Opinion

Do we have the political will to ensure effective, equitable health care?

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.

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8 Comments
  • Audrey Armour says:

    I’m not in the medical field. I’m a retired university professor with specialization in environmental and urban planning. I’d like to offer the following to this very important discussion. If we are to change political will then we need an informed public. This means making information easily accessible and countering misinformation quickly and head on. When COVID-19 was being talked about online as no more than seasonal flu and herd immunity proposed as the reasonable pandemic management strategy, I didn’t hear anyone briefing the public on the pandemic situation address this point of view. It is a point of view that maintained traction, as evidenced by a recent poll revealing that nearly a third of Canadians believe the seriousness of the pandemic is overblown. I tried to find reliable data that would let me compare hospitalizations, ICU admissions and deaths for influenza and for COVID-19. I have a PhD and I found it challenging. The data source I ended up using was health-infobase.canada.ca and it had serious limitations. For example, influenza data was not provided by BC, ON and QC. And I had to go back and forth on web links and dig into various annual reports to find data to cobble together and share with family, friends and colleagues. Similarly, while “flatten the curve” was an effective rallying cry, it would have been much more effective if the public had been provided data showing in real time the actual number of ICU beds available in each province and the number occupied or being drawn down by C-19 patients. The public needs to be much better informed about hospital capacity in Canada and specific ways in which that capacity gets stretched and the point at which it will break down. Finally, bringing urban planners into the discussion of options for the better provision of health care in our communities is absolutely essential. Bravo to the person who put this point forward.

  • Philip Russel says:

    Our (pre COVID) insistence that our system was the best is probably your most important point. How can we improve the “best”? Do not start the discussion with statements like, “The answer is not a two-tier system.” Like it or not, that is a political statement. I refer you to Jeffrey Simpson’s “Chronic Condition” to get a start on possibilities and what can or should be done. Look beyond our borders, and forget comparisons to the US system. There is a great deal we can do. For my part, I am trying to increase the availability of hospice-palliative care in Toronto. There are many things we can do to improve our over stretched, over bureaucratized system, and we had better start now!

  • Pamela Fuselli says:

    Great article that proposes some perspective to the “before times” and what the acute care sector experiences that was invisible. When we speak about a system level, it’s important to include the upstream, prevention part and not just on how the parts of the healthcare system respond after an event, disease, injury, has occurred. There is a power in prevention that is untapped and has the potential to significantly impact downstream services.

  • James Murtagh says:

    I started my career in health administration 35-years ago. What consumed my days (and evenings)? Too few beds (in those days our response was to divert ambulances provided we knew other hospitals had beds), too many inappropriate admissions (social admissions and ALC), waitlists/wait-times, unattached patients and a never-ending stream of compensation demands from physicans. We ‘actively’ managed all those issues, in some cases more aggressively than is done today. Consider waitlists/wait-times. We routinely reallocated OR time across surgical services on a quarterly basis in order to keep wait-times roughly equal (later I moved to a province where surgeons all but had a land title to ‘their’ OR). Our problems are long-standing and not for lack of active management. I too oppose a private option (based on evidence) but we are approaching a tipping point where the government will need to capitulate and permit a private option; you can not promise for decades to fix something (e.g., primary care), repeatedly fail and still insist people cannot pursue other options even if the result is inequitable. My suggestion…1) strip everything out of hospitals that doesn’t need to be in hospitals (e.g., ALC to the community); 2) create a new vision/model for primary care that is something more than an adjustment of what previously existed…something that isn’t a slave to existing payment schemes, professional roles, clinic structures etc…something that patients (most important) and physicians clamour to be part of; 3) de-insure services for which there is no evidence while insuring essential services like dentistry; 4) develop a professional management cadre (perhaps similar to the NHS) and ensure they operate at arm’s length from politicians; 5) rationalize the plethora of regulatory colleges and nationalize those that remain (professionals would hold a Canadian license as opposed to provincial licenses); 6) transfer control of training programs including number of enrollees etc to the health sector (as opposed to education); and, 7) prohibit medical associations from representing both family physicians and specialists.

    • Elizabeth Rankin, BScN says:

      Excellent summary! You and others like you should be the decision-makers about our health care system. Most people know the OHIP model, that is, we have access to care when we need it and it is our tax dollars supposedly that contributes to this expenditure.
      We most definitely need an over haul in the way decisions are made.
      I’m sure there are many you know who could change the model that exists. I hope you continue to work to change the system so we spend the allocated health care dollars wisely yet provide the services we need.

  • Mark Taylor says:

    The issue of Canada having fewer inpatient beds than other countries is frequently raised. Having worked in acute care hospitals as a surgeon and then as an administrator, my perception is that a much bigger problem is that there are many patients in the existing beds who do not need to be there. They are stuck in those beds because there is nowhere for them to go. In my opinion there first needs to be a dramatic increase in investment in developing the infrastructure to allow these individuals to live in the community, preferably in their own homes wherever possible. If we merely increase the number of inpatient beds in the current system, in a year or two those beds will be filled with people who don’t need to be there and we will be no further ahead.

    • Julia Appleton says:

      The solution is always “over there” I work in home care and will tell you many homes are not built for disability, palliative care or aging. Bathrooms and bedrooms are upstairs. Hallways and doorways do not accommodate walkers. Split level homes of 1960’s and sunken living rooms are not walker friendly either. Bathrooms are not organized for versa frames around the toilet, transfer boards, walkers or even the space for a PSW to occupy space to bathe people.
      In the city there is a large number of people in very old homes which have limited electrical circuits to run high flow oxygen not to mention that high flow oxygen can cause $700 a month in power costs.
      I have not even touched the truth around people who are “collectors”. You might call them hoarders. There is sometimes no potable water, functioning refrigeration or food preparation surfaces. These homes can be in lovely neighbourhoods. As people become infirm and their family is not available (or died themselves) their property can fall into disrepair causing the falls and fractures that created repeated ER visits.
      Many people do well in their own home but…walk a mile in my shoes. Home is not the answer anymore for so many. The wonderful success in cardiology, stroke prevention and oncology have produced a lot of older frailer people but this success in medical care has not been met equally with urban planning. The solution is perhaps many small elder group homes in neighborhoods in the same model the intellectual disability community has done with great skill.

      • Elizabeth Rankin says:

        You raise so many important points and issues related to disabled and elderly people.
        Urban planning is something I hadn’t considered but is definitely part of the solution.
        Thanks for your good ideas.

Author

Noah Ivers

Contributor

Noah Ivers is a family physician at Women’s College Hospital and the University of Toronto and holds a Canada Research Chair in Implementation of Evidence-Based Practice.

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