Ottawa benefits from a neighbourhood approach to health care

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The shortage of family doctors has become a pressing concern across Canada, and Ottawa is no exception, with about 15.6 per cent of Ottawa residents — 165,362 people — unattached to primary care. Long wait times for a primary care provider and the difficulty of finding a family doctor are now familiar stories in many households.

As a family doctor myself, I worry about the impact of this crisis on our community, given the important role we play in preventing illness, managing chronic conditions and coordinating care. As a primary care researcher, I’m also keenly aware that access to primary care is just one of many determinants of health that influence well-being.

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For this reason, I started working with the Ottawa Neighbourhood Study (ONS), a collaborative initiative that provides comprehensive data on the social, health-care, economic and physical environments of neighbourhoods across the city. By combining these data, we uncovered stark differences in access to primary care across Ottawa.

In some neighbourhoods, most residents have a family doctor, while in others, more than 25 per cent are unattached. This disparity correlates strongly to factors such as income, education and housing stability. Surprisingly, we found that Ottawa’s most socioeconomically disadvantaged neighbourhoods have the highest levels of primary care unattachment, even though they often have a higher concentration of practising family physicians.

How can these data help us address the primary care crisis in our region?

First, focusing on the distribution of the social determinants of health shifts the emphasis from individual care to addressing the root causes of poor health within a population. Neighbourhoods are where people’s daily lives unfold, where they experience the barriers or supports that profoundly shape their well-being.

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Second, neighbourhoods offer a natural framework for the cross-sector collaboration required to comprehensively address resident well-being. Health outcomes aren’t shaped by health-care changes alone; they depend on interconnected factors like housing, transportation, education and community services. Recognizing this, ONS neighbourhood boundaries have been integrated into the planning and operations of organizations such as Ottawa Public Health, the Ottawa Police Service and the Ottawa Food Bank. This integration enables more cohesive and effective initiatives for everything from food security programs to community safety efforts.

Third, in many parts of the world, new residents to a community are automatically assigned a primary care team close to home. In addition to ensuring that patients have access to care, this system ensures that doctors manage rosters of patients from the same neighbourhoods, allowing them to address localized health challenges more effectively. The new Ontario Ministry of Health announcement heralding a geographic approach to primary care attachment for all Ontarians is a reason for optimism.

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By adopting a neighbourhood-focused approach to health planning, Ottawa can empower policymakers, providers and community leaders to allocate resources strategically and collaborate on addressing localized health disparities. For example, we could deploy health navigators in high-need areas identified using ONS data. These workers could assist isolated residents — such as seniors living alone — in connecting with available services. We could also design interventions tailored to the needs of specific neighbourhoods, such as those with high densities of newcomers and linguistically diverse groups, ensuring language-accessible services and culturally competent care. We could locate new clinics within walking distance of underserved populations and collaborate with city planners to improve public transit connections to health-care facilities.

As a pilot initiative, we at Bruyère Health partnered with local health and social service agencies to address primary care access in Lowertown, one of Ottawa’s most disadvantaged neighbourhoods with the highest levels of primary care unattachment in the city. Using data, we successfully connected 200 homebound seniors, newcomers, youth with mental health challenges, low-income families, and young children to local primary care teams.

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Addressing Ottawa’s primary care crisis will require collaboration, creativity and data we can act on. By investing in neighbourhood-level data, planning and action, we can build a healthier, more equitable community for everyone. Let’s ensure that every resident, no matter where they live, has access to the care they need.

Dr. Claire Kendall is a family physician and scientist with Bruyère Health and its Research Institute, and the associate dean of Social Accountability at the University of Ottawa’s Faculty of Medicine.

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