A recent report describes how Canada’s healthcare system performs compared to 13 other countries.
Canada ranked at the bottom in access to care and use of electronic health records, and in the middle regarding costs and health outcomes.
Thirty-eight percent of Canadians felt the system works well, 51% thought it needs fundamental change, and 10% believed it needs to be completely rebuilt.
A recent report from the American organization The Commonwealth Fund provides information about how Canada’s health care system compares to those in thirteen different high-income countries. Some of the findings are summarized here.
Access to Care
Canada consistently ranked poorly on access to care. In Canada, wait times were longer than in any of the other country for specialist appointments and elective surgeries. For example, 41% of Canadians waited two months or more to see a specialist, compared to just 5% of Swiss and 7% of Germans. One in four Canadians waited four months or more for elective surgery, compared to none in Germany and 5% in the Netherlands.
Canada was the second worst country for accessing health care after hours. Sixty-five percent of Canadians report that it is very or somewhat difficult to find care after regular business hours, compared to 33% of people in the Netherlands.
This poor performance has occurred even after the federal government commited $4.5 billion to reduce wait times in 2004, as well as major investments by the provinces. Stephen Duckett, an Australian health economist and former CEO of Alberta Health Services says that “the waiting list money was highly targeted at specific services, such as hip replacements” and that other countries like the United Kingdom have been able to reduce wait times by setting up aggressive targets for providers and penalties if the targets were not met. At the same time, funding for health care was markedly increased in the UK.
Electronic Medical Records
While significant investments have been made to increase the number of primary care providers, Canadian primary care doctors had the lowest use of electronic medical records in their practices – 37% in Canada, 46% in the United States, and above 90% in seven countries.
The poor uptake of electronic medical records in primary care has occurred despite considerable investments in eHealth provincially and nationally. Tom Noseworthy, a Professor of Community Health Sciences at University of Calgary argues that there was “an insufficient investment in [electronic medical records] Canada-wide that did not operate from a careful blue print on how to achieve gains in every province” leading to a situation where “there are little pockets of doctors using electronic medical records that do not connect as a whole”.
Duckett believes that “the introduction of electronic health records is much more complicated in primary care because of the disorganized nature of primary care, as opposed to the hospital sector.
Hospitals
The report also includes measures related to hospitals. Canada had the fewest acute care beds per population and the highest average length of stay (7.7 days). This information suggests that few Canadians are being admitted to hospitals unnecessarily, which is a good thing. However, the lack of hospital beds for acutely ill patients is a major cause of emergency department overcrowding, and our long wait times for some surgical procedures suggest that more hospital beds are needed to accommodate these procedures.
However, this may not require the construction of more hospital beds, because about 14% of hospital days in Canada are currently taken up by patients who no longer need acute care. Investments in community and long-term care might help the hospital sector. Noseworthy believes that “it is a good thing that Canada has been able to get by with so few acute care beds” and that in spite of the low numbers of beds, they are still “not being used optimally.” He suggests that “we do not have good substitutive services, leaving acute care beds as the only port in the storm for sick patients who could receive care in less acute, sub-acute or intensive home care environments.”
Costs of Health Care
All countries in the report had some form of publicly funded health care paid by government revenues from taxes. However, the amount spent on health care varied markedly. Canada was in the middle of the pack when it comes to the percentage of gross domestic product (GDP) spent on health care. The United States spent by far the most at 17.4%, and Japan spent the least at 8.5%. Canada was similar to countries like Denmark, France, Germany and Switzerland, and spent 11.4% of annual GDP on health care in 2009.
Canada’s proximity to the United States means that we often compare our health care system with our neighbour to the south. However, as mentioned above, the United States spent by far the most on health care of any country, and its measures of quality were frequently among the worst and rarely among the best (except for access to specialists and surgeries). We might gain valuable insghts by carefully looking at the health care systems of other countries.
Public Satisfaction with Health Care
While performing poorly in terms of access to care and the use of electronic health records, Canada was average in survival after a heart attack and was in the top two performing countries in survival after the diagnosis of breast cancer and the frequency of a lower-limb amputation in persons with diabetes. Given this mixed picture in performance, it is not surprising that Canadians were far from unanimous in their views about the need for change in the health care system – 38% felt the system worked well with only minor changes needed; 51% felt that fundamental changes were needed, and 10% felt that the health care system needed to be totally rebuilt.
