A stethoscope and blood pressure monitor.
A stethoscope and blood pressure monitor. Credit: Marcelo Leal / Unsplash Credit: Marcelo Leal / Unsplash

The federal and provincial governments are heading toward a deal on health care, which they could announce any day now.

Both sides have been sending out positive signals. They say they have found large areas of agreement.

Such an accord will inevitably include a significant increase in the federal contribution, which now goes up at a mere three per cent per year. For their part, the provinces will agree to some tangible measures of accountability for how they spend the money. 

The deal cannot come too soon.

The crisis in the health care system is real. The recent deaths of two women who sought, but failed to get, treatment at emergency departments in Nova Scotia hospitals drove that point home.

One woman waited hours in agony and when doctors finally saw her it was too late. The other got tired of waiting, left, and then, within an hour, died.

Not just in Nova Scotia, but throughout Canada wait times are a huge challenge facing our provincially-run health care systems. 

Canadians in every province fear they will suffer pain and discomfort, or worse, while they wait for essential treatment.

Wait times and lack of family physicians

Even before the pandemic wait times were, overall, unacceptably long. 

Emergency departments were frequently over-crowded, in large measure because, lacking adequate primary care, many Canadians had no choice but to go to emergency when they had relatively minor health problems such as colds and coughs.

There were also long waits for many diagnostic procedures and surgeries, especially those considered elective, that is, not essential to save a patient’s life. 

Hip and knee replacement surgeries, and some non-urgent pediatric surgeries, were chief among those. 

Some patients, in some provinces, also reported distressingly long wait times for tests to detect cancers and for cancer treatments – although provincial health systems were generally more prompt for such essential care than for the elective kind.

The pandemic made all of that worse. 

In response to the exigencies of COVID, hospitals had to radically change their modi operandi, which meant even longer waits in emergency departments and indefinite delay for tens of thousands of surgeries.

Health care in this country has not yet recovered. Today, the surgical backlog, to cite but one issue, still numbers in the hundreds of thousands.

Of equal importance, frontline health workers, such as nurses, are suffering burn-out at an alarming rate, while hospital emergency departments must, more than ever, deal with a range of problems that more appropriately belong in community, primary healthcare settings.

Indeed, the difficulty millions of Canadians have in accessing basic, primary care might be the greatest of the many challenges facing the health systems everywhere in this country.

There are multiple millions of Canadians, from coast to coast to coast, who do not have, and cannot find, a family doctor.

My wife and I consider ourselves lucky to be enrolled with a family medicine centre in Ottawa. The team there provides us with humane and high-quality care, without unreasonable wait times. 

But every time we phone the centre we get a reminder of the generalized crisis in primary care. Before we get through to a person, almost the first words of our family medicine group’s recorded greeting are: 

“Please note, we are not taking new patients.”

That is a sadly familiar message throughout Canada these days.

Family doctors are the gatekeepers of our health systems. Without a referral from such a physician it is extremely difficult to see any kind of specialist. 

Even routine matters, such as getting prescriptions refilled or having regular check-ups and routine tests, are problematic when you do not have your own doctor. 

Public health authorities regularly enjoin Canadians to “consult your doctor” before getting a vaccine or test or procedure, or if they have symptoms of disease – words that must ring hollow for the millions of Canadians who have no doctor.

Time to innovate in primary care

Canada’s health systems need more trained people and more facilities to provide grassroots, basic care. 

The fee-for-service model for family medicine, with individual doctors forced to act as small business operators, might have once worked, in a simpler time. It does not fulfill our medical needs in 2023.

Today, we need bold and innovative solutions to the primary health-care crisis. We need to study what other countries with similar health care systems to ours do, and we need to be ready to think outside the box. 

Among the possible solutions are local community health and social service centres, with doctors, nurses, nutritionists, social workers, dentists and even physio and occupational therapists under one roof.

A more modest option is the family medicine centre, where doctors, nurses and other professionals, including administrative staff, operate in a group practice setting, often affiliated with a hospital. 

Doctors at our family medicine centre, and others like it, are not paid per-patient-visit or per-procedure, which is the unfortunate norm for most doctor payments throughout Canada. 

