (such as home care and long-term care); performance management and accountability; and broader population needs.Reference3

Canadians should not go to EDs in desperation because they have no alternative; they should use EDs when they think they have a true emergent or urgent problem. Primary care access is not a major driver of ED crowding but is a reflection of important challenges across the wider health care system. — Dr. Howard Ovens, Staff Emergency Physician and Chief Medical Strategy Officer, Sinai Health

• Shared Health Priorities
• NACRS emergency department visits and lengths of stay
• Access and wait times data at CIHI

If you have any questions or would like to learn more, please send us an email.

hsp@cihi.ca

If you have any questions or would like to learn more, please send us an email.

hsp@cihi.ca