By Dr. Al Lauzon
Ruminations on Rural Health - The first article in a blog series that highlights one expert's opinion
As I look at the rising sun and the promise of a new day, I think of the struggles of a couple of friends who work in healthcare and how tired they look, and how exhausted they feel. The healthcare systems in Canada are in crisis. Healthcare workers are burned out and quitting their profession, or moving on to new opportunities elsewhere. I remember taking note one morning last summer in the Globe and Mail that featured an article on a nurse who left her job here in Ontario and moved to Texas where she is being paid more and has better working conditions. In the same edition, there was an article on the increased incidents of violence, sexual assault and racism that is being experienced by healthcare workers since the beginning of the COVID-19 pandemic. And it was also noted in that edition that we were continuing to see emergency rooms being closed temporarily as they are unable to find enough nurses and others to staff them. Healthcare professionals feel they have no recourse, leaving jobs and in some cases leaving healthcare altogether, leaving residents in those communities vulnerable. The pandemic has left the healthcare system in Canada in peril, and no one seems to know what to do. But the reality is the proverbial writing was on the wall prior to the pandemic as we grappled with long wait times, physician shortages and hospitals being dominated by the “cult of efficiency”, being told by governments to be more efficient but innovative, two discourses that are not compatible; efficient means getting rid of the “fat” while innovation requires “fat” in order to have the capacity to experiment and learn from experience. These competing discourses have not served us well, and left hospitals swirling in confusion, not really knowing how to move forward, and that is the question we now find ourselves collectively facing, although there are no clear answers. How do we move forward in healthcare?
As many have noted, what we really need is a transformation of the healthcare systems in Canada. Ray Romanow, former Premier of Saskatchewan and principal author of the 2002 report The Royal Commission on the Future of Healthcare in Canada, had suggested that we need a new paradigm that focuses on the wellness of individuals rather than the limited vision of simply making sick people better.
Many of the challenges that have faced governments in Canada requires dealing with the demographic anomaly of the baby boomers. We built schools, then colleges and universities to accommodate them as they moved through the life cycle. And now in the final stage of the life cycle we need to increase care for them while they take up significant healthcare resources. Yet the pandemic has demonstrated how ill prepared we are in the long-term care sector and hospitals continue to flounder in response to an increasing demand for care for people suffering from chronic conditions. Part of the challenge is hospitals were designed for acute care but many of the challenges they face is dealing with an ageing population and associated ongoing chronic conditions. This can be particularly challenging for rural hospitals where the population is often older and ageing more quickly than in urban centres. As a result of the shortage of long-term care beds in Canada, seniors often occupy acute care beds which they are not really intended for, denying access to others and leading to delay in treatment; they become a “holding ground” until long-term care beds become available. This is not an efficient use of limited healthcare resources.
If we look at the allocation of healthcare resources, we find that those 65 years of age and older cost the healthcare system four times as much annually as those under the age of 65. Already provincial governments spend around 40% of their budgets on healthcare. We need to think beyond a healthcare system that is preoccupied by a “repair-shop” mentality whereby the healthcare system fixes people when they get sick rather than keeping them healthy. When Tommy Douglas first brought healthcare to the province of Saskatchewan, he argued two things: (1) we need to provide people with healthcare when and where they need it; and (2) we must develop policies that keep people healthy. We have ignored Douglas’ second point. In other words, we need to help people recover when they are sick, but just as important, we need to keep them healthy. That is where the real system leverage is. The bottom line is we need to find a different way to deliver services and supports to an ageing population in the management of chronic conditions and not let their conditions deteriorate until they require hospitalization. We must develop policies, procedures and practices that keep people healthy.
But it is not just seniors that burden the healthcare system, but changes in social care and support have changed over the last thirty years, increasing the number of vulnerable people across all age demographics and this has increased the demand on hospitals. For example, many of the changes in social care and support have reduced services and have inadequate supports (e.g. disability or social assistance support), resulting in more people having poor health status and often becoming ill and relying on the healthcare system as a support of last resort. As governments in Canada explore the issue of healthcare system transformation, there must be a recognition that the challenges that are faced in healthcare will not be resolved by simply confining solutions to the silo of healthcare, but as we have learned through the social determinants of health, much of our health and wellbeing is a product of the socioeconomic conditions we live in. A rule of thumb is that the healthcare systems produces 25% of health outcomes but uses around 40% of government financial resources while the socioeconomic determinants of health account for approximately 50% of the health outcomes. Over the last three decades, under the guise of a neoliberalist agenda where the market rules all, we have seen an erosion and an unravelling of the social safety net, and changes in employment and labour practises have led to increasing numbers in the population being precariously employed, while food insecurity rises as does the number of homeless people all undermining people’s health and wellbeing. Now we see rampant inflation increasing the cost of everything. We need to ask the question what has been the impact of these changing supports and practises on population health? I would suggest that they have been significant and as we look to transform the healthcare systems in Canada, we need to look beyond the silo of healthcare to begin to understand how we can keep all people healthy, we need a transformation to a wellness system that not only helps people get better, but helps people stay healthy and well in the first place, and in doing so we can reduce healthcare expenditures, allowing hospitals to do what they were designed to do—treat acute care issues.
Disclaimer: The views expressed in this opinion article are solely those of the author and do not necessarily represent the views or opinions of Gateway CERH. We believe in providing a platform for a diverse range of perspectives, and this article is intended to stimulate thoughtful discussion.