Family medicine centres use a payment system called capitation. Doctors are paid a fixed annual amount per enrolled patient. They don’t bill the provincial insurance scheme for each visit or procedure. 

There is greater financial stability and predictability and far less bureaucratic paperwork with capitation than with fee-for-service. Family doctors in their own practices frequently complain about their costly and time-consuming administrative burdens.

But capitation is only one of many options. Creating salaried positions for doctors is another. 

In the final analysis, there is no add-water-and stir, instant, magic solution. It will take a concerted and focused effort on the part of governments, community organizations and medical professionals to make sure every Canadian has access to high-quality, primary health care, in their own community. 

It will also take money – to train and hire more doctors, nurses, and other professionals.

If Canada were to succeed in making primary care a lot better than it is now, among the benefits would be less pressure on emergency departments. 

And if vastly improved primary care were accompanied by enhanced preventative medicine and population health measures – which means everything from reduced air pollution to greater economic security – we could put a damper on the demand for the acute care hospitals provide.

In that context, it is more than a bit surprising that when the Doug Ford government of Ontario decided the time had come to innovate in health care its first priority was to open the door to for-profit centres to perform elective surgeries.

Some, including the Ontario premier, have characterized concerns about his for-profit plan as a knee-jerk reaction from the usual left-wing suspects.

READ MORE: Doug Ford’s private surgery plan is driven by ideology not innovation

But it is not just the New Democrats, healthcare activists and unions who are protesting. 

The College of Physicians and Surgeons is also concerned. They worry the new for-profit facilities will make the situation for hospitals worse, not better, by luring away nurses and doctors. 

Dr. Robert Bell, the former head of Toronto’s University Health Network and former Ontario Deputy Minister of Health, is also strongly opposed to using the profit motive as part of the solution for long surgery wait times.

Bell sees great virtue in setting up not-for-profit surgery facilities outside of hospitals, especially if they are associated with hospitals or community health centres. But, he argues, inviting in corporations seeking to make a profit from the taxpayer-funded health system would have a harmful impact.

In an article for the Globe and Mail Bell writes:

“With an expanded mandate … for-profit surgery providers will almost certainly compete for staff, including nurses, currently employed in hospital operating rooms … Just as Ontario emergency rooms have closed this past year because of inadequate staffing, we may see operating rooms shuttering – especially on nights and on weekends – even though there will still be a need for surgeries.”

Bell points out further that in two of the provinces Ford cites as models for expanding private surgeries, Alberta and Saskatchewan, wait times for hip and knee replacement surgery are substantially worse than in Ontario.

Instead of proceeding with the false panacea of a private-sector magic wand, Bell has some constructive suggestions for Ford.

For one thing, the premier could repeal Ontario’s Bill 124, which restricts salary increases for nurses to far below the rate of inflation.

Another idea would be to move surgeries to not-for-profit, “dedicated community facilities”. 

No help from the feds

It is understandable that prime minister Justin Trudeau would want to be diplomatic in his reaction to Ford’s plan. There are delicate negotiations happening and Trudeau does not want be seen as trampling on provincial rights.

Health care, like education, is clearly a provincial jurisdiction in this country. The Constitution Act of 1867, which we used to call the British North American Act, unambiguously says so.

Over the years, the federal government has gotten involved in health care through its power, affirmed by a series of court decisions, to spend in provincial areas of responsibility.

In the 1980s, when provinces allowed practices such as extra billing by physicians to undermine the universality of their healthcare systems, the federal government pushed back with the Canada Health Act.

That Act allows the federal government to use its only lever, its financial contribution, to punish provinces who defy its basic principles of comprehensiveness, universality and portability. 

The Canada Health Act has helped keep health care throughout the country accessible to all, rich and poor alike, on an equal basis. But it does not forbid contracting out of medical procedures – including surgeries –  to the private sector. 

And so, the federal government is not going to stand in Doug Ford’s way. 

If the people of Ontario want their government to focus not on its misguided privatization plan, but on the real problems facing their health care system, they are going to have to make that happen themselves.

Karl Nerenberg

Karl Nerenberg joined rabble in 2011 to cover Canadian politics. He has worked as a journalist and filmmaker for many decades, including two and a half decades at CBC/Radio-Canada. Among his career highlights...