These numbers are similar to most of the other countries. The greatest desire for change was expressed by citizens in Australia and the United States, with 20 and 27% respectively saying that their health care system needed to be totally rebuilt. The United Kingdom was on the other extreme, with 62% of citizens feeling that the system worked well, and only 3% indicating that the system needed to be totally rebuilt.
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Mental healthcare in Canada is particularly lacking. It is easy to get an appointment with a psychologist or counselor to talk to about mental health concerns; given that you are willing to pay out of pocket. However, if medication is required to remedy any issues and your GP isn’t comfortable providing treatment wait times to see a psychiatrist can be ridiculously long. I waited over 4 months; and I am one of the lucky ones. I have read of others experiences who waited upwards of 18 months; some run out of patience and choose to take their own lives. We have a broken system in this country
In B.C. the Frazer institute is attacking Hospital costs and performance as they have done to school systems. I looked up this site to see if their comments were justified and you have reassured me that they are not. The Institute would like to adopt the philosophy of no free lunch – every individual paying for what they receive. The rich getting full benefit of the resources of the country and the poor getting none. I am surprised that the media gives them air time, but maybe they own the media. There are some changes I would like to see made but I am appalled by the negative comments I hear Canadians saying to Americans about our system.
Canada’s Health Care system needs to be changed. Wait times are outrageous and quality of care is not optimal due to lack of contact between Primary care doctors and Specialist. The length of time to see Specialists are long and travel is needed as only the larger centers have them. Wait times for some surgeries are extensive. Pain management is very poorly organized so people are suffering while they wait in ques. Something has to be done. People who have jobs can not work when they have injuries that need surgery as they wait so long to receive them. During the wait to have surgery they can not make a living and that is not a consideration to anyone. Change is needed and modernization to electronic medical reporting is a must.
Canada and the U.S. have greatly different demographics and geographic issues. From sparsely populated rural areas with very few services overall, to overcrowded urban cities that face different pressures. It is almost impossible to do a rational comparison without looking at populations, ages, ethnicities, climate, and even the geography ie Canada and the U.S. are very large countries compared to most European countries and/or OECD. Canada also has a reserve system that requires funding a third population with appropriate healthcare resources. I can’t imagine France has to fund various tribes like the Celts with healthcare. If this was the case then it would make comparisons easier. We also have an Arctic and sparsely populated northern areas that also need some form of healthcare. These comparisons cannot take these issues into account when comparing healthcare outcomes.
I live in Vancouver, BC. I have been waiting for 9 months for hip replacement surgery. Because I am still working, I have been informed that I am a high priority and was also placed on a cancellation list. The surgeon says that he could do the surgery tomorrow, but the hospitals closely ration the operating room hours allotted to each surgeon. Having spent many hours waiting in various hospitals with my father-in-law over the past 10 years. It became only too evident that these institutions do not run efficiently. On many occasions I would watch groups of 4 or 5 people all dressed in scrubs, standing around talking for 30 or more minutes. I have friends who work in hospitals and say the levels of administrative bureaucracy is massive. Perhaps the problem is not how much more money we need to put into the health care system, but how we spend the money which is already allocated.
This isn’t very accurate. People that weighed in seem to be the more bitter people that have had a couple bad experiences or entitled people that have unrealistic expectations. If I go into a clinic or lab wait is nonexistent to an hour even at peak times. If I want an appointment with my doctor who is very busy, I can get in end of day or next day. Ultrasound/xray/etc same day or next day. Emerg at hospital has been immediate to a few hours depending on what I went in for. Specialists are within a few weeks at most. The system works. People who clog it up with the sniffles because it’s free, are the problem.
Thanks Kaitlyn for your positive comment at http://healthydebate.ca/2012/02/topic/innovation/how-does-canada-compare . I have been working overseas and want to return to BC for my retirement. As i need to be near good medical care, i need be careful as to where in BC i move to. Can you tell me what area and hospitals you are near [as that is probably the best place to start!]? You can email directly at tropic1000@yahoo.com or just post a comment.
Much appreciated in advance!
Canada needs a better drugs and denial plans for sure and fewer wait time would be a good thing thanks
Where is the report for me to read to see if I agree with the report writer’s point of view before I vote.
The Commonwealth fund’s board of directors are led by the president of Kaiser Permanente. This is an American group of doctors. I would recommend that fellow readers review European reports.
