A Proposal to Resuscitate Canada’s Ailing Healthcare System

Provincial healthcare systems in Canada are our most cherished public services and they are failing so many of us. People will say we have a great system and at times that is true, but overall it isn’t.

Hallway treatment in hospitals is becoming more and more commonplace, wait times for a family practice appointment can be dangerously long and even stretch into years for elective surgeries. Furthermore, many basic services are not covered, and long-term care is not people- or family-friendly. Others will say the problems are too big to fix; that is even less true. We should strive for and sustain a system of excellence.

Let’s look at the failings of our health care systems and what needs to be done to achieve excellence. With the perseverance and cooperation of the public, public sector unions, individual healthcare workers, physicians and corporate Canada we can make our healthcare systems impressive. We have to hold our politicians accountable and expect much better from them. This article will discuss healthcare at the national level but for the most part will focus on Ontario. Ontario is the largest province with the fastest growing population , driven by immigration, and the province where this writer worked as a physiotherapist for 36 years in private and public settings. The problems and solutions are quite universal.

So how well does Canada’s healthcare system perform and what does it cost in comparison to systems in other countries? There are many ranking systems that use different metrics. The list below shows how they rank the quality of Canada’s overall healthcare system.

1. Legatum Prosperity Index ranks Canada as 14th
2. CEO Magazine ranks Canada as 23rd
3. Commonwealth Fund on August 4, 2021, ranked Canada as 10th out of 11 high-income countries
4. World Health Organization ranks Canada as 30th of 190 countries
5. Statista 2021’s health index score places Canada as 34th of over 100 countries

If you rate our costs as a percentage of GDP, we have the 7th most expensive system in the world (excluding small countries like Palau, Tuvalu and Armenia). With respect to per capita costs, Investopedia economy ranks our system as the 11th most expensive in the world.

On the issue of ranking and cost, we’ll give the final world to the Winnipeg Free Press. On November 23, 2022, based on findings by the Fraser Institute, it said: “Of the 30 countries with universal coverage, Canada ranked as the highest spender on healthcare as a share of the economy and 8th highest spender on a per-person basis (after adjusting for age). However, despite this spending, Canada’s performance was middle to poor…Based on 2022 data.”

The message is we spend a lot and do not get nearly enough for it. So what are the problems? They are listed below, with a particular focus on Ontario.

1. There are 1.3 million Ontarians without a physician.
2. In Ontario, we still do not have a centralised electronic healthcare system.
3. Canada and Ontario both have the second highest prescription drug costs among comparable countries, and there is no universal coverage for them
4. In Canada, there are excessive expenditures on unnecessary tests, procedures and medications.
5. In Canada, there is no universal dental care.
6. In Ontario, there are 38,000 people waiting for a long-term bed. And the beds we do have do not provide a common level of good care. The recent pandemic showed us the flaws. Ontario had the highest death rate of seniors in long-term care in the world.
7. There is no central system in Ontario which ranks the quality of surgical units, hospitals, and doctors.
8. In Ontario, it takes too long to access primary or specialist care.
9. In Ontario, our system is based on sickness care and not enough on health promotion.
10. Mental health care in Ontario is not broad nor is it deep, except in a few psychiatric hospitals.
11. In Ontario, we have the fewest (2.3) beds per 1,000 people of any of our peers (other provinces and other high-income countries) and are only marginally better than Mexico and Turkey. In the OECD, the average is 4.8.
12. Nonuniformity of good care across Ontario. Rural care is generally worse than urban care. When the Local Health Integrated Networks were operating in the 14 regions of Ontario, rankings on service delivery showed great discrepancies among regions.
13. The Ontario Health Quality Report of 2019 stated that public spending on healthcare in Ontario for 2016 was the lowest among all provinces at $4,125. The Canadian average was $4,487 per person.

What can we do about the situation?

In order to create a system of excellence, our leaders must feel pressure from the people they represent. No party can claim to have a stellar record on healthcare administration. MPs and MPPs must hear from their constituents that we expect better. Below are some proposals to address the problems listed above. You can use them as talking points in your conversation with your MP, MPP, and other politicians. They need to be reminded that all Canadians are stakeholders in the healthcare system.

