My brother lived in New York for more than a decade before returning home last year. In numerous instances since his move, he has expressed his disappointment with the Canadian health system. I get on the defensive, of course. Here in Ontario, we have had lower per-capita deaths throughout the pandemic than comparable states in the U.S. That’s important. And we’ve done that with historically far lower per-capita total spending on health care.
But ultimately, I admit what he can see clearly: We could do so much better.
The truth is that every flu season, our hospitals burst at the seams. Before the pandemic, we all knew that the problem of hallway health care needed solutions. When you constantly run a system near 100 per cent capacity to ensure maximum efficiency, you cannot accommodate increases in demand. Ontario has near the lowest number of hospital beds per capita among the 38 member countries in the Organization for Economic Co-operation and Development. Predictably, the pandemic has exacerbated this problem – doubly so with so many health-care workers off sick.
To accommodate the wave of admissions, we have had to cancel surgeries. Most surgeries need bed space in the wards for recovery, staff to monitor patients and space in the ICU to handle the complications that sometimes arise. When all of those resources are taken up by the surge of COVID-related admissions, the result is longer and longer wait times for patients with cancer, heart disease or other problems. This is heart-breaking for patients, caregivers, and their health-care team. But when you have no slack, something must give.
So, right now we must do all we can to prevent COVID-related hospitalizations. That means helping people reduce the risk of getting infected. But we also need to quickly identify those with COVID who have risk factors for severe illness, monitor them closely, and get them treatments that reduce the chances they will need hospital care.
The Ontario Science Table guidance indicates that best evidence supports the use of a particular monoclonal antibody known as Sotrovimab to prevent hospitalizations. At time of this writing, we have been told there are plans to ensure this will eventually be available at hospital infusion sites across the province. However, our patients need access now and we have been requesting action on these “plans” since August. Five months later, there is no centralized approach to referral or standardized referral form or criteria. It remains unclear to most in primary care how to access this treatment for patients (unless they live near Hamilton, where there is an active site accepting referrals). Currently, we have so little of this treatment anyway that it is reserved for those at greatest risk – namely, unvaccinated people. Something seems grossly unfair about reserving this for unvaccinated people living near Hamilton.
“The truth is that every flu season, our hospitals burst at the seams.”
The Ontario Science Table guidance describes a role for the antiviral Remdesivir for those who cannot access Sotrovimab. This treatment is also delivered intravenously, so would likely be implemented at similar sites. But again, there is little available and no details about how appropriate patients might access it when a shipment does come. Will one hospital again provide it for local patients?
What’s the point of having a single payer system if not to enable a standardized approach for equitable access to such treatments?
So, family doctors like me are left with two other options recommended by the Science Table for our patients who have COVID and risk factors for hospitalization but who cannot access the preferred treatments. One is a puffer known as Budesonide for those with respiratory symptoms. The other is an old antidepressant with special immune-modulating effects known as Fluvoxamine. The first is running low in pharmacies. The second is difficult to safely prescribe due to many drug-drug interactions.
At some point soon, another antiviral known as Paxlovid will become available. Again, it is expected that we will have a limited supply. I’ll do what I can to make sure that my patients who need it can actually get it. But asking doctors to constantly go above and beyond because there is no system in place to support them or their patients is not acceptable.
As new guidance comes out to enable appropriate use of these and other treatments, there is no standard mechanism to ensure it gets into the electronic medical record systems of those working on the front lines. There is not even a standard output from each COVID test result describing whether the patient meets the criteria for treatment. Patient outcomes seem to depend not only on where the patients live but whether their doctors are well-connected.
What would a first-rate health system look like?
The answer is not a two-tier system. Adding a private option might help wealthy people to the front of the line, but the evidence is clear that it would increase our overall health spending per GDP and it would severely exacerbate our limited health human resources. It’s the simple solution to a complex problem, often suggested by those who don’t want to bother with things like evidence.
A better answer is to fully take advantage of our single-payer infrastructure by having the political will to more actively manage the system. An effective, efficient and equitable health system can be a competitive advantage and a source of pride, but it requires leadership, investment and active management.
Our good outcomes so far are a credit to our highly trained and hard-working health workforce. It’s past time to reward them with the system they deserve.