I have been in Canada for four years having lived in Scotland for the previous 55 years. This is a lovely country with lovely people but the healthcare system compares very poorly to the one I left. In Victoria, BC, I have waited between 4 and 7 months routinely to see a specialist. Appointments are then followed by anything between 2 and 8 months as you wait for tests (MRI wait was 8 months), then you have to wait to return to the specialist taking well over 6 months between referral and treatment is fast!). %featured%In one instance, I faced a 6 month wait for prolapse surgery on top of the 4 month wait to see the specialist, making 10 months in total. Time from GP referral to treatment is therefore routinely extensive. %featured%In Scotland the target is 18 weeks in total – I am not aware of similar targets in BC. In exasperation and discomfort, I have therefore had a hugely expensive operation through the rare private option in Vancouver (about to be challenged legally!) and returned to Scotland this year to see 2 private specialists at further additional cost. Not so great for a first world country – I remain dismayed. Dentists and vets are great – albeit immorally expensive – so my teeth and my dog are well catered for…. Access to low cost mortgages actually seems to be more important than access to good and timely healthcare. The one good thing I have encountered is the Walk In system. However if anything requires specialist referral or surgery, you’re back in appalling queues. Lovely country – your healthcare system needs overhauled.
This report is so spun in favour of the private sector that it’s credibility should not just be disbelieved, but discounted. This is NOT my experience of the outstanding system we have in Canada. I guess it is necessary to attack what is good to protect what is crap… and that is what the American system is for the average American.
It is easy to say that Canada’s health care system is better than the American system. The World Heath Organization ranked US health care around 38th so at 30th Canada is better than that.
So we are a bit better than one of the worst systems. When we compare Canada’s healthcare to European countries we fare much worse.
Allocation of Beds is important, but allocation of the people working in the system is more important. Here in BC have shortages in many health care professions, from lab techs to respiratory therapists to occupational therapists. I would like to see some comparisons with European countries regarding number of various professions per capita, the shortages of doctors and their fees (which I suspect would be lower than in Canada ). I think these drive costs and wait times more than anything.
I’m a social worker in health care and I think the strongest feature of your report is the emphasis on the lack of residential care beds and lack of subacute care. I also wonder if other countries de-institutionalized their mentally ill population, as I think that’s an enormous hidden cost. Many hospital admissions could be avoided if people with mental illness got proper care in the community.
Thanks for the good work.
Bruce MacDonald
Vancouver
macb423@gmail.com
the only really compatibilities are the city sizes and the possible demographics. Except Maybe Chicago has a split SES (bimodal) rather than an smoother mean. Also depending on the sorts of “metrics” used for Quality of Care and access determinants(e.g. wait times) from who ever is doing the regulation that is going to be different too. So these systems are not really comparable on “outcome” by individual or group.
All sorts of confounding occurs.
The actual individual care provided at the “point of care” may very well be similar.
If there was an internist “hospitalist” that practise is less available in Canada that changes the continuity of care dynamic and therefore the resource use pattern (for the “better”?) in the tertiary care center in the USA .
What sort of patient navigation occurs during all this decision making? Is there a patient advocate assisting the one whose body it is that is being assaulted? Is there someone available to assist the person through the process during and after for them to feel as though they are still in charge of their heart, head and the remainder of their body and soul? Or are they being ‘resourced out’?
Given the information from the situation there are more differences and disparities than there are similarities.
All we really know is that :
specialists are trained similarly so operate similarly if the OR procedures are the same.
the cities are the similar size
the SES may be comparable (as a mean, but what are the modes and distribution of “insurance and access issues)
What are the teaching ctr. and care access similarities and differences?
There are specialists who are trained in very similar fashions due to tertiary care /teaching center models not effectively changing since WWII, especially for specialist
the payment and Quality metrics vary across both countries hence by institution/payee/ payer
As someone who has observed and written about Canadian healthcare since the 1970s, I want to join Mary Szabo in her critique of this comparative commentary. The writers have organized their comments around their conception of what is important and thus waiting two months for a specialist is a problem. The report is about comparative statistics, not the experience of medical care in Canada as opposed to elsewhere. To do that would require deep knowledge of different systems, something the Commonwealth Foundation has not acquired. What is it like to deliver a child in various parts of Canada, how does that differ for a modest income person in Chicago or Toronto, two broadly similar cities, just as Vancouver and Seattle, or Minnesota and Manitoba are useful units of comparison. What happens if you have a heart attack in x or x setting? How about the treatment of cardio-vascular disease? How much paperwork does a patient with x hospitalization face? What about the thoracic surgeon who operated, or the internest whose patient it was. These are part of the comparative picture that is missing.