1. Address the shortage of doctors

We are short of doctors because we have not been training enough. It will take 15 years to fund, set up and expand existing medical programs and graduate the new class, so we require short-term solutions. This means we will have to quickly repatriate Canadians who are training in medical schools abroad by offering them residency positions in Canada. We will also have to allow in more foreign-trained doctors, but in the short term only. We should not be raiding doctors from the global south. For instance, South Africa supplied us many doctors during the 1990s when they were needed in South Africa. We also get a lot of doctors from India, a country already short of physicians.

Ontario’s governing Progressive Conservative Party is opening up a woefully low number of new medical training spots. This is an inadequate response to meet the needs of our current and aging population, let alone the needs of 250,000 plus new immigrants coming into Ontario each year. The Ontario Liberals did not tackle this issue during their 13 years in power and the NDP actually cut 75 positions at the University of Toronto during their mandate in the early 1990s. If those NDP cuts had not been made, an additional 2,000-plus doctors would have graduated, and most of them would likely still be working in Ontario.

Training Canadian youth to be doctors will grow our economy by expanding our medical schools; it will give our children an opportunity and we can ensure the quality of care we require. We take too long to train doctors: up to 11 years for family doctors and up to 14 years for specialists. Training could be shortened by allowing those with the aptitude and work ethic to enter medical school after two years of undergraduate education. Reducing student debt and making it possible to work before 30 years of age is a win/win. If our public universities are not able to respond to the challenge, then we should certify private universities to train doctors. After all, most foreign doctors have been trained in private institutions and we already train chiropractors, nurses and dental hygienists in private institutions.  When considering new training positions, we must account for the welcome addition of more women entering medicine. As women will often chose to have children, we have to account for the need for even more physicians to cover maternity leave. Further the current cohort of new doctors are taking on larger case loads, so, yes, even more need to train additional doctors.

The same model could be applied to training more physiotherapists, social workers, occupational therapists etc. Let us train our own citizens in Canada, keep our money on shore and provide opportunities for many thousands of bright young Canadians every year. Of course, we do not want to shut ourselves off from learning from the world, but our dependence on importing large numbers of foreign-trained professionals is not the right answer.

2. Create a centralised Electronic Health Records System (EHR)

In 2009 the auditor general of Ontario stated that Ontario could save 6 billion dollars in the entire system by linking patients to hospital, physician clinics, healthcare clinics and the like. Taiwan had the rudiments of a comprehensive system in 1995, where every citizen has a NHI ID card (a smart card), which was used to identify the person, store a brief medical history and bill the national insurer. Such systems allow healthcare providers to understand their patient better, and help in diagnosis, medications, procedures and testing. Current US studies have shown that EHRs reduce repeated exams and medications, which saves money and improves patient safety and quality of care. Establishing large medical databases will help prevent medical errors. Too many redundant medical tests can result in confusion and false positives which can make a diagnosis difficult.

3. Lower the cost of drugs

Drug costs are a function of what drug companies can get away with, especially when it comes to drugs that treat rare diseases. The worst case of predatory capitalism in the healthcare system is the development of so-called unicorn drugs, where venture capitalists turn multi-million-dollar investments into multi-billion-dollar returns. All other countries aside from the US and Canada put effective measures in place to keep drug cost low.

Lowering drug costs is a matter of political will. The purely business consideration of Big Pharma should be challenged. The marketing of a drug called Glybera (CBC Canadian Breakthrough that became the world’s most expensive drug, then vanished, gets second chance) is a case study of how the pharmaceutical business maximised profit and bypassed a not-for-profit system. It was developed at the

University of British Columbia and ended up in the hands of a Dutch corporation. Canada did have a publicly owned pharmaceutical company called Connaught Labs, which was privatised by a federal Conservative government. Connaught Labs or some other health agency in the federal government could have been the distributer of Glybera. This is not to say that we want to exclude private engagement in the development of new treatments, but we do want to limit profit. This will allow us to free up capital to meet our many other needs.

