Diagnosing Canada's Health System: What would the Doctor order?

The COVID-19 pandemic thrust Canada’s already fragile universal health care system into unprecedented crisis. According to a recent Report from Statistics Canada ₁, there were 136,000 health care and social service job vacancies in the second quarter of 2022, representing a 28.8% increase from the same timeframe only a year earlier. Health human resources shortages have resulted in long-term care homes temporarily closing beds/units, and most recently have also forced several hospitals to announce a reduction in services, including the unprecedented closures of emergency departments and pediatric intensive care units (ICU’s). Further impeding Canada’s health system recovery is the diagnostic and surgical backlog as a result of required cancellations due to COVID-19 restrictions. In May of this year, the Ontario Medical Association (OMA) ₂ estimated the magnitude of this backlog to be approximately 22 million cases.

Individuals impacted by the surgical/diagnostic backlog tragically continue to suffer with undiagnosed and progressively worsening health conditions, consequentially requiring increasingly acute and complex medical interventions, further compounding the already catastrophic strain on health system and health human resources. If our healthcare system was a patient, these symptoms would be diagnosed as an “acute-on-chronic” condition - an acute crisis compounded by a chronic systemic disorder. The treatment plan would consist of a combination of short and long-term interventions to first address immediate needs to achieve stabilization, followed by a long-term evidence informed plan of care with the goal of maintaining optimal health and proactive mitigation of future acute episodes. A comparable approach to addressing Canada's current health care crisis might be just what the doctor ordered.

Because healthcare is a science-based profession, it goes without saying that we love applying analytical models and frameworks. Not only are these concepts evidence informed, they provide a “recipe” for intervention strategies that not only promote an objective versus subjective perspective, but also typically hit the “quadfecta” of science 101: assessment, planning, implementation, and evaluation.

Considering the situation at hand, the multi-level Social-Ecologic Model of Health System Integration ₃ seems most appropriate, particularly in the context of spheres of influence. The model illustrates the interplay between individual, relationship, community, societal and global influences, and also supports identification of influences that place individuals and/or populations at either a risk or advantage position for various health outcomes.

In order to accurately prescribe any form of remedy for Canada’s ailing health system, it is important to first establish a clear understanding of what constitutes an optimal state of “health”. The World Health Organization first defined health in 1948 as “a state of complete physical, mental and social well-being and not just the absence of disease and infirmity”. Huber et al. (2011) ₄, criticized that the rigidity of this “complete” definition of health fails to solidify the necessary biopsychosocial connection between health and a broader definition of overall well-being that is more accurately reflected in evidence based multi-modal models for health and well-being inclusive of the Social Determinants of Health (SDOH).

In developing a treatment plan, we first need to assess barriers to achieving optimal health. Despite overwhelming evidence supporting the impact that health inequalities and determinants of health have on the overall health and well-being of Canadians, Canada’s publicly funded healthcare system continues to focus on illness, applying biomedical metrics to measure and evaluate health and health system outcomes. Using illness as a measure of health is a vicious cycle rooted in a fear-based narrative that drives public perception, political decisions, and resource allocation. In fact, according to a November 2022 snapshot on National Health Expenditures₅ released by the Canadian Institute of Health Information (CIHI), only 5.3% of Canada’s healthcare spending is dedicated to upstream public health programs aimed at preventatively addressing the underlying conditions required to actually reduce the burden of illness. This is significantly less than the 24.3% of downstream funding currently being allocated to supporting hospitals that are overwhelmed with patients suffering from chronic diseases and co-concurrent conditions. High-cost health resource consumption which could be significantly reduced through increased investment in primary care interventions.

Another significant barrier to achieving the health reforms necessary to shift prioritization towards upstream preventative health is Canada’s political and electoral system. In Canada, provincial and federal elections run on four-year terms. Politicians and political parties who are consistently seeking public approval towards re-election have an inherent tendency to pick “the low hanging fruit”, utilizing the cycle of illness driven health policy and funding allocations to their political advantage. Propagating public fear of disease sets a convenient stage for politicians to swoop in with calculated media campaigns boasting about policy and funding decisions that increased surgical capacity, purchased more diagnostic equipment, and created more hospital beds to accommodate voters when they become sick - rather than prioritizing healthcare reform that would prevent their constituents from becoming sick in the first place. Preventative health is simply a tough political sell. It’s hard to prove you prevented something that never happened.

Let’s talk about short-term treatment options. Treatment of Canada’s acute health human resource crisis will require challenging both the old hierarchal constructs of health delivery systems, and the traditional “command and control” approach applied by healthcare administrators who have failed to evolve their management style from methods ought to have been left behind in the industrial era in which they were conceived. Organizational leaders working under the antiquated notion that healthcare workers will unobjectionably comply with an authoritarian approach and who believe employees should “do as their told”, “are lucky to have a job” and will “respect and obey me because I’m the boss” have found themselves without a workforce. Academics specializing in labour policy assert that in the current era of transitioning health workforce demographics, health sector leaders must develop new and innovative approaches to work organization. Scheduling practices must be creatively re-imagined to simultaneously and empathetically accommodate the varied needs and preferences of their diverse employees. Realities that must be considered include older workers who might be looking to slow down, younger workers who may value freedom and flexibility over pay and promotion, or workers trying to balance work and family obligations such as caring for young children, aging parents, or both. Furthermore, compensation and benefits must be reflective of the value of the work being performed (Berkman, 2015).

