Having better health care than the U.S. shouldn’t be good enough for Canadians

Posted on July 7, 2019 in Health Debates

Source: — Authors:

NationalPost.com – Opinion
Matt Gurney

We have well below the OECD average of number of physicians per 1,000 residents and barely half the hospital beds per 1,000 residents

One of the reasons it’s so hard to have a decent conversation about Canadian health care is that we all have anecdotes. And those anecdotes form our understanding of the system.

Take, for instance, this scenario. A young child presents a combination of symptoms that could be an imminently life-threatening emergency. That child is taken to a pediatric hospital and is examined by two doctors, two nurses and an ultrasound technician within 10 minutes of arrival, and is quickly deemed to be in no danger. The sick child is taken home with his relieved parents an hour after his arrival.

Here’s another scenario: a young child falls and is injured. A family doctor sends him to a hospital for examination. After an hour of waiting for triage, his condition is assessed as “urgent” but the child waits for five hours, receiving no meaningful care and virtually no information from staff. The exhausted child is taken to a different hospital, where he is immediately triaged and confirmed to have suffered a broken bone.

The child waits for five hours, receiving no meaningful care and virtually no information from staff

Imagine how radically different your understanding of the health-care system would be if you experienced the first scenario, or the second. You’d think you had an absolutely terrific system, or you’d think it was a mess. Both of those perspectives are valid, because these scenarios both happened in the past few months. The child was my four-year-old son.

I thought it was important to set up that context, to head off the most predictable complaint that arises any time someone dares point out a failure in the Canadian health-care system. The (uncontested) fact that our system is capable of delivering fantastic care is offered up as either a counter-argument to, or an excuse for, the (equally true) fact that the system is stretched beyond its limits, prone to breaking down under pressure.

The first scenario laid out above was in late April. My son had gone to bed mildly feverish. He awoke with a much hotter fever, breaking out into spots, and complaining bitterly of a stiff neck. Those three symptoms in combination sent me straight to DEFCON 2 — when I was in elementary school, an associate of my younger sister took ill with similar unremarkable symptoms and died hours later of bacterial meningitis. A doctor drilled into my 11-year-old brain that a fever or spots or a stiff neck is a hassle, but fever, spots and a stiff neck all at once is an emergency. My son simply had an unpleasant virus. But the triage nurse at Toronto’s Hospital for Sick Children understood instantly what the possible danger was and acted accordingly. It was the best of our system.

I wouldn’t say our experience this week, in contrast, was the worst of our system — but it sure wasn’t great.

On Tuesday, my son tripped on an awkward stair. It seemed like nothing but he was obviously in pain and was very protective of his left arm. He continued to complain of pain over the next hour or two. That’s not like him. We undressed him, which caused him acute pain, and he had a big, obvious lump over his left clavicle (collarbone). My sister-in-law is a family doctor. I sent her photos of the bump and she was unequivocal — hospital emergency room.

We were at the cottage at the time; the nearest hospital is Ross Memorial in Lindsay, Ont. I was reluctant. The hospital’s reputation isn’t great (the messages I’ve received this week from many friends, including some health-care professionals, confirm that.) But it was closest. He and I headed off; my wife stayed behind with our daughter.

I wouldn’t say our experience this week was the worst of our system — but it sure wasn’t great

Triage alone took approximately an hour (I can’t be more precise as I didn’t think to start tracking times until later in the evening). The (excellent) triage nurse took one look at him and said, “Oooh, yeah, that’s broken.” She gave him some Advil and an ice pack. We were sent back to the main lobby to wait, and she did warn that things were “a bit busy.” “But we’ll want to get him looked at soon,” she said.

You know the rest. Five hours later, we left. Some had been waiting much longer. During our stay, handwritten notes were taped up around the ER warning of a four-to-five-hour wait, and that was about all the communication anyone received. One of those handwritten notes warning of a four-to-five-hour wait had been taped directly onto the electronic screen that continued, throughout, to advise patients to expect a wait of approximately two hours.

My wife took our son to Peterborough, the next nearest (but much further) hospital. He was triaged almost immediately, rapidly admitted, X-rayed and confirmed to have broken his clavicle clean through. He hates his sling, but he’ll be fine in a few weeks.

He was confirmed to have broken his clavicle clean through

I was, to put it very mildly, unimpressed with the care provided at Ross Memorial. I wrote them a series of questions. The PR staff there was (at first) co-operative. They apologized for my frustrating experience, and explained that a normal day at the ER sees 110 patients. On the day of my arrival, they had 154 (my son included), a 40-per-cent surge, apparently their busiest day since 2016. They also explained that the patients they were dealing with were generally more serious than would usually be the case, including two heart attacks and several other people in life-threatening condition.

No reasonable human being, and I do try to be reasonable, would demand a broken bone be seen before a heart attack. But given that there was a surge, for which the hospital can’t be blamed, I asked if the hospital had adjusted its staff to compensate.

They had. They had called in one additional nurse to help handle 44 additional patients.

