Health care is showing the cracks it's had for decades. Why it will take more than cash to fix it
Pouring billions into broken system like 'pouring hot water into a leaky bathtub': Canadian Health Coalition
The one-nurse emergency room that serves the remote community of Alert Bay, tucked off the northeast coast of Vancouver Island, has shut down until January because it has no available staff.
That means any urgent medical cases not serious enough to warrant an air evacuation are looking at a water taxi or ferry ride of at least 40 minutes to Port McNeill, B.C.
So people living on Cormorant Island hope nobody needs help quickly anytime soon.
"It gets you very nervous. It gets you angry," said Don Svanvik, a retired paramedic and chief councillor of 'Namgis First Nation, which is based on the island traditionally known as Ya'Lis.
The ER has relied on contract nurses for years, Svanvik says, but at least it stayed open.
"With the system broken it's just tough to get people to go into a haywire situation," he said, of the struggle to attract health-care workers. "What the hell can we do about this?"
It's a question facing politicians, policy analysts and health-care workers across Canada.
During the pandemic, this country's health-care system was pushed to the breaking point in many places, with emergency rooms shuttered, patients facing lengthening wait times and shrinking access to everything from long-term care to mental health supports.
And though some of these issues have been going on for years, COVID combined with an unprecedented level of respiratory illnesses compounded these systemic problems — and sparked demands for everything from billions more in federal funding to more privatization.
All the while, the price of Canadian health care is edging close to the highest per person of the 38 democratic countries in the Organization for Economic Co-operation and Development.
On Tuesday, Prime Minister Justin Trudeau told CBC: "There's no point putting more money in a broken system. If I were to send people all the money they need in the provinces, there is no guarantee that … folks would be waiting less time in the hospitals."
Cash demands
Trudeau was responding to the ongoing impasse between Ottawa and the province ever since premiers demanded an increase of $28 billion to the $45.2-billion Canada Health Transfer this year and talks broke down over that and data sharing.
So how did we get to a day where even the prime minister calls public health care — once a point of national pride — broken?
Policy experts blame the current state on the lack of accountability built into the fragmented Canadian delivery model. Canadian health care is delivered by provinces and territories across about 100 different health authorities, all with their own separate fiefdoms, systems and private data.
A lack of national data, policies and practices that can be shared combined with chronic public underfunding and a failure to digitize health-care systems are all part of the problem, critics suggest, and it's been exacerbated by the pandemic, climate change and not having either a cap on drug costs or whistleblower protection to allow staff to flag mismanagement.
Costs soar
This year, the cost of delivering health care across the country is expected to hit $331 billion — or roughly $8,563 per Canadian — with expenses covered by Ottawa, the provinces and territories and the private sector. About 72 per cent of the cost comes from public funding, according to the Canadian Institute for Health Information (CIHI).
Though costs have risen, services have declined. Hospital beds available per capita have been dropping steadily since 1984, the year the Canada Health Act was adopted, which laid out the framework for how Ottawa would distribute health-care dollars to the provinces and territories.
And hospital bed numbers are low: Canada ranks fourth from the bottom in a measure of beds available per capita in OECD countries, with only Chile, Sweden and Columbia ranking lower.
WATCH | Trudeau reacts to premiers' funding ask:
"We definitely do need to have spending, but we can't keep pouring hot water into a leaky bathtub," said Steven Staples, national director of policy and advocacy for the Canadian Health Coalition.
COVID-19 has exposed the grim underbelly of a fragmented, regionalized, costly, and inefficient approach to health service that is an engine for health workforce burnout.Ewan Affleck, a northern physician and structural change researcher
Staples says that decades of underfunding left the system "starved" and overburdened.
"We were already at near-capacity before the pandemic hit," he said.
When the crisis hit, ERs were left scrambling, spending millions to try to keep the system running with expensive contract nurses after failing to retain employees.
Staples says the pandemic proved that Canadian health spending needs to be more accountable and less political.
"The pandemic comes and you had provinces not taking all the money," he said. "They weren't spending it. They were putting caps on wages."
Some argue that the system actually needs more public spending — but it needs to be smart spending: on preventative health care rather than reacting to emergencies.
In fact, Canada actually lags behind economically comparable countries – like the U.K., Germany, Sweden, France and New Zealand – who cover a higher percentage of health-care costs with public dollars, according to research published by Danyaal Raza, a family physician with Unity Health Toronto's St. Michael's Hospital and assistant professor at the University of Toronto's Department of Family & Community Medicine.
For example, Sweden and Germany cover close to 84 per cent of total health-care costs, compared to Canada's 72 per cent.
And Canada remains the only country with universal health care and no universal drug plan.
Staples says skyrocketing prescription drug costs also put a tremendous financial burden on the system.
