Where should the new health-care money go? Here are Canada’s most pressing problems — and solutions

Across the board, Canada’s vaunted health-care system — always under strain — has seemingly come undone after three years of pandemic stress.

Emergency departments are filled with sick patients languishing for hours before seeing a doctor. Children are facing anguished waits for surgeries. Health-care professionals are floundering, many fleeing their gruelling work conditions with little hope the situation will ease.

But this week, good news. After months of worrying, hand-wringing and political wrangling, the federal health-care funding deal is done. The arrangement sees a significant increase in annual federal transfer payments to the provinces plus an immediate $2 billion for areas in crisis, including pediatric hospitals and emergency rooms.

Provinces, now negotiating bilateral deals with Ottawa, will also receive funding from a separate $25-billion, 10-year fund to tackle top health priorities, including improving access to primary care and shoring up a fragile health-care workforce.

But how will this money restore the system? And where should funds be more urgently directed, to make the biggest difference?

With the country’s health-care system under scrutiny, and facing a long road to recovery, the Star asked key experts to identify the most pressing problems and offer solutions for how the fresh flow of funds could offer immediate improvements.

Here’s what they say.

Emergency departments

The problem: Across the country, emergency departments are being pushed to the brink: patients are facing record waits, nurses are leaving in droves and critical staffing shortages are leading some ERs to temporarily close or scale back operations, forcing patients to go to other cities — or regions — for care.

“In most places in the country, there are patients on stretchers in hallways,” says Dr. Mike Howlett, president of the Canadian Association of Emergency Physicians. “There are ambulances waiting for a spot to drop off their patients; routinely, patients are being cared for in chairs in hallways and some have to stand up because there is no space.”

While a staffing shortage compounds the problem — Howlett says CAEP estimates a national shortage of 1,500 emergency physicians by 2025 — crowding in ERs is largely due to a lack of beds in hospital in-patient units. When admitted patients have no place to go, they languish in the ER, taking up space and time from staff.

Howlett says it’s not uncommon to have half or more of an ER taken up with admitted patients. And caring for patients in crowded conditions has burned out many nurses. “We have half the number of nurses taking care of twice as many patients at the same time,” he says, noting this is not only a “recipe” for increased illness and absenteeism in health-care workers, but a “patient safety issue.”

The solution: A crucial first step is to shore up staffing levels with incentives for physicians and nurses to return to emergency departments and to quickly train the next generation by adding spots in medical and nursing schools.

Beyond that targeted, short-term investment, Howlett says, leaders need to improve access to primary care to help solve overcrowding in ERs. Many patients, especially those without a family doctor, can only access health care by showing up in emergency departments.

Creative solutions for caring for the elderly, a large and still growing demographic with a lot of health needs, is also key, says Howlett. This could mean investing in long-term-care and home care, but also in community supports to help keep seniors healthy.

“In every hospital in the country, 15 to 25 per cent of the beds are taken up by such patients who are better served at home or in the community,” he says. “We need to create pathways for (the elderly frail) to get out of hospital quickly and go home.

“People admitted to hospitals who are very sick, they need to be the ones that are in hospital and not on a stretcher in the hallway.”

Pediatric care

The problem: Canada’s pediatric health-care system is actually the perfect size — if it were still the year 2000, says Alex Munter, president and CEO of CHEO, a pediatric health centre in Ottawa.

“Canada has outgrown its child and youth health system,” says Munter. Even before COVID-19, the system was not keeping pace with the growing needs — and the growing population — of kids. Now, after three years of pandemic disruptions and an unprecedented “tripledemic” viral season that swamped children’s hospitals, the entire system is even more threadbare.

“We just don’t have the resources we need to give children the care that they need,” says Julia Hanigsberg, chair of the board of Children’s Healthcare Canada and president and CEO of Toronto’s Holland Bloorview Kids Rehabilitation, adding this is true “across the board.”

