I suspect that many readers will agree with the following statement: our Canadian publicly funded healthcare system is in trouble. While many parts of our system continue to work reasonably well, the pandemic has highlighted some serious shortcomings. I suspect that if one were to canvas average Canadians on the street, one would hear concerns about access to primary care, long waiting lists, a lack of healthcare providers, inadequate emergency services, hospital and service closures, and other issues torn from the headlines over the past few pandemic years. It was not that long ago when our healthcare system was a source of national pride: Tommy Douglas, the father of national medicare, was voted the Greatest Canadian in a nation-wide CBC poll,[i] and Canadians rather smugly raised it as one area of cultural superiority over the United States. Similarly, it was not that long ago when politicians would stand up in any provincial legislature and proudly declare that Canada has the best healthcare system in the world. Those days are over, at least for the foreseeable future. As the CEO of a provincial health authority in 2023, it often feels to me like we are just trying to “keep the lights on” and maintain what services we have. I know in speaking with my colleagues from across the country in my role as HealthCareCAN Board Chair, that they are feeling similar pressures.
So, what happened? Was the COVID-19 pandemic that damaging to our healthcare system? Were we relatively OK until the spring of 2020 when things started to fall apart? Or were there fault lines apparent years ago and the pandemic only hastened the collapse? Observers of our system will argue for the later, namely that our current system has been in a downward spiral for quite some time and that we have been living in denial, while avoiding some difficult choices that would have helped to blunt the impact of the pandemic. Our challenge is that few national programs have been more sacred to Canadians than our healthcare system. Like the National Health Service in the UK, Canadian healthcare has historically been part of our identity, on the same level as hockey, the battle of Vimy Ridge, a certain coffee company, and the invention of the snowmobile. To think that our system is struggling is shocking to say the least. How does one challenge a sacred program? Historically, we haven’t, and therein lies our problem.
Before I go on however, is it possible that the pundits and others have it wrong, and our healthcare system is only experiencing some post pandemic fatigue? If we look at comparison data provided by the Organization of Economically Developed Countries (OECD), we can readily see that Canada compares mostly favourably to the complex private/public collection of systems in the United States.[ii] But that is no reason to cheer, as our system compares poorly with almost every other developed countries’ system for most indicators and has done so for years.[iii] The Canadian system is one of the most expensive, yet we have a below average number of doctors, inpatient beds, and medical and nursing trainees per capita. In terms of outcomes, Canada is middle of the pack for most indicators.[iv] Finally, we pay relatively more costs out of pocket compared to most other OECD countries. Given all the cries for more money and turf fights between provincial and federal governments, Canadians may be surprised to learn how expensive our system is compared to others. It makes one wonder if this is really all about money, or are there other reasons to consider? We spend an awful lot of tax dollars and out of pocket, but we have at best a poor-to-middling system to show for it. We have historically made ourselves feel better by comparing our system to the most expensive healthcare system in the world next door, but we should be asking if that is the best comparison.
Similarly, our record for waitlists is poor.[v] People wait a long time for procedures in Canada, a situation only made worse because of the pandemic. In my experience, long waitlists are often the reason people quote when looking for a private payer model—if I can have my knee operated on next week and can afford to pay for it, why can’t I do that instead of sitting on a waiting list for many months? Or why can’t the public system reimburse me since they would have paid for my operation otherwise and haven’t I slightly decreased the wait for others by doing so? These are points that were easy to bat away when waiting times were not extreme and one could fairly argue against needing such an approach with a blanket comment about the evils of privatization. But it is much harder to do so now.