Thanks, Mr Marmor, for your comment. Had I been patient enough to read it, I might have cast a no vote on whether the report is fair to the Canadian system.
But I do think we’d be better off comparing Toronto to Paris, or Amsterdam, or Berlin or London rather than to cities In the US. We always compare ourselves to the big boy next door, but the US is such an outlier in so many areas of its domestic life, from gun deaths to poverty to infant mortality to wealth inequality, that I don’t think we get the information we need from these comparisons. Anyone can look good living next door to the Simpsons.
Just IMHO
I am a family medicine resident physician in Michigan planning to return to Ontario to practice.
There are a number of trends and observations I have made in the US so I will comment on a few.
1. Electronic Health Records and Healthcare Quality Benchmarks – These are the 2 biggest trends in primary care in the US. We are increasingly being told by private insurers in the US that for our patients with type 2 diabetes for example, how many of them have had an eye exam and foot exam in the past year, currently have blood pressures below 130 systolic, have LDL cholesterol levels below a certain level and have hemoglobin A1c levels below the benchmark. They actually pay the practice a certain number of dollars based on the overall % of benchmarks our practice has met as a whole and also tell us how much money has been “left on the table”. ie. additional money the practice could have earned had the benchmarks been met. It is a sort of “carrots and sticks” approach towards healthcare.
It can be extremely frustrating for doctors because it does not take into account patient noncompliance and lack of involvement in their healthcare and seems to put all the onus on the doctor. However it does force us as physicians to follow standards of care and educate our patients more often. The flip side is that patients who do not meet certain criteria like getting their cholesterol checked, continuing to smoke etc. pay higher co-pays, so for instead of a 10 dollar co-pay at each visit Mr Smith pays 25 dollars each time he visits the doctor. This might not be such a bad thing.
As for EHR there are very few doctors that sing its praises. There just is no uniform standard or system anywhere. Different practices use different systems and there is little interconnectivity. It often amounts to using a fancy word processor instead of paper charts and alot more typing and checkmarks for the doctor.
2. Lack of universal access to services in the US. I often make decisions based on the patient’s level of insurance coverage. For example, Mr Smith needs a screening colonoscopy due to his age and a family history of colon cancer. Mr Smith unfortunately has the “county health plan” and this does not cover screening. Only if he had active bleeding could we get him that colonoscopy. It can be very frustrating indeed. This is something that I brag about to my colleagues in the US that we fortunately do not have this problem in Canada.
3. Finally here in the US I can send my patient to the specialist and expect them to be seen within a reasonable amount of time (usually a few days or weeks). My main frustration comes from not always getting timely reports back from those specialists. I have heard that this has improved in Canada but I can see that not having a specialist’s opinion to back you up on occasion my prove to be frustrating from a professional standpoint.
It will be interesting to see how much of my experience in the US translates over to the Canadian system.
Very useful my Doctor in Saskatchewan told me he must prescribe for the benchmarks which are similar.
As for Cholesterol it gives me cramps and when I mention this he said well your really borderline but I must prescribed to get paid. All doctors Pratices are private business I think. The Doctors get paid by patient number so rural areas tend to have older Doctors who are heading towards retirement.
Whereas Pratices in the Cities have large business which are either private or partner owned they make more money but have much higher workload.
There also drop in clinics in the city the largest in a Wallmart with four at least full time Doctors.
Canadas precription drugs are outrageous prices because of NAFTA, the UK fixed price was much better .
If you get a good Doctor in the UK who puts everything on one Precription then my son paid $ 10 approx a month here in SK it is $160 a month was $140 when CND$ was stronger for Asthma.
Canada does have many classes, seniors, children etc who get reduced prices but no where near as good as UK where I was born and live for 50 + years.
80% of UK prescription cost are paid by NHS so prescription take up is far better than Canada.
As the Doctor told me if people have to pay hundreds of $ a month even though they are judged to be able to pay many will not, unless they actually feel the benifit.
I have lived in Sweden and the UK and I felt their systems were as good as Canada but they have problems as well.
