Much like hockey, hospital overcrowding is something that many Canadians continue to discuss with passion and concern, and rightfully so. However, the reality is that more hospital beds are not going to be the panacea that many want, hope and need them to be.
It is true, according to the Organization for Economic Cooperation and Development (OECD), that Canada is an outlier in available acute-bed base. Compared to peer OECD countries, many of which also have universal health care, Canada has 2.5 acute care beds per 1,000 people while most have figures north of 4.5 acute beds per 1,000 people.
But beds per population is not the only driver of capacity or measure of success and stability within a system of care. Given the complexity of hospital crowding, simply adding more hospital beds is not an appropriate course of action. Instead, there are several ways to drive improvements in the national health-care structures.
Public health and social determinants of health investments
The Canadian Public Health Association reminds us that if we continue on our current path, upward of 80 per cent of provincial program spending will be directed to health care by 2030. Much will be spent on largely preventable diseases, reducing the available funds needed for the critically important social determinants of health. The result? Continued greater health inequities across populations, continued preventable diseases that drive higher hospitalization rates and further unnecessary expenditures within the health-care system.
Investments in the “upstream” population health-based services, programs and interventions that focus on disease prevention, health promotion and health protection will result in a decreased demand for, and the utilization of “downstream” acute and hospital-based services.
Long-term care and alternate levels of care adjustments
It is no secret that a significant number of patients within hospital settings do not need to be there, nor do they want to be there. According to a Canadian Institute for Health Information (CIHI) report from 2019-20, across Canada, about 16.7 per cent of patient days were from patients coded as alternate level of care (ALC). More than 3 million days were used by patients waiting in beds for another more appropriate care setting!
While it is true that it is expensive in the short-term to create more of these sub-acute beds, the long-term savings and positive implications for the system of care would likely be significant.
Home-care enhancements
From a financial perspective, moving patient care out of hospitals and into homes, when safe to do so, can drive significant cost savings for health-care systems. Moreover, it removes patients from potentially dangerous hospital stays, thus freeing up beds for those inpatients that truly need those services.
Across Canada, studies continue to demonstrate that the majority of patients that could receive care in their home would prefer to do so rather than going to hospital. Frankly, receiving care in patient homes is something that is here to stay and home care and out-of-hospital structures must be bolstered to handle the current and future demand.
Medically necessary pharmaceutical coverage
As of 2016, 91 per cent of Canadians supported a publicly funded universal pharmacare plan. Remarkably, 90 per cent of the pharmaceuticals that patients use in Canada are actually used and needed in outpatient settings, which means significant out-of-pocket expenditures for patients and families. Unfortunately, nearly one in four Canadians fail to take their medication due to costs. Staggeringly, it is estimated that one in six hospitalizations in Canada could be avoided if routine prescription drugs were prescribed and used more appropriately.
The benefits of a comprehensive pharmaceutical plan for Canadians must not be ignored.
Supports for the socially vulnerable/mental health/addictions
According to CIHI, there are many provincial and territorial initiatives attempting to improve treatments and supports so that socially vulnerable, mental health and addictions patients can remain out of inpatient settings as much as possible. The programs include increasing access to community-based mental health and addictions care; increasing the number of specialized treatment beds for those with addictions; increasing access to mental health professionals for youth in schools and communities; and providing more support for families and caregivers to keep their loved ones at home and safe.
Coming out of the pandemic, the needs of these populations are immense and the services available to them are not nearly robust enough. The discussions on how we reform services to better support these patients and families must be accelerated.
For nearly four decades, our national health-care system, based on the Canada Health Act (CHA), has been focused on medically necessary hospital and physician services as the centre of health-care response. Unfortunately, this outdated Act has contributed to a general reliance on the system that is unrealistic and unsustainable on many levels. With this in mind, perhaps reform starts with addressing what the CHA is all about, and how it must be reconfigured to reflect the current and future needs of Canadians.