To pick one example, children across Canada are waiting longer than adults for surgeries. In the short term, kids are living with chronic pain and can’t go to school. In the long term, “if you miss the safe surgical window for a five-year-old, that can have an impact for someone for the next 90 years of their life.”

The solution: Munter says it’s not just a matter of growing the exiting services — it’s a matter of growing and changing. For example, until last year, CHEO had only six dedicated beds for patients with eating disorders; at one point in the pandemic, they had 30 eating-disorder patients. When the province gave children’s hospitals money to expand, CHEO added more beds, but also an intensive outpatient therapy program that lets kids go home at night — helping them re-adapt to living at home, and occupying each bed for less time.

Likewise, Munter says CHEO is discussing creating a regional pediatric surgical program to leverage capacity in smaller hospitals with free operating rooms but less staff, although a larger issue is that “nowhere is there lots of staff.”

Hanigsberg says the first priority is to increase the number of people working in pediatric health care and add resources. “It’s simply not possible for our teams to do more with the same capacity. It’s not even reasonable to ask them to do the same as they are doing now.”

Family doctors & primary care

The problem: More than 20 per cent of Canadians don’t have access to a family doctor or nurse practitioner, according a recent survey — even higher than pre-pandemic estimates. Patients without a family doctor are more likely to wind up in the ER and less likely to get routine care like annual flu shots, research shows, creating problems throughout the system.

The solution: While funding to address these gaps is certainly overdue, “the main issue is actually a problem of vision and ambition,” says Dr. Tara Kiran, a family physician and researcher at St. Michael’s Hospital in Toronto.

Kiran believes shifting to a geographic model of primary care would ensure all Canadians get access to a family doctor. The idea works like a school district: everyone would be guaranteed acceptance as a patient at the primary care teams in their neighbourhood. Kiran thinks some of the federal funding should be used to organize and incentivize this kind of model.

Kiran leads the OurCare project, a research and public engagement initiative aimed at reimagining primary care. The first phase was a survey of over 9,000 Canadians last fall that found 22 per cent of respondents didn’t have a family doctor. While the gaps in primary care were not uniform — Quebec and the Atlantic provinces were worse off, as were men, racialized and low-income people — the public was fairly consistent on priorities.

Survey-takers supported the school district-type model, with 72 per cent agreeing with the idea. But by far the most important thing to respondents was that every Canadian should have a relationship with a family doctor, and that those health-care providers “know me as a person” — strong evidence, Kiran says, that Canadians are not in favour of solving the primary care crisis with a proliferation of walk-in clinics.

Indigenous health

The problem: Plenty of data exists on the inequities that Indigenous people face within Canada’s health-care system. But instead of a number, remember a name: Joyce Echaquan, the Atikamekw woman who died at a Quebec hospital in 2020 while staff mocked and misdiagnosed her. A coroner ruled racism played an “undeniable” role in her death.

The solution: No amount of money will reverse the corrosive effects of centuries of colonialism and systemic racism, says Dr. Angela Mashford-Pringle, Indigenous health lead at the University of Toronto’s Dalla Lana School of Public Health. But one thing that would help — and that is free — is to add language to the Canada Health Act stating that provinces can’t get any of the new money until every health-care professional completes anti-racism training.

As for what she would spend money on, “I’m not going to say more doctors and nurses,” says Mashford-Pringle, who is from the Timiskaming First Nation. Her priorities are not strictly medical: improving housing, getting working toilets where needed, and ending drinking-water advisories once and for all. She would also expand broadband internet access, which would support telemedicine.

Many of these line items are things Canadians take for granted, she says. “The systems have been set up in such a way that Indigenous people are always at the bottom of a ladder.”

Youth mental health

The problem: The pandemic took a toll on nearly everyone’s mental health. But youth 15 to 24 were hit the worst, according to Statistics Canada. Only about 40 per cent of Canadians in this age bracket reported having “excellent or very good” mental health in spring 2020, compared to 62 per cent in 2018 — the biggest drop of any age group, the agency says.

