Multicultural Meanderings

How we can right-size Canada’s health system as the population grows

Good illustration of the impact of current and planned high levels of permanent and temporary immigration, offering little hope in the near and medium-term:

Last year, while knocking on doors during her campaign to be mayor of Whitby, Elizabeth Roy got a firsthand feel for the community’s top concerns.

The town of 150,000, on the shore of Lake Ontario about 50 kilometres east of Toronto, is among the fastest-growing communities in the country.

As she fielded questions about building new roads, preserving green space and upgrading infrastructure, Roy also heard resident after resident describe how difficult it was to get much-needed medical care, with many saying they feared the situation would get even worse amid Whitby’s population boom.

“Whether it was a young family needing a doctor for their newborn or a senior who just had their doctor retire and was left stranded, about one out of every five residents expressed concern about some type of medical care that they required,” says Roy, who is serving her first term as mayor after 17 years as a member of council.

“It’s clear we have gaps in our health-care system, and they need to be dealt with now, today. We need to start being proactive.”

The population of Durham Region, which includes Oshawa, Ajax and Pickering as well as Whitby, is likewise swelling rapidly. It’s expected to almost double over the next 20 years, surging from about 697,000 in 2021 to 1.2 million by 2041.

Municipal and health-care leaders worry its health system, straining to meet the community’s needs even now, won’t be able to cope with the influx of new residents.

Already, Durham faces an escalating family doctor shortage. Figures from the Ontario College of Family Physicians reveal more than 44,000 Durham residents don’t have a family doctor, though a recent report from the Town of Whitby puts the number much higher, citing estimates that suggest a third of the region’s population — some 230,000 residents — lack a family physician who practises in Durham.

Lakeridge Health, the region’s medical network, is unable to keep up with demand. Its four acute-care hospitals typically operate above capacity and wait times in its ERs continue to be “higher than usual,” according to a June alert to the community. The hospital system, Roy notes, will need 1,793 beds by 2041 — more than double its current count.

Noting that it’s primarily a provincial responsibility, Roy says “One would think that at the municipal level health care wouldn’t be a concern for us to be advocating for. It’s actually far from that. It’s actually the reverse. Daily, I hear about the health care needs in our community.”

With Canada’s population recently hitting 40 million — a milestone that arrived faster than expected — and the country set to welcome 500,000 people a year by 2025, health policy experts are warning that bolstering our fragile system, still recovering from years of pandemic pressures, has never been more important.

Across Ontario, where the head count is racing toward 16 million, communities face struggles similar to Whitby’s. More than 2.2 million people do not have access to a family doctor or a nurse practitioner, which puts their long-term health at risk and makes them more likely to visit the ER, placing further strain on the system.

Hospital emergency departments continue to overflow; the most-recent data from Ontario Health shows that patients admitted to the hospital from the ER wait an average of 19 hours before getting a bed.

And despite efforts to strengthen the health-care workforce, ongoing shortages are triggering temporary closures — and in a recent case in Minden, the permanent shuttering — of some of the province’s hospital emergency departments. 

“We are in an extremely difficult moment in our health system in Ontario,” says Dr. Jane Philpott, former politician and dean of Queen’s Health Sciences and director of its medical school.

“It’s probably in a more critical state than at any other point in the four decades that I’ve been involved in health care. The only thing that makes me hopeful is that it’s reached such a state of crisis that there is a broad public and political imperative to find solutions and to do the things that we should have done long ago.”

Among the first steps to propping up the system in the near term — and preparing it for future demand — is to ensure everyone in the province is connected to a family doctor or nurse practitioner.

“It’s the only way we’re going to be able to cope,” Philpott says. “We need to get a very firm commitment from all orders of government to establish a primary-care-for-all system.”

Across the country, calls are growing for targeted reforms to primary care, including the expansion of team-based care, which connects patients to interdisciplinary groups made up of pharmacists, social workers, dietitians and other health-care professionals, in addition to nurses and physicians. Evidence suggests such teams improve patient outcomes.

Health leaders also want to see primary care shift to a geographic model to ensure every resident has access to a family doctor within a 30-minute drive of where they live or work. As well, there is a push to allow patients in a team-based environment have a non-physician health professional co-ordinate their care. 

Such reforms are necessary given the scale of primary-care needs in the province, says Dr. Rick Glazier, scientific director of the Canadian Institutes of Health Research’s Institute of Health Services and Policy Research. 

Even as the need grows for more family doctors to fill the gaps, research shows about 17 per cent of Ontarians are attached to a physician over the age of 65 who is nearing retirement. Glazier says there aren’t enough MDs graduating medical school to replace the aging workforce.

“We don’t have the generation coming behind those people who are retiring,” says Glazier, a family doctor at St. Michael’s Hospital, a part of Unity Health Toronto.

“We will need these interprofessional teams for primary care. We will not be able to do this with doctors alone.”

Dr. Andrew Boozary, a primary-care physician and founding executive director of the Gattuso Centre for Social Medicine at Toronto’s University Health Network, agrees governments must firmly commit to primary-care expansion and reform.

Finding new ways to connect people to a family doctor or nurse practitioner will be key, not only in anticipation of the growing population but also because of the country’s aging demographics, as older patients typically have greater health care needs.

Boozary sees an expanded role for community health workers in primary care, noting that they played a crucial part during the pandemic by bringing health services including COVID-19 vaccines into neighbourhoods, building trust with residents who wouldn’t otherwise have easy access to health care.

