Canada and the health care system crisis

by Maj (ret'd) CORNELIU. CHISU, CD, PMSC, FEC, CET, P. Eng. Former Member of Parliament Pickering-Scarborough East Last month's Council of the Federation meeting of the leaders of the Provinces and the Federal government dedicated a lot of attention to the "recruitment and retention of health-care workers" as a key part of addressing broader health-care challenges. The notion of a major labour supply problem in Canadian health-care systems is on the news in the media and the political field. Scarcely a week goes by without yet another story or study about physician access and shortages in Canada's health system. It seems to me that health care has become atopic of futile daily conversation without a proposed solution in sight. Will a committed leader please step forward to deal with this issue? There is no doubt that family physicians play a crucial roleas the point of first contact and gatekeeper for health services. Nationally, a Canadian Medical Association Journal (CMAJ) report has stated that as many as one-fifth of Canadians are without a primary care physician. However, there is variation across Canada's regions, with 13 percent of Ontarians, 27 percent of people in British Columbia and 31 percent in Atlantic Canada saying they are without a family physician. These numbers have increased dramatically since the pandemic and even with a family doctor, large proportions of Canadians are reporting difficulty in getting appointments. The reason Canadians continue to experience a health-care system with shortages of physicians and other health-care professionals is really due to a lack of a well-established health policy. To effectively deal with a conjunction of forces that span provincial and federal policies regarding health care and its funding, physician behaviour, and demographic and technological changes we need competent professionals and committed politicians. The complex issues that need to be navigated and sorted to establish a better heath care system require political will and competent professional input. The basic dimensions of the problem are well established but the solutions are missing in action. To understand the issues affecting physician supply and access, let us first look at physician numbers. When it comes to international comparisons, Canada ranks near the bottom.Of 47 countries compared by the OECD in 2021, Canada ranked 35th at 2.9 physicians per 1,000 population. Provincial governments view physicians not only as health service providers, but also as cost centres and a source of expenditure. So as costs increase, decisions are ultimately determined by budgetary pressures. While governments seek to meet the need for health-care services through physicians, the supply of physicians is regulated by the same governments through medical school admissions and licensing. Does the left hand know what the right hand is doing? Governments perceive physicians as a major cost driver despite evidencethat while "physician numbers are a positive and significant driver of provincial government health care spending;the overall contribution to real per capita health spending is relatively small for most provinces. Access and availability of physician services are affected by demand and supply factors rooted in the structure of our health-care system and changing social, economic, and demographic forces.The demand factors include increasing utilization of services per capita, as well as a growing population. Canada's population has soared past 40 million from 35 million a decade ago. Then there are the increased demands from an aging population, as the proportion over age 65 grows in conjunction with rising needs in mental health, particularly amongst younger populations. Technological change also offers new and better procedures-witness, for example, the improvements in cataract care and knee and hip replacements. Such improvements can foster enhanced demand and increased expectations. Many current physicians are aging.It has been estimated that one in sixfamily doctors are nearing retirement age. While some of this loss could be counteracted by recruiting more international medical school graduates,the process for accreditation is long, and there is a shortage of residency positions for them, restricting their entry into the physician workforce. Another problem is that many graduates trained as family physicians,don't go into traditional primary care. They go into other fields, such as sports medicine, work solely in hospital emergency rooms or anesthesiology, or work part-time. Part of this is a function of changing preferences, and part is due to monetary incentivesgiven the costs and administrative burdens of running family practices. Obviously, financial and market incentives are a factor if physicians pursue work where they can earn more than they could by seeing more patients as a family physician where fees are capped. On average, physicians are working less than they did a decade ago as more seek better work-life balances. While physicians are working fewer hours, they are also experiencing higher administrative burdensgiven the highly regulated nature of provincial government health systems that reduce patient-centred working time and the explosion of technology that has expanded health information. Governments and health bureaucracies ultimately determine what public health services should be, what procedures are necessary or unnecessary, and what the budgetary envelope will bear. The allocation of public money requires accountability, and this desire for efficiency, combined with new technology, has created an exponential increase in paperwork and administrative costs for physicians. Generally speaking, a family practice is a small business with rising costs and expenses, but physicians have no control over the priceof their services.Simply increasing the quantity of patients they see runs up against reducing time per patient, rising paperwork burdens, and work-life balance concerns. In 1971, there were 125 physicians per 100,000 population, and their services seemed abundant. In 2022, there are 247 physicians per 100,000, and there are issues of scarcity and access. One can increase the number of physicians by boosting medical school enrollments further and licensing more international medical graduates, but this is no guarantee that they will go into family practice. Of course, one might venture that if governments do not want to spend more on physicians or reduce their administrative burdens, the public should be allowed to spend their own money on attaining the physician services they need. Here, we come up against the politics of Canadian health care that is committed to public health care and the belief that more private care creates an inequitable and unfair two-tier health care, even as increasing numbers of Canadians experience the unfairness of not having access to the physician services they expect. Provincial governments essentially ration access to public medical care but do not make it easy to spend your own money on health care unless you choose to cross the border into the United States or somewhere else; a version of two-tier care we seem prepared to live with. What is to be done? The story has been much the same for the last thirty years. Problems brew for a long time and periodically rear their head as health crises of waiting lists, crowded emergency departments, and shortages of physicians and other health professionals fester. Isn't it time for some new thinking and effective action from governments?