Rates of mental health problems like anxiety were already rising before COVID, and not equally: youth in the poorest households were less likely to report being in good mental health, and were more likely to have contemplated suicide, according to StatCan.

Data from the Mental Health Commission of Canada also shows a rise in youth mental health and substance-use concerns, including suicidal ideation, and that risks for such concerns are higher in LGBTQ+ youth or racialized youth, says Mary Bartram, director of policy for the organization.

The solution: Part of the problem is how the health system was built. It doesn’t meet young people’s needs, says Jo Henderson, director of the Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health at the Centre for Addiction and Mental Health.

“Youth tell us very clearly that they do not separate out their mental health from their health, from their relationships, from substance use, from employment and education,” says Henderson, executive director of Youth Wellness Hubs Ontario. “These are all part of a holistic approach to health.”

Hubs are designed to take a holistic approach to youth mental health; a hub might have a harm-reduction drop-in one evening, a queer arts and crafts night another day, and walk-in counselling appointments available through the week. The centres constantly analyze data to ensure programs are effective, Henderson adds.

Henderson says her priority for new federal dollars would be to expand integrated programs like this so that every young person has access to one. Bartram, who agrees such integrated approaches are necessary, says the cash should also flow directly to community mental health and addiction services, especially agencies working with the most underserved populations, such as racialized or LGBTQ+ youth.

A national health workforce data strategy

The problem: It’s clear Canada doesn’t have enough doctors, nurses and other professionals to staff hospitals, long-term-care homes and primary care offices. It’s less clear where the workforce shortages are most pronounced — across Canada and within the system — because too few metrics are tracked nationally. And data is fragmented, collected inconsistently between regions and sometimes not readily at hand for policymakers.

“It was very evident, in the midst of the pandemic, that our lack of data on patient needs — and who can provide that care — was an Achilles heel,” says Dr. Alika Lafontaine, president of the Canadian Medical Association. “We were not able to mobilize quickly, and put resources toward places that needed them, because we literally didn’t have a line of sight on what the problems were.”

The solution: Creating a database of Canada’s health-care workforce is key.

“We need to know the magnitude of the problem,” says Sara Allin, an associate professor at U of T’s Institute for Health Policy, Management and Evaluation. “Without this type of data, we don’t know where the major gaps are, and we can’t identify the most pressing issues when it comes to workforce shortages in the country.”

In addition to having data on the numbers of doctors, nurses and other regulated health professionals and where they are, it will be key to track how they work with colleagues, their type of workplace — a hospital or family health team, for example — and how they manage their patient populations.

“Having the right team, putting in place the right mix of skills, and supporting the workers in the team, requires an understanding of: who we have, where the gaps are and where we need to invest to bring people into these professions,” Allin says, adding that it’s hard to track unregistered health workers in some provinces, such as personal support workers in Ontario.

In addition to advocating for medical professionals to more easily move among provinces and territories, the CMA is pushing for a national health data and HR strategy. Lafontaine says this is critical for recruitment and training of health workers, but will also help retention efforts and ensure workers are optimally deployed.

“The current data we collected lacks nuances to be useful in a lot of situations,” he says, adding that right now physicians are often double-counted in some jurisdictions. “We also need details on the services physicians provide; a family physician in a rural community may not just work in a family practice, they may also work in emergency rooms or deliver babies or offer surgical assistance.”

Echoing the country’s political leaders, medical experts agree the new funding deal is only the first step in repairing and rebuilding Canada’s health system. Dollars released from Ottawa have a long way to flow from federal coffers through the provinces and territories and down to individual hospitals, clinics and community services.

From his vantage point, Lafontaine says it’s going to take more than money. He points to the specific shared priorities and national commitments in the agreement as opportunities to spur change that will help health-care workers deliver better care.

“This is what gets me hopeful,” he says. “It will be very important for us to watch over the next few weeks — and in the coming years — whether this agreement is the nudge that provinces and territories need to enable them to really change the way that we provide health care in this country.”

Kate Allen is a Toronto-based reporter covering climate change for the Star. Follow her on Twitter: @katecallen

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