"People who can't afford their medication, who scrimp on it, [they] cut pills in half — then when their conditions get worse, they end up back in the emergency room."
He says Canada should do more to cap those costs, especially for medicine that helps manage chronic conditions like high blood pressure.
Money not a fix on its own
Doctor and researcher Ewan Affleck says cracks were built into the system when health-care delivery was fragmented by region.
And those weak points were then laid bare by the pandemic.
"COVID-19 has exposed the grim underbelly of a fragmented, regionalized, costly, and inefficient approach to health service that is an engine for health workforce burnout," he said.
Provincial control of Canadian health care has resulted in a mishmash of service models and a lack of shared data to learn lessons from, said Affleck, who is also a senior medical adviser of health informatics for the College of Physicians and Surgeons in Edmonton, Alta. He says that creates inequality in service delivery – in many parts of the country – but especially for Indigenous people.
"Billions of dollars will not fix matters if the structural problems are ignored," Affleck said in an email to CBC.
"[It's] lipstick on a pig."
Warnings ignored
Affleck believes health needs to be better co-ordinated through a digital patient-centred system, something to make it easier for doctors and patients to share information — and make the system more accountable to patients.
He also believes in creating universal drug coverage, something he says has been "unanimously endorsed" in a series of studies.
Others say health care needs to focus more on prevention rather than just reacting to crises.
Faisal Ali Mohamed, a PhD student in health policy and equity at York University, says health care in Canada is based on an old hospital-centric model that overlooks community care.
He believes the system needs to adapt and use tools like outreach, education and more mobile service to prevent health crises — like the opioid crisis — before they develop and overwhelm the system with chronic health issues.
"If somebody is sick we will get the ambulance out to them and take them to the hospital," he said. "It's a very reactive system."
Instead of pouring more money into hospitals, decision-makers need to look at the social determinants of health — things like food insecurity — and address those, he said.
The private sector
Pandemic system failures have also renewed calls for privatization, with Quebec political parties laying out proposals about how to do this — and private clinics moving in to try to fill gaps in Quebec and Nova Scotia.
But fissures in the system were well known, with a series of reports on system-level shortfalls and failings including poor workforce planning, inaccessible health data, fragmented technology and the discouraging of innovation, including the pan-Canadian Health Data Strategy in 2021.
Affleck, who helped develop that strategy, spent decades creating virtual tools to better link Northern Canadian health services. He believes digitized health care should better connect patients to resources and their health records.
But he says so far that's proven almost impossible in a Canadian system where provinces guard data and information.
For example, in B.C. alone there are five regional health authorities that each have a food services team with systems that don't easily share information — even things as simple as the daily food menus.
A culture of silence and 'peanut butter gate'
Health-care culture is also under scrutiny as stressed nurses — the backbone of the system — exit in droves.
By 2021, one in four nurses reported they planned to leave their jobs, according to Statistics Canada.
One of the reasons is that front-line staff who call out wrongs often face punishment.
Natalie Stake-Doucet — who teaches at McGill University — says hospitals are bleeding staff, but not just because of the pandemic.
"There is no shortage of nurses. We've never had so many nurses in our province. It's just that decision-makers obstinately refuse to treat us like human beings and so they can't keep nurses in the health-care system," said Stake-Doucet.
She points to a previous situation that she nicknamed "peanut butter gate," the suspension of a 21-year nurse at a Quebec long-term care facility for eating a piece of bread with peanut butter, meant for residents. That nurse was accused of theft and concealment for the illicit snacking, until it hit the news and she won a reprieve.
Then there were hospitals that forced staff to work overtime, in one instance, even locking them in.
"That sort of treatment really eats away at your soul," she said.
The standoff over new funding that ended in an impasse in November infuriated her and others who have worked in health care, she said.
"I find it outrageous that the premiers refused that extra money, because they won't be accountable," she said. "We've no idea where the money goes. You know, hospitals are like a black hole for money."
Hit, punched and kicked
Back in Alert Bay, Mayor Dennis Buchanan frets about the ER that closed due to a lack of nursing staff, given the average age in his community is 58.
He's met with regional and provincial officials — and nurses. Finding housing for nurses is part of the challenge, but he says abuse on the job is the biggest issue.
It started with protests outside hospitals at the height of COVID-19 restrictions in B.C.
Buchanan can't understand why people go after doctors and nurses who are trying to protect their health.
"They are being sworn at and hit at and punched and kicked – that's why a lot of them are leaving the profession."
He said he'd like to see Canada invite more international nurses.
And as for those who heap frustration and vitriol on health-care staff, Buchanan has no more patience.
"I think people have to start taking responsibility for their actions and their words because it's not going to help the situation."
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