If the referenced items above were supported more robustly and were included in the comprehensive basket of insured services for Canadians in some fashion, we would see an overall decreased demand on hospital and physician services, improved patient outcomes and wellbeing, decreased hospital overcrowding and decreased costs across health-care structures.
Throwing more money into a “downstream” hospital-based system of care and more inpatient beds is likely one of the most expensive and inefficient things we can do. It is time to think beyond more beds being the solution to overcrowding, and actually do some things “upstream” that will truly revolutionize the national health-care system, a system that sadly, many have lost pride and trust in.
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Excellent article. Thank you for pointing out that building a more resilient health care system will require more than just the addition of more beds, especially that it will require serious investment in Long-Term Care upgrades and in community based health care resources. I would add that there might be room for further expansion of the role of pharmacists, and I wonder whether it might be prudent to incorporate a substantial amount of health care education into provincial secondary school curricula. Health literacy, you might say. Again, thanks for sharing your thoughts.
Excellent points Damian. We knew back in the mid 2000s that we were going to need more LTC at this time, but very little was done. It will take 10 years to plan and build more spaces and by then, the need will have dropped significantly.
Pharmaceutical coverage is a great step forward, as is improved remuneration for Family Physicians to enable patient attachment. So many opportunities that need to be actioned now, especially with the critical health human resource crisis.
Awesome! Awesome! Awesome! Awesome!
And also common sense when we pause to think.
The hardest part seems to be implementing these common sense ideas when a whole lot of companies offering “downstream” treatments are going to lose a whole lot of income.
These are very insightful observations and recommendations so where are these discussions happening. Is there the political will to do the hard work upfront and commit to preventive medicine?
I agree with your argument. So far the efforts towards prevention, home care etc. have been half efforts. There needs to be more collaboration between all sectors to insure that quality is not compromised.
Approximately 175,000 people in Ontario live with dementia, a significant contributor to mortality, morbidity, and health-system expenditure. This is expected to double over next 20 years. Persons living with dementia would remain at home if given early access to a coordinated mix of supports through a cordinated dementia care network based in primary care for Ontario.
Best practice dementia primary care occurs in MINT clinics which manage patients with this condition from onset to death with multi-disciplinary teams led by family physicians. In collaboration with the Alzheimer Society, more than 100 MINT clinics operate in rural, remote, under-served and urban settings, caring for more than 26,000 patients and their caregivers. Health Quality Ontario’s 2019 evaluation based on province-wide real-world data (IC/ES) produced high-quality evidence that MINT clinic patients, compared to dementia patients receiving care elsewhere, have:
• fewer referrals to specialist referrals to neurologists, psychiatrists, and geriatricians,
• more admissions to home care,
• fewer and delayed admissions to long-term care,
• longer periods until the first emergency department visit,
• delayed hospitalizations and
• lower cost per day to the health system following the identification of dementia.
The Health Quality Ontario report however revealed MINT clinics reach only 15 per cent (26,000 of 175,000) of persons living with dementia in Ontario. They are not accessible in all regions of Ontario, including in areas with higher dementia prevalence such as Toronto, Ottawa, Peterborough (location of GAIN), Thunder Bay and the upper Great Lakes. The report also revealed other types of dementia clinics operate across Ontario but these, unlike MINT clinics, benefit from government funding through organizations, for example, hospitals, that do not have an explicit mandate to support the population of persons living with dementia and their caregivers.
In summary, Ontario does not have a standardized dementia primary care model with inequities in access and target populations. There is an absence of policies that mandate funding of dementia primary care in a systematic manner across the Province.
I agaree. The Canadian health-care system and the Canada Health Act places hospitals as the topmost priority. While this choice was justified in the last century to meet the needs of a younger population, it is less appropriate today in the context of an aging population with complex and long-term conditions and disabilities. When the Canada Health Act was the core of the health-care system 60 years ago, older adults comprised eight per cent of the population. In 2021, older adults comprise 18 per cent and in 2041 this will increase to 25 per cent.
Healthy Debate article on September 16, 2021: Let’s invest in helping more seniors stay at home – and stay active – Healthy Debate