I am a family doctor working in Ontario’s health-care system. I love my profession and my patients, but it is exhausting. Our health-care system has many strengths: highly trained professionals, a deep ethic of public service, daily acts of compassion under tremendous stress. But I also see unbelievable strain – evidence of a system operating well beyond the pressures for which it was designed.
The media and many have described the situation as a crisis. Emergency department closures. Expanding surgical backlogs. Long waits for routine care. Doctors and providers leaving the profession they once expected to be their lifelong careers. These failures are real. But repeated and intensifying emergencies are no longer true emergencies; they are seismic signals of Mount Vesuvius.
Ontario’s health-care challenges are not the result of a single shock. They are the predictable outcome of design choices made for a different era.
For decades, health-care planning in Ontario assumed relative stability: predictable population growth, manageable demand, gradual funding, a workforce that could be expanded incrementally and political stability. That framework reflected the realities of its time. It no longer reflects it now. The past is a reference point; it is not a strategic plan.
We now operate in an environment defined by rapid demographic change, rising chronic disease, restricted funding, workforce mobility and constant disruptions. Yet our system continues to behave as though equilibrium is inevitably around the next corner.
It is not.
As our Prime Minister, Mark Carney, told an international gathering: “Nostalgia is not a strategy.”
MISTAKE 1: Efficiency was maximized while resilience was deferred
Ontario’s health-care system has been engineered for efficiency. Hospitals operate near full capacity. Staffing models minimize redundancy. Surge capacity is treated as an avoidable cost rather than a core requirement. Funding is assumed to be sub inflation.
Under stable conditions, this approach appeared prudent. Instead, it has made the system brittle. Forced efficiency without contingency plans becomes incapacity.
Demand now exceeds capacity structurally, not episodically. That is why every hospital in Ontario is struggling with a “structural deficit.” This is not just in funding. It is in its people, infrastructure, supplies, management and risk planning. Emergency departments back up because patients who should be supported in the community have nowhere else to go. Hospital hallways are overstuffed not due to clinical failure, but because the system lacks safeguards.
A system that collapses under pressure was never resilient. It was merely built for another set of assumptions.
A resilient health-care system does not aim to function perfectly in ideal circumstances. It is designed to perform under strain. That requires shock absorbers: flexible staffing, interoperable data, strong family and community care and sustained and growing investments in prevention. Buffers are not wasteful. They are the price of durability.
MISTAKE 2: The workforce was disregarded as a cost
No reform agenda is credible without confronting the workforce reality. Ontario does not simply face shortages. It faces a systemic failure to support and sustain the very people on whom the system depends.
We train doctors, clinicians, health-care providers at great public expense, deploy them into chronically overstretched environments, pay them below market rates and then deny their burnout and attrition. We bring in internationally trained professionals while forcing them through years-long accreditation bottlenecks. Provinces compete against one another for talent, creating a “hunger games” in the system. We fail those who we used to celebrate.
Health-care workers are not a cost to be managed; they are critical investments to be maintained. No system outperforms when it exhausts its own human health resources.
Stability will not come from periodic recruitment announcements. Recruitment without retention is churn, not a strategy. Long-term workforce planning – safer workloads, predictable scheduling, credible mental health supports, rising salaries and faster integration of internationally trained professionals – is not optional. It is foundational.
MISTAKE 3: Hospitals absorbing systemic failures in society
Hospitals have become the default solution for problems they were never designed to solve. Gaps in housing, home care, mental health and drug addiction services, access to affordable food, disregard for vulnerable populations and long-term care incapacity lead to overburdened emergency departments.
When hospitals overflow, accountability is often narrowly assigned. But what looks like crisis is often design revealing its limits. Hospitals are absorbing failures across the system.
A functioning health-care ecosystem depends on strong family medicine and community-based care. When that foundation erodes, hospitals become pressure valves. Eventually, these valves break down and explode. Acute care is not a substitute for a well-functioning comprehensive health-care system.
Upstream investment is rarely politically immediate, but it is unavoidable. You cannot treat your way out of structural neglect.
MISTAKE 4: Fragmentation weakens resilience
Ontario’s health-care system is fragmented by design. Services are siloed. Data does not flow easily. Regions operate in parallel rather than in concert. Patients experience care as a series of disconnected encounters rather than a co-ordinated journey.
This fragmentation is often defended as local flexibility. In practice, it undermines resilience.
Middle powers do not succeed by standing alone; they succeed by aligning. Health-care systems are no different. In Ottawa, we have multiple hospitals with different electronic health records and many more different electronic medical records (EMRs) in community practices, specialists’ offices, dentists, optometrists, radiology clinics, pharmacists and allied health-care providers. Coordination is not centralization for its own sake.
It is coherence: shared data standards, aligned incentives and integrated planning that allow systems to absorb inevitable shocks. We choose to fragment care because we cannot invest in a coordinated health record.
SOLUTION 1: Honesty is the starting point
The most difficult reform begins with honesty.
We cannot credibly promise immediate access to all services for all people while operating with finite staff and resources. We cannot ask clinicians to absorb unlimited demand without consequences. And we cannot rebuild public trust without transparency about trade-offs.
Trust is built on clarity, not reassurance. Transparency does not erode confidence; evasion does.
A mature health-care system treats the public as educated and educatable partners, not passive naïve recipients. That means clear reporting on access, outcomes and constraints – and genuine engagement in deciding how resources are allocated.
SOLUTION 2: Designing for the world we are in
Ontario does not need another pilot project or temporary funding patch. Temporary fixes compound permanent problems. In fact, my 35 years of experience reinforces the errors of temporary fixes. We are worse at managing health care now than when I started.
The future will not be more predictable. Pandemics, climate-related health events, demographic pressure and workforce mobility are not exceptional risks. They are the operating environment of the present day.
Systems optimized solely for efficiency – and sustained by nostalgia – will continue to fail. Resilience is not only about building more hospitals, more long-term care facilities and operating rooms. That is the past: when all patients waited for emergency or end stage care. The future is about investing differently – more upstream; more team-based funded care in community in which every Ontarian gets a family doctor and a Family Health Team; a digitally connected system; preventative care focused with housing, fitness, and food; an AI enabled system that can reduce administrative burden and incorporate health tracking; and home-care service that can deal with acute care issues in community or in home rather than hospitals.
Ontario’s health-care system retains extraordinary potential. Realizing it will require abandoning outdated assumptions and committing to structural reform. The question is no longer whether change is necessary.
It is whether we are prepared to design a system for reality instead of continuing with wistful nostalgia.