4 Eliminate unnecessary tests, procedures and medications

An organisation called Choosing Wisely (choosingwiselycanada.org) relies on the input of physicians and pharmacists and you can subscribe to their email list. This group clearly shows how we can increase patient safety while decreasing costs by eliminating unnecessary tests, procedures and medications. The futility of first x-raying a patient’s injury, then CT- scanning it, then doing an MRI is revealed. That process wastes valuable time, is expensive, and exposes people to unnecessary radiation. The answer is to skip some of these steps, which means perhaps more MRIs taken and much fewer x-rays and CT scans. Purchasing MRI machines does not have to be expensive. Many countries provide MRI machines for much less than we are charged in Canada, for example Japan.

Unnecessary medications are wasted, as witness the drug cabinet in the home of many seniors. But more concerning is that drugs can be overprescribed. There is no better example than the over prescription of antibiotics, according to Choose Wisely 30% to 50% of antibiotics prescribed for acute respiratory infections in primary care are unnecessary It is estimated that 40 percent of antibiotic prescriptions are unnecessary. That means millions of prescriptions a year are not needed. We could be saving money while making our healthcare safer.

5. Provide universal dental care

Many countries such as Germany provide universal dental care. That country’s total healthcare costs per capita are slightly higher than ours, but they have better outcomes. Oral health is integral to overall health. Infected gums can lead to systemic problems like low-birth-weight babies, stomach ulcers and heart disease, to name a few. We could start by providing universal dental hygiene care as disease prevention and gum health is a major focus of their role. Dental care would be provided for those who are financially challenged and may not go to a dental office at all. Cosmetic dentistry would be left to the private sector payers. We already have many privately offered medical services, such as private laboratories and indeed most family physicians are private business people in that they own their own office, pay their own staff and cover their own expenses. They merely collect payment form one payer.

6. Create a rating system

Simply put, we need a rating system of the medical service providers, including physiotherapists, occupational therapists etc. This system could be provided by a combination of patient ratings and third-party ratings. After all, if you can get a rating on a perspective new car, why not on someone who is going to open you up? We have entities who rate the bonds that are issued by governments. Ratings lead to competition which can result in excellent care that translates into a longer more productive life and fewer expensive and life-defining errors.

7. Increase the number of long-term care bed (LTCBs)

As discussed, the issue of wait times can been addressed by increasing the number of doctors and allied health professionals. But that is just a part of the problem. Many surgeries are delayed because of the large number of acute care beds that are occupied by seniors who cannot find a long-term care bed (LTCB). That must be addressed. Also, a hospital may have enough surgeons but not enough assigned surgical units with all the backups required. More assigned surgical beds are needed.

Currently there are at least 38,000 seniors in Ontario waiting for a long-term care bed, a number that has doubled in the last ten years. More LTCBs need to be built and regardless of whether they are built by public institutions, not-for-profits or for-profits, they have to be well-regulated so as to avoid uneven service delivery. We do not want to see the army having to take over LTC services in private homes, as happened during the pandemic. Currently, the Ontario provincial government is increasing the number of beds built. But like the new medical school training opportunities announced, the number of beds is still not enough. Further, the cost of building a new bed has increased significantly since the government’s announcements, meaning that the number of planned beds will fall even shorter. (Financial Accountability Office of Ontario:Long-Term Care Homes Program 2019). There is not much choice: we need to build as many LTCBs as we need. Otherwise, we slow down the acute care hospitals and the consequences are well known.

Perhaps the need for LTCBs could be slowed if we provided better homecare. If a family is capable of keeping an ill member of the household in the home, then we need to spend more on supporting that service. Currently that system is broken; the wait for care is slow and when you finally get the services in home, they are not comprehensive enough. Home care services vary considerably by region in Ontario.

8. Distinguish wellness from sickness – and promote the former

There are no easy-to-access resources to indicate how much we spend on preventative medicine and wellness promotion. Let us say it is not enough. Some provinces seem to take prevention more seriously than others. For example, starting in 1980 Quebec banned commercial advertising of all goods and services to children 13 and under. By 2011, that 1980 law was associated with a 13% decline (compared with Ontario) in the likelihood of the purchase of fast food. Quebec also has the lowest obesity rate in Canada among children ages 6 to 11. Another revelation, probably of no surprise, is that our purchase of processed foods has doubled between 1946 and 2016, resulting in 60 percent of a family food budget being spent on processed food. (Heart and Stroke Foundation of Canada: The kids are not alright. 2017 Report on the Health of Canadians.)

