Canadian healthcare needs radical structural change

Journal of Psychiatry Reform Vol 10 #1. January 2, 2023

Author

Alan Eppel MB, FRCPC

https://orcid.org/0000-0002-4880-4097

Universal Canadian healthcare has been dramatically successful. Starting in 1966 and developing over several decades, it has provided medical care to the whole population without the worry  of cost. Standards for training and practice of healthcare professionals are among the highest in the world.

It is now clear that the system has been operating close to maximal capacity over the past decade and more. It has been overstretched with difficulty accessing timely and uniformly high quality care. There are specific gaps geographically and in relation to Indigenous and minority populations that have resulted in very poor health outcomes.

The healthcare system has grown by means of incremental and disconnected changes. Planning has occurred in the absence of a comprehensive systems approach. There is a lack of data to predict and to respond to workforce needs. Sector specific funding has led to an uneven and disjointed system of care [1,2].

Government funders and policymakers have focused on juggling payment formulas; e.g., fee-for-service, capitation, funding for episodes of care, and bundling of services [1-4]. The goal of these policies is to incentivize changes in the behaviour of practitioners and healthcare services including hospitals [4] Since 1984 a wide range of reform measures have been implemented. Most of these have been focused on additional funding to specific sectors with little real change in the dimensions of quality care. Plus ca change, plus c’est la meme chose! (The more things change, the more they stay the same!)

The Problems

Canada has fallen behind on rankings with other countries on accessibility, quality of the care process, and societal impact. Quality of care is defined by accessibility to care close to home, in a timely fashion, which is effective and delivered in a compassionate, safe and respectful manner. This has been summarized as: “The right intervention at the right place at the right time and in the right manner” [4].

i) Difficulty with access.

This includes long waiting times to access family physicians, specialists and hospital admissions.

The Commonwealth fund ranked seven countries based on measures of access to home visits and coordination of care with other services [5]. Canada and the USA ranked lowest with regard to provision of care services by primary care providers. Germany, the Netherlands, Norway, New Zealand and the UK with a score of 80 to 90% ranked much higher than Canada. Australia and France rated around 70%. Canada and the USA at around 50% [5].

ii) Regional disparities in access to nearby services and health care providers.

iii) Overdependence on emergency services.

iv) Centralization of services in large hospitals in major cities. Care at large hospitals is frequently experienced as impersonal and disorganized.

v) Competing economic interests: physicians, nurses and hospitals compete for the same dollars. Funding allocations are heavily influenced by political considerations and strong lobbying by professional organizations and unions.

vi) Shortages of physicians and other healthcare providers. This despite significant immigration of physicians to Canada. There are many barriers to licensure which may in part reflect implicit negative bias or racism towards immigrants.

vii) Lack of early intervention and preventative services for children and families.

The Solutions

i) Establish extensive and decentralized urgent care centres available 24 hours a day. This will take pressure off hospital emergency rooms.

ii) Review the benefits of large centralized specialty centres versus accessible local and regional services. This should include multidisciplinary health centres with 24 hour access to urgent laboratory and imaging investigations.

iii) Allocate major funding to the child welfare system. It is well-known that preventative care interventions with families have a multiplier effect in reducing future healthcare costs. Economic hardship, poor access to quality food, child neglect, child emotional, physical and sexual abuse result in major health problems throughout life. The child welfare system and protective services need to become a central focus in healthcare. This requires increased access to multiple levels of expertise and alternative family support services are critical to prevent future chronic healthcare problems that are very costly to society and often devastating to the individuals concerned.

iv) Remove barriers to training and licensure of immigrant physicians.

References

1. Doty MM, Tikkanen R, Shah A, Schneider EC. Primary Care Physicians’ Role In Coordinating Medical And Health-Related Social Needs In Eleven Countries. Health Aff (Millwood). 2020 Jan;39(1):115-123. http://doi: 10.1377/hlthaff.2019.01088
2. Sutherland JM. Health care funding policies for reducing fragmentation and improving health outcomes. The school of public policy publications: 2021; Vol.14:37 . 1-26 University of Calgary. http://dx.doi.org/10.11575/sppp.v14i1.74017
3. Aggarwal, M. and A.P. Williams. 2019. “Tinkering at the margins: Evaluating the pace and direction of primary care reform in Ontario, Canada.” BMC Fam. Pract. 20, 1–14. https://doi.org/10.1186/s12875-019-1014-8.
4. Eppel AB: Achieving Quality of Care. Can Med Assoc. J 1992; 147:9, 1305-1306; (Ltr. to Ed)
5. Schneider EC, , Shah A, Doty MM, et al. Mirror, Mirror 2021 — Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries(Commonwealth Fund, Aug. 2021). https://doi.org/10.26099/01dv-h208