Canada’s health care system is falling apart. It’s not too late to fix it.

CLIP You are listening to a Frequency Podcast network production.

Jordan Heath Rawlings Since the pandemic began, Canada’s healthcare system has been fighting to keep its head above water since before that, if you ask some people. But as difficult and terrifying as it’s been facing an ongoing emergency and a deadly threat, when we really needed it, the system managed somehow to keep going. To save lives that would’ve been lost. And as Covid recedes now, perhaps the system can finally catch its breath, clear those backlogs stop doctors and nurses from burning out. Refill the shortages and reset. I don’t mean to shock you here, but that’s not happening.

CLIP Covid-19 has highlighted the growing shortage of family doctors in Ontario. The Ontario College of Family Physicians says it was an issue pre pandemic, and it will likely get worse.

CLIP Doctors in Alberta are expressing concern about a lack of obstetrical care. In Lethbridge, Vermont, there’s been only one permanent OBGYN for the city.

CLIP In Minden, Ontario, there is no longer an emergency room. It closed June 1st.

CLIP Hours have been cut in Niagara, where officials say two urgent care centers will close overnight service. The president and CEO says this time the decision is permanent.

Jordan Heath Rawlings Yesterday, the Canadian Medical Association issued a statement ahead of a premier’s meeting coming up next month, warning that millions of Canadians are still struggling to access healthcare. The system is just barely keeping its head above water. We don’t have enough doctors. And the breath we hoped it could catch hasn’t happened. As we move past an emergency that took everything we had. What is broken in the system? How can we fix it, and who needs to do what? Nurses and doctors and the whole healthcare system rose to the challenge. Can politicians rise to theirs?

I am Jordan Heath Rawlings. This is The Big Story. Dr. Alika Lafontaine is the President of the Canadian Medical Association. He is also a rural anesthesiologist. Hello, Dr. LaFontaine.

Dr. Alika Lafontaine Hi. How’s it going?

Jordan Heath Rawlings It’s going all right. Thanks for finding the time for us today.

Dr. Alika Lafontaine Yeah, pleasure to join you.

Jordan Heath Rawlings I wanna start by asking you, you know, from the Canadian Medical Association’s point of view, where are we in this pandemic? I ask you this because, we’ve been tracking the state of our healthcare system all through covid, and it feels right to start with that. Is the pandemic over? Is it still an emergency? Is it manageable? How do you see it?

Dr. Alika Lafontaine Well, the pandemic’s not over. It’s moved into a different phase than it was in. So we, we know that the World Health Organization made the decision to end the Covid 19 global public health emergency, and that health systems across the world are trying to figure out, you know, where are we at and what comes next? And so there, there’s a few things that, that are really important to point out. But the first is, is that Covid continues to have impacts on healthcare, not the same impacts that it did when it first happened in that first wave way back in 2020. But one in 10 patients continued to suffer from the after effects of long covid. You know, we still have acute infections, which do cause impacts on the healthcare system. It does still impact healthcare workers and patients. And so it, it, it’s not over, but we are trying to figure out how to manage it as part of the broader scope of, of emergencies that we have to address right now. And I, I think that that’s really what the new phase means for many years covid was all we we thought about. There are a lot of different problems we have to juggle right now.

Jordan Heath Rawlings We’re talking today because the CMA released a statement this morning calling on all Premiers in Canada to ensure that health system reform is at the top of their agenda at their meetings next month. I wanna ask you broadly, we’re going to get into specifics because I think that’s where Canadians feel it, but broadly, what’s the current state of our healthcare system after three years of a pandemic? How, how healthy is it?

Dr. Alika Lafontaine Well, just like Covid is not over, the health emergency is not over. And as someone who manages health emergencies regularly, as part of my work as an anesthesiologist. You know, at, at the beginning of emergencies, everyone’s very sensitized. You know, we, we see that there’s a problem we call for help. We all start to gather around and, and do our roles and try and fill in where needed. But over time you start to get used to kind of the ebb and flow of emergencies. There’s the real risk in emergencies that never end for people to get used to a new normal. Even though what’s happening is definitely not normal, and I, I think that really is the state of the Canadian healthcare system right now, is we’ve had these long problems that were magnified in the course of the pandemic that have now reached this strange normalization, where people now don’t appreciate as much when an emergency closes in a smaller community. They believe that these pressing problems, You know, healthcare professionals leaving the profession, drawing back on clinical care, isn’t going to change the way that they imagine their healthcare is going to be. And, and the reality is, is that, the crisis is still here. And that’s the reason for the letters to make sure that politicians remain sensitized. That we are not through this yet. We, we still have a, a very tall mountain that we have to climb.

Jordan Heath Rawlings Since you just mentioned it, maybe we’ll start with emergency rooms. I know you may not be familiar with the specifics of everyone, but here in Ontario, we saw a bunch of closures last summer, temporary closures. We are now seeing a permanent closure, in Minden Ontario. And I gather that there are other temporary closures, perhaps happening this summer. Why are those ERs closing? And maybe if you can give me your perspective from, the bird’s eye view. What does it do to the rest of the system when an ER in, a rural area like Minden, just shuts down?

