The sky is not falling

If you came here from another country and opened a newspaper, you might well come to the conclusion that Ontario’s health care system is falling apart.

It seems that every day there is a headline about a scandal in one part of the health care system or another. An Auditor General’s report is released criticizing the government for ineffective oversight, or a major newspaper exposes outright venality or just plain old incompetence.

But does the health care system really deserve to always be viewed in such a negative light? I recently prepared a presentation for first year medical students at the University of Toronto on the Ontario health care system. I decided they should know the answers to two questions as they prepare to see patients for the first time ever. First, how is the health care system structured? Second, how does the health care system perform?

My answer to the second question is the reason I’m writing this post. Yes, there is no doubt the health care system fails Canadians in many respects. Access to primary care in the evening and on weekends is poor, not enough doctors in Canada use electronic health records and we fail to provide coordinated care to patients with complex conditions. We need to do better in these and other areas.

But there is also no need to run around like Chicken Little shouting that the sky is falling. Many indicators suggest our health care system performs reasonably well. We spend almost exactly the same on health care as Austria, Denmark and France, which is probably right where we want to be. Considering that we are situated right next to the United States, and have to provide comparable compensation to physicians and nurses, the fact that our spending is much closer to European levels could be viewed as an achievement in its own right. On many of the most important measures – life expectancy, deaths that could be avoided by health care, survival after a diagnosis of breast cancer or a heart attack, we also do quite well.

So why the constant chatter that the health care system is on the verge of collapse? There are several reasons. First, the media has an interest in focusing on crises and bad news. A story that we are doing about the same as European comparator countries might not even make the paper, let alone the front page. Second, those who stand to gain from privatization have an obvious interest in making the claim that the public system is failing miserably. Third, people who work in the system, including not only health care professionals but also managers, academics and consultants, can more clearly make the case for more funding if they claim that the health care system is broken. Fourth, if the health care system is the most important public policy issue to Canadians, then opposition politicians have the most to gain by spending their time and energy focusing on what is not working in health care.

I am neither in the “sky is falling” camp nor in the “status quo is just fine” camp. I feel fortunate to be able to tell my patients who are in the throes of a major medical emergency that they will get the care they need. At the same time, I feel disappointed when I have to tell patients with chronic medical problems that the health care system may not provide them with the high quality care I think they should be getting. I think my patients believe me on both counts. Similarly, I think the general public is not easily fooled. They know that there are problems in health care but that we are not in an acute state of crisis. If we were, people would be marching in the streets.

We need to improve Medicare, but we could do without the Chicken Little rhetoric.

The comments section is closed.

  • Gerry Goldlist says:

    Our health care system may be performing reasonably for some Ontarians, especially the ones that are healthy. Once a patient gets into the hospital it appears that could care is readily available but they should not have to wait for hours or days in the emergency department waiting to get a bed.

    Having good inpatient care is only a small part of the healthcare delivery system. Most healthcare is not delivered on an inpatient basis. Patients waiting in pain from arthritis to see a rheumatologist is not good healthcare. Patients waiting for skin biopsies is not good healthcare. People suffering in pain while waiting for knee and hip replacements is not good quality healthcare. People begging secretaries for appointments is not good healthcare. I have seen or heard of all of these from my patients.

    Canadians are very accepting group. We rarely march in the streets. This is not a measure of the quality of healthcare especially when we have been brainwashed to believe that we have the best healthcare system in the world

    In the article there is mention of “those who stand to gain from privatization” having an interest in claims about the public health system. Those who stand to gain from current healthcare system or continue to gain from the system also have biases. Attacking the motives of those who deliver information as part of the debate on improving health care does not address the facts of the argument itself. Ad hominem is the last refuge of a failed argument.

    The fact that we spend almost exactly the same on health care as Austria, Denmark and France does not mean that we are doing well in delivering quality healthcare. According to the most recent Euro-Canada Health Consumer Index (ECHCI) published by Winnipeg’s Frontier Centre for Public Policy and based on 2010 figures, Canada is fourth among developed nations in per capita spending on health, yet just 25th out of 34 countries in quality and accessibility of care. (The ECHCI does not include the United States because it has no universal health care system.) The fact is, for more than a decade most evaluations , including the World Health Organization, have shown that the results produced by Canada’s health care system have consistently been in the bottom third among the world’s 30-plus industrialized democracies. We have among the longest waits for specialized treatment in the world. We have 25% fewer doctors per capita than most Western nations and fewer nurses and other health workers, yet far more health bureaucrats, We have as many as 10 times more bureaucrats than Germany.

