Today’s Canadian healthcare system faces many challenges. In the upcoming years, these challenges will apply strains on primary health and quality of health. In response, many strategies have been proposed and implemented to address the concern. However, it is impossible to address all these issues in one setting. The focus of this paper will be on three of the main issues that presently affect the Canadian healthcare system; sustainability, recruitment and retention of healthcare providers; and the health of rural and remote communities. In addition, strategies proposed to alleviate these concerns will also be discussed.
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State of Canadian Healthcare Today
Tommy Douglas created Medicare with good intentions for Canadians; to provide basic coverage for citizens to meet their healthcare needs. Today, it is better recognized as the Canadian Health Act. However, the Canadian healthcare system is not in the same condition as it was when first created. Thus, although Canadians are proud of their healthcare system, they are worried about its future. For example, the 2010 Commonwealth Fund report card ranked Canada six out of 7. In addition, its patient population is drastically changing as it prepares to address a more culturally diverse population with unique healthcare needs, an aging baby boomer generation, and geographic challenges of different communities across the country. Our current healthcare approach may have served Canadians well years ago, however as healthcare has become more complex, more innovative solutions need to be sought after
Sustainability
Sustainability is referred to many as the problem of maintaining equitable quality health care as sustainability. This implies having mechanisms to ensure that Canadians, irrespective of their ability to pay, will have continued access to prompt, technologically current, competent and compassionate health care that addresses the full range of their health needs (quote). Currently, there are contrasting views towards the sustainability of the current Canadian healthcare system.
Statistics show two main patterns; sustainability is heavily tied into the economic growth of Canada and that healthcare spending is steadily increasing. For example, healthcare spending as a % of the GDP has increased over the years, from 8.8% in 2000 to 10.4% in 2008. This pattern is consistent across all other OECD countries as well, with Canada showing one of the more moderate increases as compared to other nations. The primary reason for Canada’s success in constraining expenditures is that a single payer, the government, is responsible for the provision of physician and hospital services. Single-payer funding allows administrative efficiencies and the necessary redirection of spending (quote). Nevertheless, sustainability issues have the public wanting to know the value of their taxpayer money.
The challenge of what is thought as an increasingly unsustainable healthcare system has been created by various factors, including population aging, inflation, increases in size of population, enrichment of health care services and cost of dying. These challenges have further lead to Canada’s restrained spending, producing long waits in emergency departments for unavailable hospital beds; delays in cataract, joint replacement and cardiac surgery; and the unavailability of needed home care services. Solving these problems will require increased commitment of resources to health care. Yet, a declining tax base is creating, especially under the tax cuts during the 1990’s, is working counter intuitively with the problem. Without the necessary resources to counteract the increased “loads” placed on the healthcare system, we can expect to encounter a doomsday scenario. This will include lack of timely access to family physicians and specialist care/treatment, lack of ER access and an aging population with end-of-life issues and lack of access to palliative care (quote).
As stated in the Romanow Commission, the system is sustainable, but only if the system changes in some very important and crucial ways. However, one strategy that could have strikingly profound effects would be to see the federal government matching new health expenditures by the provinces, in some fixed proportion. Currently, both levels of government accuse the other of being responsible for health care delivery problems and for inadequacies in funding, while failing to address the problem. For instance, in 1995, the federal government unilaterally instituted large cuts in the health care funding available to the provinces (quote). At the same time, provinces can avoid committing increased resources of their own to healthcare and effectively use the federal money to fund tax cuts. This resistance of both federal and provincial governments to committing adequate funds to health care in a planned and consistent fashion represents a serious threat to sustainability (quote).
A solution would begin with the provincial and federal governments agreeing to establish the current funding levels as a base situation and instituting mechanisms to ensure that base funding committed to healthcare is actually spent on healthcare. A solution must also ensure that both levels of government acknowledge their responsibility to provide adequate funding for universal access to needed physician, hospital and other health services, without imposing on patients financial barriers to care. Further, provincial governments must acknowledge that the federal contribution to spending entitles the federal government to have a say in how the money is spent. Finally, any workable solution will make transparent the relative contributions of the two levels of government to health care spending. In return, the federal government would place conditions on the transfer of funds, one of the stipulations of the original medicare plan. Thus, this funding formula would remedy the current ability of both provincial and federal governments to cut health care funding indiscriminately and obfuscate the situation to mask their cuts.
Recruitment and retention
Healthcare is a cutting edge industry with highly trained and skilled people who care deeply about the future of the health care system. This includes physicians and nurses, but also chiropractors, occupational therapists, opticians and specialists. These professionals are central to the effective and efficient delivery of healthcare services to the patient population. However, much like other sectors of the healthcare system, healthcare human resources are also facing their own challenges, including recruitment and retention.
Recruitment of healthcare professionals affects different groups to differing degrees. For example, with the aging of the current physician workforce, the decrease in the number of new graduates and the continued level of out-migration of Ontario physicians, the current relative undersupply will become more severe in the future. In addition, the nursing workforce faces are too few graduating nurses, too many nurses leave the profession due to stress, an aging workforce, and interprovincial rivalries for scarce resources and changes in health care delivery.