“Through the pandemic, community health workers supported people in apartment buildings, in parks and basketball courts, in religious settings,” Boozary says. “They brokered the trust. They had the lived experience and understanding of the needs of their communities.”

Including such workers in primary-care delivery would lead to more equitable access and could mean helping patients connect with social supports, accompanying them to medical appointments, helping with medication (including adherence to prescription renewals), and working closely with a nurse practitioner. 

This kind of model could be especially important in marginalized communities, Boozary says, including refugee and newcomer populations.

“We can’t say we have a universal health-care system when millions of people don’t have access to primary care,” Boozary says. “This mirage of universality was exposed during the pandemic and has been further eroded.”

In his role at CIHR, Glazier is leading an initiative that’s mobilizing research teams to better understand the country’s health-care workforce. That data, he says, will be used for “evidence-based planning” to help Canada meet its future health-care needs.

Ivy Bourgeault, a professor of sociology at the University of Ottawa and lead of the Canadian Health Workforce Network, says when political and health leaders talk about capacity within the health system, they are primarily talking about its workers.

“This is a labour-intensive industry,” she says. “Three-quarters of the costs of the health system are related to the workforce, which means that health system responsiveness — in wait times, in backlogs — it’s the workforce that’s the rate-limiting factor.

“Primary care issues. Long-term-care issues. These are workforce issues.”

Boosting nursing numbers is among the top priorities, Bourgeault says. This includes finding ways to retain nurses working in the system, bring back those who left (through retirement or a profession change or dropping to part-time), and strategically recruit new nurses to fill gaps in the system.

All of this, though, is to only solve the crisis at hand, she says. Preparing for the more-populous future will require understanding the gaps in the system, collecting and analyzing workforce data and studying and evaluating new models of care.

“We need to build a culture of planning,” Bourgeault says. “The most expensive situation is continuing to do what we do now: Not plan. Not retain. Just constantly trying to recruit to fill a system that is like a sieve.”

Sara Allin, an associate professor at the University of Toronto’s Institute for Health Policy, Management and Evaluation, says Canada doesn’t track health-workforce numbers thoroughly enough. Data that is available is often fragmented, inconsistent between regions and not easily available to policymakers.

And while having a view of regional and professional gaps in the workforce is key, Allin says it’s also imperative to collect data on patients’ medical needs to help inform planning. For example, she says, an aging population, the rise in chronic disease, such as diabetes, and social risk factors, including food insecurity and unsafe housing, all play into population health. 

“We need to project and model our future medical needs and map those against future capacity,” Allin says, adding that there is currently a “mismatch” between the two. “Good data is fundamental to both exercises. And we’re not able to accurately and effectively measure these things right now.”

Given the health system’s current “precarious” state it will be difficult to meet the needs of the growing population, she says. This sentiment is shared by Farah Ahmad, an associate professor in York University’s School of Health Policy and Management, who agrees solutions must be found to the workforce challenges ahead of the country’s projected population growth. 

“We are going to have a lot of newcomers, which is great for our overall economic development,” she says. “But if we are not preparing our health system, who will take care of them?”

Ahmad points to the most recent figures from the Paris-based Organization for Economic Cooperation and Development that show Canada has only 2.8 physicians for every 1,000 residents, a rate well below other countries. In the 2021 OECD data, Canada also graduates far fewer physicians than other countries, ranking 33rd out of 36.

While Canada’s immigration goals provide a partial solution to the country’s worker shortage by bringing in internationally trained professionals, Ahmed worries too much burden is being placed on newcomers. “The answers, they cannot all come from new immigrants.”

Philpott, a family physician and a former federal health minister, says the country should be able to build and train its own health-care workforce even as it removes barriers to let internationally educated professionals work here, also an important strategy.

She points to a unique initiative from Queen’s University and Lakeridge Health, designed to train and graduate family physicians, as one type of solution. In September this program will see 20 medical students interested in family medicine train in Durham, with the goal of having them graduate and set up their practice in the region. 

Eight months into her term as mayor, Roy says advocating for more health-care services gets pushed higher and higher on Whitby Council’s list of priorities.

Last month, council approved funding to help support the Queen’s-Lakeridge Health MD Family Physician Training Program as well as a plan to establish an incentive program to recruit and retain family doctors to the region. And Roy herself is advocating for the province to approve a $3-million planning grant for a new hospital in Whitby, the location recommended by an independent task force. 

She notes a provincial task force in 2015 recommended a new acute-care hospital for somewhere in Durham. Eight years later, and with the region’s population ballooning faster than ever, that plan remains stalled.

“This crisis is one that’s here today,” says Roy. “Lakeridge Health Oshawa is operating at one and a half times what it was first built for, and it will take at least 10 years after approval for that hospital — anywhere in Durham — to open its doors.”

Roy fears that as time passes, and the population grows, the health-care gap in the community, already stark, will continue to widen, putting residents health even further at risk.

“I’m really concerned,” she says. “We have to have a community that provides all the health-care supports. But if we don’t have them in place, we may end up having residents whose ailments are further along, their cancer diagnosis not diagnosed at an earlier stage, that it takes longer for treatments or medications to be prescribed.

“We know early intervention is key. And that may be at risk.”

Source: How we can right-size Canada’s health system as the population grows