How did we get here? As a complex adaptive system, there is no one reason why Canadian healthcare is in trouble and no one person or government is to blame. Rather there are multiple reasons and well-meant past decisions that have brought us to where we are today. When our national publicly funded healthcare system was created over a half century ago, it was meant to pay for doctors’ fees and hospitalization costs, including inpatient procedures and medications.[vi] Perhaps surprising to the general public, doctors’ pay as a percentage of healthcare funding has been fairly static and is not a large driver of increasing costs.[vii] That being said, the doctor fee-for-service payment model from the 1960s is no longer so simple today with multiple payment modalities and practice settings. Unlike doctor payments however, hospitalization costs and pharmaceuticals have skyrocketed. In the 1960s there were no CT scanners, MRIs, ICUs, endoscopes, molecular diagnostics, or cardiac catheterization laboratories. Rather there were simple radiologic tests like plain film radiographs, and frankly, people succumbed to their often-untreatable illnesses at a much younger age.[viii] With respect to medications, the pharmaceutical armamentarium was very limited compared to today’s huge drug formularies, listing biologics and specialized cancer drugs that can cost hundreds of thousands of dollars per treatment. Of course, other OECD countries have faced the same increases, but they have largely done a better job at controlling their costs.
One reason for our difficulties in controlling costs is the lack of economies of scale. Canada has 13 healthcare systems, not one, with each region repeating infrastructure that could otherwise be shared leads to wastage. In smaller provinces such as PEI where I currently work, we are relied upon to maintain a nearly complete healthcare system for only 176 000 people, yet we need the same leadership roles and other support functions that a much larger system would require. Similarly, smaller buying groups tend to pay the highest prices. Were Canada to have one healthcare system, we would be buying for 40 million people and have single federal licensing colleges and organizations replacing multiple provincial ones. This inefficiency is built into our system.
Another driver of out of control costs is the lack of public conversations regarding what our healthcare system should (and shouldn’t) provide. The media in the summer of 2023 were replete with stories of rural hospital[ix] and Emergency Department[x] closures, largely due to a lack of staffing, demands for more services, all in the background of ever more sophisticated, i.e., expensive, treatments. While Canada’s huge geography necessarily introduces inefficiencies into our system if we are going to provide reliable healthcare services anywhere near rural populations, there is little doubt that thoughtful centralization of services could be achieved, albeit at a political price. This is one topic where our proximity to the United States, where literally any treatment is available if one can afford it, drives our prices continually upward. Should our system pay for cutting edge treatment or only for established middle of the road therapies? How long is a reasonable drive for a Canadian to access dialysis and medical imaging? The treatments available today could not have been dreamed of in the 1960s and we long overdue for a relook at our system. Before going down that road, we need as a country to decide on the guiding principles of what we want our system to provide. Today, it feels as though we have a patchwork of add ons and temporary solutions that have become permanent.
This type of honest conversation is frightening. However, the prevailing argument that the provinces simply need more money, accompanied by national federal/provincial/territorial finger pointing is wearing thin with the public. Without setting boundaries outlining what our system can and cannot provide, and at what distance from one’s home is acceptable, and how many professionals we ought to be training and employing, there will be no efficiencies or improvements to our services. We are spread far too thinly. Healthcare will truly gobble up any available funding and look for more. Not putting serious limits on what our system can provide will lead us to financial ruin, and more closures.
We also need to look at what health services we prioritize and support for the most long-term benefit. How do we provide the most good for the most people? Knowing what was originally included in Canadian medicare and its focus on hospital services, it is perhaps not surprising that funding of and thinking about primary care was not a priority. Fast forward to today, and governments now clearly recognize the importance of preventing and treating chronic illnesses, but our system thinking has not yet caught up. Family physicians remain at the bottom of the public’s perception of doctors, and remain the poorest remunerated, with subspecialty surgeons at the top. If primary care is to be the foundation of our healthcare systems, then shouldn’t we be paying our family physicians and other members of the primary care team, such as nurse practitioners, more competitively? Of course, family practice can be very rewarding, but the predominant model of solo practice also can easily lead to burn out as we have been seeing during the pandemic. Our recent moves to team-based care cannot come fast enough, but again, doctor as team member is quite different from role of doctor as a solo business owner in the 1960s when our system was created. We need to think of primary care as a system unto itself and recognize its importance. These changes won’t come without challenges – make no mistake, we are in a system disruption phase in Canadian healthcare, with all the hiccups and bumps that come with that.