It’s clear that the hospital was either unwilling or unable to muster sufficient resources to cope with the demand

I honestly wish I could tell you more, but Ross Memorial suddenly decided they’d said enough, and I was told I’d receive no further information. I’d love to know if the totality of the extra staff called in was limited to one nurse because of budget constraints, because of a lack of available staff, or even simply the personnel challenges of trying to run a hospital around the Canada Day long weekend. There might have been a reasonable explanation for what otherwise seems a pretty weak response to a huge surge in demand. It seems we’ll never know.

But whatever the specific reason, it’s clear that the hospital was either unwilling or unable to muster sufficient resources to cope with the demand. At least four other people had left before I did. A few others looked about ready to hit the road, too. For my son, the medical consequences of the delay were zero. But we cannot be confident that that was the case for all those who sought help that night and didn’t get it. Delays in accessing health care are an undisputed contributor to poorer health-care outcomes. It’s also not disputed by anyone that people sometimes make stupid decisions when they’re tired, frustrated and in pain — like maybe deciding that whatever ailment took them there can wait until another day. Most of the time, it probably can. But not every time.

Not everyone who shows up at an ER needs to be there, but some of them do, and no triage system is perfect. If patients are walking about hospitals having not received care, when you scale that problem up to the size of a province, people are going to suffer or die.

Crowded ERs and long wait lists for treatments, another chronic problem, are symptoms of a system that is simply being run far too close to the edge — or beyond it. Other examples abound. In 2016, Statistics Canada reported that 10 per cent of Ontarians did not have a family doctor — and that number was going up. The international best-practice standard for hospital occupancy is 85 per cent — full enough to not be wasteful but with a bit of reserve capacity left over for emergencies or surges. Ontario hospitals routinely operate at over 100 per cent capacity; this is why we have so-called “hallway medicine.” Ontario’s long-term care (LTC) and rehab hospitals, where patients are transferred after they no longer require acute care, are also seriously backlogged, so much so that the former Liberal government began re-opening hospitals that had been deemed surplus and mothballed simply to use them as LTC or rehab wards. The Ford government has pledged to open 15,000 new beds over the next few years. That’s a good start, and would ease hospital overcrowding — on any given day, roughly 15 per cent of patients in primary care hospitals are waiting for a bed at a LTC or rehab facility.

Ontario hospitals routinely operate at over 100 per cent capacity

Ontario’s system struggles to provide routine care in normal circumstances. Imagine what would happen if there was a major incident or disease outbreak. Imagine what will happen when the baby boomers really start getting old and sick.

According to the Canadian Institute of Health Information, in 2017, Ontario spent the second-least per capita on health care, beating out bottom-ranked Manitoba by $46. In 2016, Ontario operated the fewest hospital beds (per capita) of any province, with 2.24 per 1,000 residents. The national average was 3.28. Alberta spent almost $1,000 more per capita than Ontario; matching that level of spending would cost Ontario over $13 billion a year. That’s roughly the size of Ontario’s current annual deficit.

These numbers, though, obscure a broader point. Simply picking on Ontario relative to the other provinces gets it wrong. Canada in general is a laggard. As horrifically offended as Canadians get when that’s pointed out, habituated as they are to reflexively comparing our system only to that of the United States, our system is, by international standards, mediocre. We spend more — considerably more, in some cases — of our total GDP on health care than our economic peer countries (as tracked by the Organization of Economic Co-Operation and Development, the OECD). Canada spends 10.7 per cent of GDP on health care, the OECD average is 8.7. For that money, we have well below the OECD average of number of physicians per 1,000 residents (2.7 vs. 3.5) and barely half the hospital beds per 1,000 residents (2.5 vs. 4.7). These are not great results for a country spending more than 25 per cent more of its GDP than the average OECD member.

These are not great results for a country spending more than 25 per cent more of its GDP than the average OECD member

Those are just top-level numbers. Your mileage will vary (we do, for instance, beat the OECD average on nurses per capita). But the unavoidable truth is that Canadians are paying more to receive less. Other international comparisons routinely rank us as decidedly meh on critical metrics such as delays for procedures and timely access to specialists.

But Canadians don’t seem to care. Far too many will tell you that the system is fine, because in the U.S., your health-care costs can bankrupt you. That’s true. It’s also irrelevant. There are many other advanced democracies in the world who’ve figured out how to provide health care better than both the U.S. and Canada. But we insist on the comparison we find most flattering, not the one that’s most useful.

We insist on the comparison we find most flattering, not the one that’s most useful

The Canadian fixation on the U.S. as the only meaningful point of contrast isn’t limited to health care. Obsessing over how we rank against the Americans is woven into our national identity as much as our somewhat misplaced pride in our health-care system is. But it’s a major obstacle to progress. We need to stop settling for “better-than-America” and aim for “as good as much of Europe.” We also need to realize that there are ways to improve the system that are not either “just throw ever-more public dollars at the problems” and “burn medicare to the ground and pay for everything out of pocket.”

But I’m not sure we will. The system is sending us clear signals that it is struggling. If we ignore them while they’re still fixable — when the economy is good, there’s no weird epidemics afoot and the full impact of the upcoming demographic shift hasn’t yet hit — we’ll pay for it later. The next person stranded in an ER that can’t cope could well be you or yours. And it might be worse than a busted collarbone.

Matt Gurney: Having better health care than the U.S. shouldn’t be good enough for Canadians

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