The problem is only partly about supply. It also is about distribution, scope of practice, quality of working life patterns of practice, and the right mix of skills among various health care providers. Changes healthcare service delivery, especially with the growing emphasis on collaborative teams and networks of health providers, means that traditional scopes of practice need to change (quote). This will require solutions and strategies that go beyond the immediate and looming shortage of health care providers. Canadians are concerned about the supply and distribution of nurses, doctors and other healthcare providers. Too many Canadians still do not have a doctor in their community, have to wait to see a specialist, or find too few nurses in the emergency department when they need urgent care. On the other hand, health care providers also have serious concerns about the quality of their work life and have repeatedly called for action to improve morale and day-to-day working conditions. If these patterns continue to extend into the future, Canadians can expect to see a lack of supply and distribution of health providers and professionals, especially in underserved communities.
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Short-term solutions aimed at increasing the supply of physicians do not translate into improvements in the supply of physicians for communities in need, from rural and remote areas to inner cities. For this reason, one of the most important strategies in strengthening the recruitment and retention of healthcare providers, as recommended by Roy Romanow, are that The Health Council of Canada should review existing education and training programs. Changes are needed in the relationship between providers and patients as patients take a more proactive role in their health and health care; this requires the need to review and renew education and training programs for health care providers. As changes in health care services delivery and the need for providers to work together in integrated teams and networks focused on meeting patients’ needs, corresponding changes must be made in the way health care providers are educated and trained.
Changes are already in progress as we speak, which includes collaboration between the Canadian Nurses Association, the Association of Canadian Medical Colleges, and the Canadian Association of University Schools of Nursing in partnership with Health Canada (quote). These organizations believe a learning process in which different professionals learn from, learn about and team with each other in order to develop collaborative practice. Their belief includes that if health care providers are expected to work together and share expertise in a team environment, it makes sense that their education and training should prepare them for this type of working arrangement. Such collaborative education approaches must also be careful in avoiding destructive top-down approaches that work against the very relationships they are trying to promote integrated educational curriculum for future health care providers. Through its leadership role, the Health Council of Canada can bring together health care providers, provinces and territories, and other key players in the health care system to address long-term issues and make a lasting and profound change in the future of Canada’s health workforce.
Rural and Remote Communities
The vastness of the Canadian landscape makes it difficult to ensure that all citizens have equal access to healthcare services regardless of where they live. This presents unique challenges in the delivery of health care services, especially for Canadians living in isolated rural and remote communities. Their aging population, economic difficulties and geographic isolation are among the factors that could contribute to specific health vulnerabilities in rural areas and small towns. Nonetheless, healthcare needs vary for different communities with no “one size fits all” solution.
These concerns require specific approaches. However, a review of current approaches points to the following issues: the lack of consensus on what “adequate” access should include; the need for effective linkages with larger centers; the challenges of serving the smallest and most remote communities; the predominance of “urban” approaches applied to rural communities and; the lack of research. In addition, healthcare providers working in rural communities also face differing challenges as compared to their urban counterparts including high physician turnover, location of medical training, and lack of professional support. In this sense, geography in itself becomes a determinant of health for these smaller communities.
In addition, Canadians in rural communities have difficulty accessing primary health care and keeping health care providers in their communities, including accessing diagnostic services and other more advanced treatments. In some northern communities, the facilities are limited and in serious need of upgrading. About 16,000 people live in the most northern part of Canada and two-thirds of them live more than 100 km from a physician. And no physicians normally live above 70 degrees north latitude to serve the 3,300 people living there (quote). This is amplified by competition between provinces and territories trying to attract and retain the supply of health care providers, leaving the health care needs of rural and remote communities in the backseat.
The experiences of many provinces and territories as well as OECD countries suggest that short-term solutions aimed at increasing the overall supply of physicians do not necessarily translate into improvements in their supply in these communities (quote). Instead, strategies and policies will need to work towards assisting rural and remote community needs over long-term periods. A strategy as recommended by the Romanow Commission includes having the Rural and Remote Access Fund support the expansion of telehealth approaches. Telehealth is a prime example of using innovative methods to deliver healthcare services to communities in need. It has the potential to overcome the obstacles of distances to improve access to health care in rural communities, ranging from diagnosing, treatment, and consultations over various distances. A variety of approaches can be used ranging from tele-triage to tele-education, and more recently, to tele-homecare.
Provinces, such as Newfoundland and Labrador have done extensive work on telehealth initiatives. Recognizing these potential benefits, the Government of Nunavut has also signed agreements with the governments of Australia and Newfoundland and Labrador to share information and new developments in telehealth. In their view, increased use of telehealth technology will result both in cost savings and in improved health for territorial residents. Thus, the Rural and Remote Access Fund should be used to expand telehealth applications. Funds should be used to support the necessary equipment within smaller communities as well as the necessary education, training and support to allow these technologies to be used and managed effectively. In addition, telehealth investments should reflect individual community needs and ensure that necessary policies are in place for licensing health care providers to deliver health services at a distance; training and support is available to facilitate effective and efficient use of telehealth applications; and the impact of telehealth applications on health outcomes in rural and remote communities is assessed (quote).
Transition paragraph
As mentioned earlier, it is not possible to examine every challenge currently facing the Canadian healthcare system in one setting, and additionally suggest strategies that should be implemented for each issue. Nonetheless, this paper has examined three of the main concerns, including sustainability, recruitment and retention, and the health of rural and remote communities. These issues are expected to continue to be a concern if effective and efficient strategies are not put into place in the near future. By examining the proposed strategies, a common theme stretches across the spectrum. This includes the need for strategies to take on more innovative approaches, such as telehealth, and also to involve collaborative multi-levels of government, healthcare agencies and professional organizations, such as inter-governmental funding formulas and collaborative education training. With the fast pace growth of healthcare needs forecasted to place a “heavy burden” on the healthcare system, such strategies will be required for today and tomorrow’s healthcare challenges.
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