One thing is clear, Canada itself is responsible for our healthcare human resources shortages. We have historically built up a series of walls to strictly control the number of healthcare workers in the country. For example, provinces have historically tried to trim healthcare costs by limiting the number of doctors in practice. I experienced this personally in 1992 when I graduated from medical school in Quebec as a resident of Ontario. On graduation I was informed that Quebec was not going to be offering licenses to out-of-province residents, while Ontario had also put a hold on issuing new licenses. Unfortunately, the ebb and flow of human resources occurs over a much longer time frame than four-year election cycles. The cutting of medical school positions will not be felt by the current government, so may be seen as an immediate safe budget saver. In a similar fashion, our Canadian colleges and licensing bodies have created substantial barriers to foreign trained physicians, even if they are Canadian citizens. A longstanding argument for this has been quality and patient safety; however, there are without a doubt medical schools and residency programs that are on par or higher ranked than most of those in Canada whose graduates we are rejecting. For example, a Canadian with a good record who attended medical school, completed a residency and passed her examinations in Australia should be eligible for a provincial license immediately, not after many months of bureaucracy.[xi] Our current shortage of medical resources was foreseeable years ago, based on the impacts of the baby boom generation retiring, population growth, and limited Canadian training opportunities. But of course, the governments and organizational leaders that made these decisions years ago that led to our situation today, are long gone. This is not about poaching doctors from other countries, which can be ethically dubious, but rather about giving Canadians a way back to practice medicine at home. That said, recent immigrants with equivalent training and successful licensing examinations in their home country, should not need to routinely repeat the process in Canada. There must be a simpler way of welcoming such individuals into our system and ensuring they are fit to practice, such as practice-ready assessments.
Healthcare and to a lesser extent, education, are areas of huge concern to provincial governments, and rightly so. Not only is healthcare by far the costliest line item on the budget, but nothing gets Canadians more riled up than healthcare, or rather, a lack thereof. Over the past few years as healthcare delivery has stumbled, political involvement our healthcare systems has become more evident, with elected officials wanting to understandably show the public that they are “doing something” to fix healthcare. Unfortunately, these solutions can be shortsighted or short term in nature (remember the four-year election cycles) and may have negative ripple effects throughout the system. As H.L. Mencken has often been quoted as saying, “for every complex problem, there is an answer that is clear, simple, and wrong”.[xii] For example, incentivizing workers in one area, may lead to deficits elsewhere or lead to burnout and attrition due to overwork or tired workers being pulled in multiple directions. When everything is a priority, nothing is: it is hard to understand how we can catch up on waiting lists and keep rural emergency departments open and expand services when there are not enough healthcare workers, all while attending to their burnout. Trying to squeeze more out of an exhausted workforce is likely not going to result in significant improvements, but it will hasten resignations.
Prominent, highly qualified healthcare leaders and boards have been replaced or have resigned over the past few years, again with the publicly stated intent of politicians addressing healthcare delivery issues.[xiii],[xiv] Healthcare systems have been reorganized and reorganized again, with the stated aim of bringing about improvements, but I am unaware of evidence that proves that any of these changes have fundamentally transformed a system for the better. To be clear; the political concern with healthcare is understandable, even laudable; however, it is unclear whether these inventions have brought about measurable improvements in most circumstances, but they certainly have caused ripple effects and unforeseen consequences in the system. Perhaps it is less about how our systems are organized and more about the other issues I have discussed.
Paradoxically governments have argued that it is because healthcare is so expensive and so important to Canadians, that politicians must become involved in the details. Perhaps, but if we look at other governmental organizations, such as the Bank of Canada, politicians are far less able to become involved in operational issues.[xv] One reason for this independence is that economists need to play the monetary policy long game and politicians rarely possess the depth of expertise to opine, and have an obvious conflict in wanting to look for solutions that will pay off during their mandate. It is important to note that there is a difference between commenting that the Bank of Canada should not raise interest rates, versus taking political action to remove the governor and force changes as has been done repeated with healthcare leaders across the country. Of course, the Bank of Canada still has a relationship with the federal Minister of Finance; however, the Governor and the Board of Directors have far more independence than their counterparts in your typical Canadian health authority.
