Dear Editor,

I applaud Breton et al. (2018) for their recent logic analysis on primary care centralized waiting lists (CWLs) in seven Canadian provinces, recently published in your journal. This is an important step towards better understanding the effectiveness of these approaches. Given the dire situation of primary care in many jurisdictions across Canada, CWLs deserve greater research attention. In particular, I agree with the authors' comments that future research should explore CWLs effectiveness from the patient perspective. I make these arguments as a researcher and a Canadian, who recently experienced the challenges with one of these systems first-hand.

Last November, my family (wife, two-year-old daughter, and I) relocated to Waterloo, Ontario, from Victoria, British Columbia. We sought a new family physician as part of getting settled. While we were (and are) lucky to be in good health, I am familiar with the research on the importance of a family physician, and I was eager to find one for my family. I was further motivated by the fact that my wife was pregnant with our second child at the time, and our daughter was continuing in licensed childcare, which require notes from physicians on occasion attesting that a rash, cough, etc., is not contagious and that the child can return to care. We registered with Health Care Connect (HCC) as soon as we could. However, every encounter with a healthcare or public health provider reinforced that engaging with HCC was pointless.

We were encouraged by family members to contact their physicians to ask if we could become patients, since we were relatives (this did not work). A public health nurse and our midwife advised us to contact a new clinic that had recently opened (unfortunately, they were already at capacity). Later, the maternity nurses who cared for my wife and newborn provided us with a printed list of local physicians accepting patients (unfortunately, the list was out of date, and they were also at capacity). Eight months after arriving, we finally found a family physician last week, because my wife happened to drive by a new clinic that had a sign in the window. We completed the necessary forms and became patients that day. Throughout this period we heard nothing from HCC.

Conversations with friends, family and colleagues suggest that our experience is either typical or a good news story, in this part of Ontario. Precisely because this is typical, I felt it was important to write this letter in support of future research on CWLs. Clearly there has not been enough written, studied or argued about the current situation to identify best-practices and initiate reform. I am not the first to report frustration when trying to find a family physician (e.g., Galloway 2011; Kitching 2017) and access to primary care is one of the most well-known healthcare issues across Canada. However, my experience with HCC raises serious questions about HCC and CWLs elsewhere. For example, how effective is a CWL when every representative of the healthcare 'system' discouraged its use? Why are family physicians actively preferring other methods over the CWL (e.g., sign in the window, hospital lists)? Why was there so little communication or service from HCC? Do those who administer CWLs fully appreciate the importance the public places on the need for a family physician? In our case, perhaps my family was too healthy and the needs of others were more pressing. Breton et al. (2018) report that HCC prioritizes the needs of "complex/vulnerable patients" (p. 75). I support this approach, and I am pleased that those with greater need get quicker access to care. However, some communication, guidance or other types of service from HCC would have been appreciated.

Breton et al. (2018) report that "the lack of a common or standardized approach makes it difficult to measure and compare the effectiveness of the different CWLs as provinces do not monitor and report the same indicators (e.g., not all provinces monitored and reported wait times for attachment) and similar indicators are often measured differently" (p. 79). Clearly, there is much more to investigate regarding CWLs. I hope the authors will continue their work on this important topic, including exploring their effectiveness from the patient perspective.

Sincerely,

J. Ross Graham, MSc, MPA

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