9. Improve mental health resources

Mental health hospitals in Ontario can provide a fairly wide number of services, if you are fortunate enough to be admitted. However, too often these facilities focus excessively on consumers with chronic major mental health challenges, with the result that there tend to be a number of repeat intakes. That needs to come to an end. People with chronic major mental health issues should be cared for in community settings backed up by clinical support teams. Some of the resources that are freed up should be available for children living in a mental health crisis situation in families in social crisis. New expenditures for community-based supports should be available to family and youth living in crisis. This would be the best way to prevent, for instance, drug addiction. Such early intervention would help prevent the development of chronic major mental health issues.

For less severe mental health issues there clearly needs to be more counselling services and less reliance on medication. For instance, England trained many councillors to help people with mild to moderate depression and anxiety instead of providing medication. The results are starting to come in and look promising.

Affordable housing provision is a key to helping stabilise and prevent some types of mental health. It is well known that our high levels of immigration are the number one cause of housing shortages and expense. As the number of new immigrants coming to Canada approaches 500,000 a year, with half of these coming to Ontario, housing availability and housing costs are put under more pressure. Why are we putting the needs of non-citizens, most of whom are economic migrants, ahead of the needs of our own citizens? A thorny issue, but nonetheless a topic for thorough discussion. Who benefits from Canada’s policy of mass immigration? Aside from the pressures put on housing by immigration, our higher levels of government must free up money to provide affordable housing and do so in the most efficient manor.

10. Increase the number of hospital beds

You maybe surprised to know that Ontario has the lowest number of hospital beds per 1,000 amongst all peer countries except for the two other bottom dwellers, Mexico and Turkey (Ontario Health Coalition Fast Facts 2015 Hospital Beds Per Population International Comparisons). The only way such a low number of beds could be justified is if the Ontario government addressed the appalling lack of comprehensive home care and shortage of long-term care beds, enabled more day surgeries in non-hospital units, and took measures to promote a healthier population. But given that there are still not enough LTCBs planned, the inadequacy of home care services is not being addressed, and wellness is not being emphasised, we must provide more hospital beds and any new bed should be in a single room This will promote healing and reduce infections. The costs are big; achieving excellence is not free.

Summary and conclusions

In summary, you have been presented with some cost-saving measures, the savings of which can then be applied to the many areas that need increased expenditures. Under our current system of universal healthcare with an emphasis on public delivery, it is clear that more money needs to be spent and obviously taxation increased. This taxation should rest on the large corporations that benefit from our universal health care system (they do not have to provide comprehensive health care benefits) and the top 10 percent of taxpayers.

On the other hand, we could adopt a system like the one in Germany which is heavily regulated and where the poor are provided comprehensive care (including dental care) while the rest are obliged to purchase their own private insurance. In the German system, the level of care is superior and more comprehensive than ours, with shorter wait times, more choice in doctors and costs that are only marginally higher.(Commonwealth Fund June 5, 2020 International Health Care Profiles, Germany). There are many other countries that have comprehensive public medical care, with German administrative features.

Many will find a mixed system like the German, one totally unacceptable. However, based on various outcome measures it is superior to ours. Many Canadians would welcome the much shorter waiting times and the option of changing their family physician or surgeon. Taxes would also be lower if income-earners purchase their own insurance.

It is also clear that the federal government should transfer tax points to the provinces that will allow the provinces to act autonomously. The federal government is not a reliable source of money and it creates a situation where the two levels of government play off each other and waste time. For instance, why is the federal government doling out some money for drug addiction and mental health. Leave it up to the provinces to fund and operate the system and the federal government can strengthen the Canadian Health Act to ensure by law that the provinces provide for well regulated comprehensive care.

The Canadian healthcare system is failing. Despite this, we rigidly and ideologically cling to our universal single-payer option. It is time to abandon the “ideological purity” of our current system and look at what is providing better real-life outcomes in other countries around the world. No small task but we deserve excellence.

By Peter Stubbins BSc, BSc, Physiotherapy
March 3, 2023

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