UK has far superior treatment when it comes to mental health at least in Cambridge where I lived but it also varies greatly depending where you live. If you require emergency procedure or treatment no problem but if it is elective you really wait unless you go to the public side(private in Canada).
I worked for a large pharma company at the TA research head office and research physicians used to joke about how inefficient the USA system was but not the Canadian.
In Canada I have been volunteering at the board level of a successful hospice association in Ontario and have been frightening for increased funding. Though visiting hospices provide well trained volunteers to provide social and psychological support we receive no recognition from healthcare burocrates for the value we provide. Hospices in Ontario are forced to restrict services because of lack of funding. Beds in hospitals are plugged with people dying because of the lack of proper discharge notes and hand off to CCAC or long term care facilities.
Well I hope you don’t frighten them too much :)
Good post Jim. It’s heartbreaking to see people dying I crowded noisy hospitals because hospice beds are note available.
This is a good summary. I particularly liked the overview of Countries compared. It is fairer than most comparisons I have seen. I do want to understand why “wait times” were lumped together. I also want to understand overall why specialty surgical wait times across the country took 20 years to develop measurement criteria and eventually only produced weak results on “report cards” when other measures could, and are now more sensitive to actual effectiveness to real system change at the hospital departments and in the community setting.
There was also not much revelation of the definition of how we can measure the entire cost of health care in relation to overall national productivity ratios rather than just GDP (a growth only ratio).
The glaring gap in our lack of not coming to consensus in data equity even now is a pillar vs collaborative turf war issue and a micro vs. macro definition issue (1st normal form solutions) and is easily resolved if interdisciplinary functional groups can actually work together and use some open source functions and software development across the nation. We do not have the proprietary restrictions that the USA has and should be able to break the ego barriers for price and excellent care now and the future.
This is a very imbalanced report presenting Canada in a negative light, and fails to present areas where Canada ranks high. For example, Canada ranks in the top 9th of 31 OECD countries of overall health care provision. Since the report focuses on ranking of OECD countries, we need to see all the rankings of major areas, including positive aspects of Canadian Health Care, to provide a contextual report. Furthermore, the map of the world in the masthead deceives readers in believing that this is an OECD report. The question on the top “Do you think that the Commonwealth Report paints a fair picture of Canada’s health care system?” is also misleading and misrepresents OECD as this piece does not in any way represent the OECD reports due to lack of balance and author biases.
When it comes to electronic medical files I have told my Doctor in no uncertain terms if he puts my file in any computer that has Internet access I will sue him into oblivion. I care not one bit if the government want my med file online, I don’t and will do all in my power to keep them PRIVATE!
As for the rest of it, I am sick and tired of having to pay for others healthcare. Allow people the choice to opt out of the communist government control of the healthcare business. I just want to pay cash when I see my Doctor.
I’m not really sure what you mean by wanting your records to stay private. Whether medical records are on paper or are electronic, they are all protected by confidentiality. Health care professionals cannot share this information without due cause Eg. your permission, collaborating with other health workers to treat you or a transfer of your file if you change family doctors.
Confused… you have the option to op-out of your OHIP by simply walking into the government office and returning your health card and telling them to cancel it.
I don’t believe Ontario Dr’s are permitted to take cash..
If this person does not like what our health system gives our population then
he is free to move to another country.
Thank you for this very valuable piece! I often feel that we can get very internally focused and need to step back and get more perspective from other countries. One of the major differences between Canada and other OECD countries that isn’t mentioned here though is our public-private spending split. We do spend about the middle-of-the-pack in general, but our funding is also only 70% public and 30% private (spending on drugs, dental, rehab, vision etc). Most European nations have closer to an 80-20 split and with doing this, offer many more services, often including drugs, dental, sometimes homecare etc. The maximal efficiency of having a single payer system is important – our administration costs in OHIP are somewhere between 1-2%, whereas they are more than 10% in the private funding sectors of our healthcare system due to multiple insurance companies etc (similar issues as with the US healthcare system). Especially in a day and age where the antiquated definition of ‘medically necessary services’ falls far beyond simply doctor and hospital services – we can’t even imagine ‘medicine’ without ‘medicines’ for outpatient chronic disease management. We should be looking to see how we can save money as a country by taking more services under the Canada Health Act, saving us money overall with the simplicity of the single payer system. Many European countries spend the same amount (or less) than Canada but offer much more in their universal health care system than we do currently, and it doesn’t have to be this way!