    Being able to deliver good quality health care for medical emergencies is not the only factor we should be considering. For the 1 million Ontarians who do not have a family doctor and need an appointment, the sky is indeed falling. The failures mentioned in the article have just gotten and will continue to get worse in Ontario following the Health Minister’s imposition of regulations on May 7, 2012. These regulation changes have triggered the end of healthcare as we know it.. Access to family doctors in Ontario has been getting worse since then. Family doctors have been retiring in droves. Still other family doctors are watching the situation closely and are on the verge of retiring. This was confirmed in discussions last week at my class reunion. Some family doctors are even retiring because they are being forced to convert to electronic health records. Specialists are retiring as well. Many are watching and waiting to make decisions about retiring, slowing down or leaving the country. The reason that there is constant chatter that the health care system is on the verge of collapse is because it is on the verge of collapse, in fact, in some areas it has already collapsed with loss of family doctors in smaller towns and cities and sudden increase in wait times for surgery. In some Ontario cities cataract surgery wait times have jumped by 2-6 months in last 2 weeks. Several hospitals are shutting down their cataract OR’s permanently in order to balance their budgets.

    Our health care system no longer covers preventative visits to an eye doctor for patients between the ages of 20 and 65. There are patients on wait lists for cataract surgery. While on the wait list some of them are also waiting to reapply for drivers licenses. Some of them cannot work if they drive for a living or need a car to get to work while waiting for surgery. Some people have difficulty getting to doctors and shopping. Some cannot get out of the house for social activities. These may not be life-threatening but they certainly are life-altering. Long waiting lists for cataract surgery is not good healthcare.

    Another example are patients waiting for heart bypass surgery. Most will not die but are unable to work, comfortably walk up stairs, walk a block on the street or engage in sexual activity. These may not kill them but certainly affect quality of life. Our health care system is failing them.

    Dr. Goldlist is a community ophthalmologist practicing comprehensive medical ophthalmology in North York

  • Nicholas Leyland says:

    The answer to the question of whether the sky is falling depends upon which part of the sky you happening to be standing under. Canada does OK in emergency care, poor in preventive primary care, poor in timeliness, mediocre in access to many types of care, not very well in efficiency, effectiveness (evidenced based care. I could go on. We do not rank well with most other western societies in such metrics ( with the exception of the USA who because of the huge disparities in care and coverage ranks behind us and many other countries). This fact is often a surprise to Canadians who think that because we are “better” than the USA we are the best in the world. Not so I am afraid.
    Does this mean the sky is falling? An example of one type of care with which I am familiar may be relevant. As a GYN surgeon I do laparoscopic surgery for severe endometriosis, a disease that causes pain and infertility; the inpact on a woman’s quality of life and the cost to society is equivalent to a number of orthopedic problems and inflamatory bowel diseases. There are very few providers available to manage the most problematic cases in Ontario. The management includes very complex surgery and medical management. With the reductions in hospital surgical resources most women with very debilitating problems have to wait what the patients consider (and I consider) unacceptably long times for the care that an Oxford University study demonstrated significant improvement in quality of life. Not infrequently women cannot afford the expensive medications to treat the disease and are literaly forced to choose surgery over effective drugs- Pharmacare anyone?
    Therefore, if you are a woman with this disease they would say, “the sky is falling”. There are so many other areas to address but I think the point can be made that it really depends on whether for each citizen’s particular problem there is a timely, appropriate, evidenced based and available health care solution.
    Unfortunately these types of gaps have widened and are continuing to widen during my Canadian health care career…

  • Rick Janson says:

    Agreed! Its a continual challenge to push for better while at the same time doing the seemingly contradictory act of defending public Medicare. Fortunately poll after poll shows Canadians still suppor their public Medicare system and perhaps understand the situation better than we think. After all, we are all users of the health system. Maybe the Chicken Littles are not being quite as effective as we think.


Irfan Dhalla


Irfan is a Staff Physician in the of Department of Medicine at St. Michael’s Hospital and Vice President, Physician Quality and Director, Care Experience Institute at Unity Health Toronto. Irfan also continues to practice general internal medicine at St. Michael’s Hospital.

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