In 1991, B.C. had more family doctors than it needed. So why are so many residents unable to find one now?

Finding a family doctor in British Columbia is almost impossible and policy decisions made decades ago could be partly to blame.

Recent figures show that almost a million British Columbians don't have a family physician, while wait-times for walk-in clinics are higher than in any other province.

Questions about the shortcomings prompted Premier John Horgan to swear on the floor of the B.C. legislature this week, in a move analysts say shows the government's vulnerability on the issue.

And, it turns out Horgan may be able to trace the roots of this problem back to policy changes made three decades ago when a newly-elected B.C. NDP government was grappling with its own health-care challenge: Too many doctors.

Too many physicians

When Mike Harcourt became premier of B.C. in 1991, he appointed Elizabeth Cull as health minister, a position she held until 1993.

In her role, Cull received a report on the state of health care in B.C. titled "Closer to Home: Summary of the Report of the British Columbia Royal Commission on Health-Care Costs."

A previous government commissioned the report in response to the rising cost of health care not just in B.C., but across the country.

"It concluded that there was a mismatch between the health-care professionals that we needed and what we actually had," Cull said, speaking to CBC's On the Island.

The report found that B.C. had more family doctors than it needed, and that the number of physicians provincewide had increased by more than 50 per cent since the 1970s. It also found they were seeing fewer patients than anywhere else in Canada.

In order to reduce costs, it was recommended immigrant physicians not be allowed to practise in B.C., that international medical students be made to leave the province after graduation, and that domestic graduates train in fields where there were shortages — which, at the time, did not include family medicine.

Cull said those recommendations were followed but, in hindsight, "There were unintended consequences of simply curtailing the supply of physicians."

Among the problems: The surplus didn't apply to all parts of B.C. equally. The concentration of family doctors was primarily in urban parts of the province's southwest, while rural and northern areas didn't have enough.

But the policy changes put in place would affect B.C. as a whole for decades to come.

As Cull says: "It wasn't so simple."

Unintended consequences

Dr. Benjamin Chan highlighted the consequences of those policy changes in a 2002 report for the Canadian Institute of Health Information.

Chan found that by the new millennium, most medical internship programs in B.C. had been converted to specialist residency positions, reducing the number of new family physicians being trained between 1993 and 2000.

His research also shows that retraining opportunities for physicians have been reduced and suggested this was discouraging graduates from going into family practice because they worried it would prevent them from being able to specialize later.

Chan also says there was a large exodus of doctors to the United States in the 1990s that peaked in 1994. He suggests this could be because B.C. doctors wanted to change specialities or because they wanted to earn more money outside of B.C.'s fee-for-service system, which has been blamed for deterring aspiring physicians from pursuing the work.

Fee-for-service system discouraging doctors

These changes continue to impact B.C.'s medical system, even as successive governments have tried to refocus opportunities for people to go into family practice.

For example, a record number of family medicine graduates are coming out of UBC's medical program, which has campuses on Vancouver Island, Prince George and Kelowna.

But the B.C. College of Family Physicians says many of those graduates opt out of going into family practice because they don't feel there is enough support for them to do so.

Darlene Hammell, a clinical professor at the Island Medical Program who has worked with students since the early 2000s, says many do not want to practise family medicine because of all the additional administrative work created by the fee-for-service system, in which physicians run their practice as a business, getting paid about $30 per patient and covering overhead costs like staff and office space with those fees.

"New cohorts look at how we practise and say, well, no thank-you," said Hammell.

Office rentals and housing costs have also skyrocketed since the 1990s, and the B.C. Liberals lifted a freeze on university tuition in 2002, which all make it harder to strike out early on your own as a new graduate.

'We are in a crisis'

Carrie Marshall, a family doctor in Ucluelet, B.C., on the west coast of Vancouver Island, says despite being rural and remote, the median house price is about $1.6 million and current inflation rates have made running a practice incredibly costly.

"The reimbursement for primary care just has not kept pace with how expensive it is to be running a business and so we are in a crisis," she told CBC's On The Island.

Doctors of B.C. president Ramneek Dosanjh says the province needs to look at alternative payment models to improve the current system, such as paying doctors a salary or signing them up for contracts. The B.C. Green Party has also called for a system overhaul.

Health Minister Adrian Dix says B.C. doctors receive the highest fee payments in the country but the province is increasing alternative payment models and connecting more British Columbians to physicians by building Urgent Primary Care Centres.

B.C. residents fear the situation could continue to worsen.

According to a February research poll done by Mustel Group on behalf of the B.C. College of Family Physicians, 40 per cent of British Columbians with a doctor worry they will lose them to retirement or practice closure.

"We're going to have to continue to work on this day in, day out for the coming years," Dix told On The Island Thursday.

Learn more about B.C.'s family doctor shortage in the CBC Victoria series A Crisis In Care.