A way forward
Complexity science shows us that no one person has all the answers: rather it is through creating generative conversations with diverse groups of people, having challenging and difficult conversations, and encouraging debate, that new ways forward will emerge. My mentor, the late Dr. Brenda Zimmerman, taught that reforming healthcare requires us to rethink the nature of the relationships in the system, how we make decisions, determining who holds the power, how we handle conflicting ideas, and how we support our system to learn.
Canadians need to ask what we want our healthcare system to be. It cannot be all things to all people. For example, access to specialized care will never be the same in downtown Edmonton versus Hay River. But what does need to be similar? What needs to be local, such as primary care and a form of emergency services, and what needs to be centralized, like subspeciality surgeries? Should we be investing more heavily in patient transport to ensure access if a service is not available locally? Our geography is a very real issue and not something that smaller European countries such as the Netherlands and Denmark –who outperform us on almost every measure – need to be as concerned about. Once we have decided at a high level where we want to get to, we need to stay focused, yet open to opportunities along the way. This type of restructuring has been done in Canada in the past and it is not for the faint of heart and it highly political. But what is the alternative except more rural hospital and ED closures?
We need to be able to discuss the guiding principles of our system, including asking questions about the Canada Health Act (CHA),[xvi] and debate which parts may need to change. Is there Canada-wide agreement that all the tenets of the Act are still appropriate? Whenever the CHA is raised, we never seem to get past the immediate cries of impending privatization, which kill further debate. I personally have no idea whether adopting a private/public hospital system like other countries have is a good idea, but I would like us to be able to talk about it and study it, learn from other systems, and not immediately shut the conversation down. As I stated earlier, most other developed countries who have such systems are performing better than us on most indicators, although the relative contribution of the private healthcare arm to this success is unknown. Many Canadians know other countries are doing better than us and are rightly asking why we can’t at least challenge our assumptions.
Of course, a pan-Canadian conversation about healthcare is in trouble from the get-go, given that the provinces have responsibility for healthcare. Back in 1867, the creators of the BNA act considered healthcare to be a minor issue, and hence not worthy of federal oversight. They could have never predicted the scientific advancements in the subsequent century that would lead to huge improvements in life expectancy and the astronomical costs of modern healthcare. That said, given our experience with constitutional reform since the 1980s, we will likely never change our division of constitutional responsibilities. Facing this reality, provinces, especially the smaller ones, should look towards increasing formal partnerships with each other to avoid some of the unnecessary duplication and achieve some economy of scale, or else be doomed to crush provincial budgets where healthcare continues to eclipse other departmental spending. For example, why not have a formal partnership with a neighbouring province for a particular service so that the other province does not have to prop up a smaller service? This avoids the inherent issues related to small programs, such as it collapsing when someone leaves or goes on vacation, and reduces competition for scare human resources. We are starting to see some of this thinking emerge with the creation of the Atlantic Registry for physicians that allows for greater mobility.[xvii] Partnerships can run up against provincial senses of identify and independence, but this will have to give way for us to address ever increasing costs and poor access. I personally feel Canadians care far less about where the service is located, especially specialty services —they just want access to it in a timely fashion.
A pan-Canadian approach for health human resources is sorely needed to ensure a steady supply of healthcare workers and to allow for long-term planning. Although schools and colleges are provincial, each province planning individually ignores the reality that healthcare workers are not captive resources and can work elsewhere. Any increase or decrease in training capacity needs to be looked at from a national lens, not just the needs of a single province. In the absence of a national strategy, each province goes its own way and we complete with each other for the same resources—another band aid solution rather than our national balance between supply and demand. It simply not working.