For example, pay parity for traditionally female dominated essential public service health professions should correspond with that of comparable traditionally male dominated professions such as police, firefighters, and paramedics. “According to data by the ONA, nurses’ wages have increased by just over 15 per cent over the last 12 years, compared to over 30 per cent for both police officers and firefighters” (Hunt & Bond, 2022)₆. This disparity should not exist, must be addressed with urgency and then monitored closely to ensure equity moving forward.

Immediate treatment options for Canada's calamitous diagnostic and surgical backlog will require priority consideration to innovation, collaboration and integrated referral pathways. We must step out of a habitual and arguably entrenched organizational, regional, and/or sectoral siloed approach to “Health Care”, instead shifting focus towards a “Health Systems” perspective. “A health system comprises all organizations, institutions, and resources whose primary intent is to improve health. In most Countries, the health system is recognized to include public, private, and informal sectors” (White, 2015). While under the Canada Health Act provinces and territories must ensure that there are no patient charges for insured health services that constitute extra-billing or user charges, there is significant potential and numerous benefits that can be achieved through public private partnerships (PPPs), as long as there are checks and balances in place to ensure the ethical integrity of these partnerships. This “all hands on deck” health system approach is currently being exemplified in Eastern Ontario with an unprecedented collaboration between more than 15 hospitals working together to address the diagnostic and surgical backlog using an innovative “first-in-Ontario” surgical waitlist HUB developed by Novari Health. The HUB will improve the coordination of surgical services between hospitals in Eastern Ontario, meaning the system will pick up on patients who may be able to receive their surgery sooner at a different hospital. In their November 25th News Release ₇ the Ontario Government details that the HUB will not only decrease surgical wait times for patients in Eastern Ontario, but will also contribute towards improved surgical waitlist management across the province.

Once stabilization of Canada’s health Crisis is achieved, there are many factors to be considered in developing a long-term treatment plan to maintain a “healthy” health system and proactively mitigate the risk of another crisis. Key considerations for future direction include the need to transform healthcare management systems and practices, a calculated progressive shift towards an upstream approach to health that includes programs designed to address non-medical health determinants, “healthy public policy” that mandates that ‘health’ must be on the agenda of all government ministries, truly integrated health service delivery models, decreased specialization for health providers with increased focus on ensuring competence in both patient and population centered health systems, increased funding incentives for health education, collaborative and innovative health service delivery models including ethical use of PPP’s, and providing healthy work environments for health professionals that include remuneration reflective of the value of the work being performed, work life balance, professional prestige, and opportunities for advancement (White, 2015).

Akin to managing an acute health crisis and long-term health maintenance planning with individual patients, continued health stability for Canada’s health system will be dependent on a commitment to changing modifiable risk factors. Healthcare reform is inevitable as Canada labours to addresses post-pandemic health system recovery under our universal healthcare model. There is tremendous opportunity to advance integrated care through a focus on multi-level and multimodal models of health delivery. In sum, health system and population health initiatives must address the full range of foundational health determinants, but must also be supported by comprehensive action strategies that aim to influence the underlying influences, and the factors and conditions that determine the health of individuals, communities, and our universal healthcare system as a whole.

Resources:

1. Statistics Canada. (2022) Job Vacancies, second quarter 2022 [Report]. https://www150.statcan.gc.ca/n1/en/daily-quotidien/220920/dq220920b-eng.pdf?st=MaQTgyM_

2. Campbell (2022, May 24). Ontario doctors say the backlog for certain services reaching crisis level. CTV News Northern Ontario. https://northernontario.ctvnews.ca/ontario-doctors-say-the-backlog-for-certain-services-reaching-crisis-levels-1.5915318

3. White F. (2015). Primary health care and public health: foundations of universal health systems. Medical principles and practice : international journal of the Kuwait University, Health Science Centre, 24(2), 103–116. https://doi.org/10.1159/000370197

4. Huber, M. (2011). HEALTH: HOW SHOULD WE DEFINE IT? BMJ: British Medical Journal, 343(7817), 235–237. http://www.jstor.org/stable/23051314

5. Canadian Institute for Health Information (November 3, 2022). National health expenditure trends, 2022 – Snapshot. https://www.cihi.ca/en/national-health-expenditure-trends-2022-snapshot

6. Hunt, S., & Bond, M. (2022, February 11). ‘We are all first responders’: ONA says Bill 124 contributing to nurses’ wage gap. Ottawa City News. https://ottawa.citynews.ca/local-news/we-are-all-first-responders-ona-says-bill-124-contributing-to-nurses-wage-gap-5057012#:~:text=According%20to%20data%20by%20the,both%20police%20officers%20and%20firefighters.

7. Government of Ontario (2022, November 25). Ontario Investing to Reduce Surgical Wait Times in Eastern Ontario [News Release]. https://news.ontario.ca/en/release/1002522/ontario-investing-to-reduce-surgical-wait-times-in-eastern-ontario

CURATED RESOURCES LINK