We need to be able to safely take risks and talk about our successes and failures. I cheered this summer when Quebec released information on the relative costs of its private surgical clinics.[xviii] Fantastic, let’s learn from this and move on. Typically, however, whenever a program doesn’t work as expected, it becomes political fodder for opposition parties or political pundits. The result: healthcare leaders are hauled on the carpet and risk aversion becomes the norm. Imagine if companies worked this way: when a Space X rocket blew up this summer, the company saw the launch as a success as they learned valuable information to apply to the future.[xix] If that were our healthcare system, we would never launch another rocket. It goes without saying that we cannot take risks with lives—but healthcare systems are essentially huge corporations and we can certainly take financial and other program design related risks, where the potential benefits can drastically outweigh costs.
Healthcare deals with generations and long-term trends that do not fit neatly into four-year election cycles. We need to determine how politicians can be involved in our healthcare system to hold it accountable, while still allowing the system to have difficult conversations and make difficult decisions so we can plot a better course for the most people with long term goals in mind. To be clear, healthcare deals with lives and is expensive—politicians need to be involved; however, how do we get to a level of independence like the Bank of Canada and be able to limit the amount of politically expedient solutions that may inadvertently cause longer term harm? One of the tenets of high reliability organizations is deference to expertise, which is unfortunately counter to the growing societal and political trend of mistrusting scientific expertise. How do we get to a point where we trust our healthcare leaders to do their jobs but also hold them accountable and require them to engage with diverse opinions? Healthcare systems need to be viewed through multiple lenses, including a political one, but our systems must be independent enough from political considerations to do the work they need to do.
While it is a national pastime for Canadians to compare ourselves to the United States, we need to stop using the American healthcare system as a valid comparator. The US non-universal system is unique amongst OECD countries and is the most expensive healthcare system in the world. Despite the cost, it provides highly variable access, ranging from some of the best healthcare in the world, to very poor access and results in some poor overall outcomes, such as comparatively high infant mortality. To borrow from Dickens, it is the best of care, it is the worst of care. This comparison makes our universal system look good, which prevents us from acknowledging that we have serious issues. Canada should instead by learning from other OECD countries that have universal coverage, similar to Canada.
One area where Canada is falling further and further behind is medical research, both basic and applied. For a comparatively wealthy country, Canada spends far less per capita on research than the vast majority of developed countries, for example the United States spends 50-fold more on research than Canada yet is 9-fold larger.[xx] I would argue that is partially a symptom of our overly expensive healthcare systems—how do we spend money on research when healthcare eats up a huge proportion of budgets? I also wonder though it if is a symptom of our healthcare malaise.
They say the first step in addictions treatment is for the client to acknowledge they have a problem and that they need help. I hope we are at a point in Canada’s healthcare journey where we are past pretending that everything is fine. More of the same is not going to bring about the significant reforms that our healthcare system needs. In some respects, we are at a point analogous to the early 1960s when our public healthcare system was first created because the previous system was not providing what Canadians needed.
Do we have the courage and leadership to once again challenge the status quo and create something new that Canadians can again be proud of? Many are frightened to openly talk about serious healthcare reform; however, I believe the public is ready and will demand such discussions. I see our current situation as similar to that of Medically Assistance in Dying (MAID) roughly a decade ago. The federal government felt ready to take on the issue of legalizing MAID only when it was clear that a majority of Canadians wanted them to do so. I believe we are at that moment and most Canadians are looking for renewed leadership to transform our healthcare system that goes far beyond just pouring more money into the system.
Dr. Michael Gardam, MD, CHE, is the Chief Executive Officer at Health PEI and the Chair of the Board of Directors of HealthCareCAN. He is also the Program Director of the York University Schulich School of Business Healthcare Leadership Development Program, and an instructor for the Physician Leadership Institute of Joule (Canadian Medical Association). He is a pioneer of using complexity science-based approaches to improve patient safety, system transformation, staff engagement and other complex challenges. Dr. Gardam has published more than 120 scientific works.
You can read Dr. Gardam’s full Editorial in the November edition of Healthcare Management Forum.
References
[i] Tommy Douglas crowned “Greatest Canadian”. Accessed September 18, 2023. Available at: https://www.cbc.ca/news/entertainment/tommy-douglas-crowned-greatest-canadian-1.510403.
[ii] OECD.stat. Health expenditure and financing. Available at: https://stats.oecd.org/Index.aspx?ThemeTreeId=9
[iii] Ibid. Accessed September 18, 2023.
[iv] Ibid. Accessed September 18, 2023.
[v] CIHI. Access and wait times. Available at: https://www.cihi.ca/en/topics/access-and-wait-times/indicators. Accessed September 18, 2023.
[vi] Government of Canada. Canada’s Health Care System. Available at: https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html#a3. Accessed September 18, 2023.
[vii] CIHI. National health expenditure trends, 2022—Snapshot. Available at: https://www.cihi.ca/en/national-health-expenditure-trends-2022-snapshot. Accessed September 18, 2023.
[viii] Statistics Canada. Life Expectancy 1920-1922 to 2009-2011. Available at: https://www150.statcan.gc.ca/n1/pub/11-630-x/11-630-x2016002-eng.htm. Accessed September 18, 2023.
[ix] CBC. This new map shows the extend of Alberta’s rural health-care problems—and this old report may hold solutions. Available at: https://www.cbc.ca/news/canada/calgary/alberta-rural-health-care-hospital-closures-service-reductions-map-1.6920460. Accessed September 18, 2023.
[x] Ontario Health Coalition. Protecting public healthcare for all. Available at: https://www.ontariohealthcoalition.ca/index.php/briefing-note-sampling-of-recent-ontario-hospital-service-closures/#:~:text=In%202023%2C%20up%20until%20the,of%20communities%20across%20the%20province. Accessed September 18, 2023.
[xi] CBC. Canadian-born doctor gets licence to practise here after 17-month fight. Available at: https://www.cbc.ca/news/politics/canadian-doctor-gets-license-to-practice-1.6912617. Accessed September 18, 2023.
[xii] Brainy quote. H.L. Mencken Quotes. Available at: https://www.brainyquote.com/authors/h-l-mencken-quotes. Accessed September 18, 2023.
[xiii] Edmonton Journal. Dr. Verna Yiu out as head of Alberta Health Services. Available at: https://edmontonjournal.com/news/politics/dr-verna-yiu-out-as-head-of-alberta-health-services. Accessed September 18, 2023.
[xiv] Halifax Examiner. Houston fires Nova Scotia Health Authority CEO, dissolves Board. Available at: https://www.halifaxexaminer.ca/government/province-house/houston-fires-nova-scotia-health-authority-ceo-dissolves-board/. Accessed September 18, 2023.
[xv] Government of Canada. Justice Laws Website. Bank of Canada Act. Available at: https://laws-lois.justice.gc.ca/eng/acts/b-2/. Accessed September 18, 2023.
[xvi] Government of Canada. Canada Health Act. Available at: https://www.canada.ca/en/health-canada/services/health-care-system/canada-health-care-system-medicare/canada-health-act.html. Accessed September 18, 2023.
[xvii] College of Physicians and Surgeons of Newfoundland and Labrador. Atlantic Registry. Available at: https://cpsnl.ca/licensing-and-registration/i-am-currently-practicing-in-nl/atlantic-registry/#:~:text=The%20Atlantic%20Registry%20allows%20for,between%20all%20four%20Atlantic%20provinces. Accessed September 18, 2023.
[xviii] CTV News. Some medical procedures cost more in private clinics Quebec study finds. Available at: https://montreal.ctvnews.ca/some-medical-procedures-cost-more-in-private-clinics-quebec-study-finds-1.6368157. Accessed September 18, 2023.
[xix] NPR. Why SpaceX staff cheered when the Starship rocket exploded. Available at: https://www.npr.org/2023/04/21/1171202753/spacex-starship-launch-explosion-cheer-success. Accessed September 18, 2023.
[xx] Archer SL. The Conversation. Two decades of stagnant funding have rendered Canada uncompetitive in biomedical research. Here’s why it matters, and how to fix it. Available at: https://theconversation.com/two-decades-of-stagnant-funding-have-rendered-canada-uncompetitive-in-biomedical-research-heres-why-it-matters-and-how-to-fix-it-199370. Accessed September 18, 2023.
Healthcare Management Forum 