Dr. Alika Lafontaine I think there’s a couple parts that listeners may not be fully aware of in this conversation. The, the first is, is that, these emergency rooms, especially in small towns like Minden, they’re often the only point of care that’s close by. So if these emergency rooms close for small towns, someone’s gonna have to get in their car and drive an hour, two hours, sometimes as long as five hours to get access to care. You know, I, I work in Grand Prairie, which is a city of 70,000 people. You know, it’s obviously a lot bigger in scale than Minden, but we, we run into the same sorts of problems with health services where if suddenly we lose a certain part of surgical capacity, now people are gonna have to travel four hours down to Edmonton, or seven hours down to Cal Curd. And that, that has a heavy weight on patients. Not only do they have to figure out how they’re going to travel down there, but then they also have to figure out how are they gonna survive while waiting for care, you know, accommodations, food, et cetera. And then you leave your whole social system as well. So it’s, it’s a very, very heavy weight. We do know from research that the farther you are away from acute and chronic care services away from where you live, the harder it is for you to have you know, the same sorts of outcomes as as other folks where it’s closer. You know, the, the other side of that is we don’t do a great job in the healthcare system at accommodating for help patients utilize systems.

Jordan Heath Rawlings Explain

Dr. Alika Lafontaine You don’t need an emergency room in every small town, but you do have to plan and prepare for how those folks are going to access care. So if you don’t have access, easy access to an emergency room, you then have to pour more resource resources into, you know, emergency medical services to make sure that people can be transported. You know, you have to pour more resources into virtual care and rural outreach. And I, I’m really concerned about small towns like Minden across the country where that type of planning, I don’t think is happening in real time, and that’s gonna have very negative effects on the health outcomes of those communities.

Jordan Heath Rawlings What about specific care in those kind of communities? And I ask you this because, there is a story about Alberta and, a good swath of the province. Obviously not the major cities, but has one, one person delivering the babies regularly. And other doctors have to come in and sort of perform shift work. For something that you would imagine for patients is quite anxious and needs a level of trust between them and, their medical care.

Dr. Alika Lafontaine I, I think in healthcare we’ve really reached a point where, where we allow things to happen that are just unsafe. You know, having a surgical service or a medical service like obstetrics, only having a, a single person for the size of that population, it, it, it’s objectively not a good way to design the system. And it objectively is very likely to lead to situations where patients will get exposed to harm from, you know, gaps in the system. There literally aren’t people there to support them. It leads to unsafe conditions where, where people overwork, where they’re overtired, where you know, they, they really can’t keep going on. You know, I don’t think patients often realize just how hard and how long people are being asked to work in order to keep the system that we have kind of stitched and glued together. The pandemic was an amplification of how long and how hard people worked. And I, I can see across the country, people are, are, they’re being crushed by the weight of that expectation. And there there’s a time delay between folks starting to feel the impacts and responding to the impacts of, you know, situations that are just untenable for any person in any field, and then the downstream impacts that happen that are delayed on patient care. And in those situations, if they keep going, it’s inevitable for patients to eventually suffer.

Jordan Heath Rawlings Let’s talk about access to primary care. your statement today says 4.7 to 6 million Canadians don’t have a primary care physician. And I guess my main questions about that are first, how did that number get so high? What had to happen, for that access to fail? And where are those people?

Dr. Alika Lafontaine There’s always a long tale to the stories that underlie the, the challenges that we have in our health systems. So 4.7 million Canadians, not having access to a primary care physician or a primary care team is something that’s been building over more than a decade. You know, we, we made decisions in training that decreased the amount of throughput that we had within our medical schools and training institutions. We made shifts in the working environments of family physicians. It became much more difficult for folks to keep sustainable practices going where they, they felt like they were still connecting with patients. You know, it, it’s very much a, a high volume, low-cost churn that the system wants. They, they want family physicians to see as many patients as possible at the lower dollar cost amount. And, and everyone can probably imagine that in that system inevitably, you know, quality is gonna suffer, but that, that real meaning that people get outta work is gonna disappear as well.

Jordan Heath Rawlings I wanna pause there cuz I want to ask you just to explain a little bit more about how that system works. Would that be the rates that these family doctors would get per patient making them have to rush through? Like how is it actually structured?

Dr. Alika Lafontaine Yeah, so the, there’s different ways that physicians in general get paid. There’s fee for service schedules where you have a certain chunk of money that the government puts aside, and then there’s different rules on how to access that. So doctors, every time that they see a patient in a fee for service model, they associate the activity that they do with a code inside that fee for service model, which then lets them access that money. The, the other ways that people practice are either on the other side of the spectrum where they’re salaried, or they have some sort of per hour or per month or, or some other type of salary that’s put in place. And then there’s, there’s things that are in between those two extremes. And I, I think for family physicians, when it comes to the, the financial part, you know, there there’s been cuts in the amount that they get paid per patient, changes in the rules on how they can access those types of things. There’s been additional burdens that have been placed on them without any additional resources. You know, if you look at, you know, COVID 19 and some of the after effects, you used to have public health, which is an, an enormous organization in every province and territory. Being responsible for following up on, you know, surveying, whether or not covid is a problem in the community, collecting that information, providing support to patients who you know, need additional healthcare supports. We downloaded all of that to family physicians. You know, there, there was a study that came out from Nova Scotia a couple months ago that looked at the amount of hours that people spend on this nonclinical work, and it’s in the range of, you know, 16 and a half million hours per year. That time has to be absorbed somewhere by someone. And, what family physicians in particular have been really struggling to keep up with is doing that work at the same time as having the same amount of resources, so that that spills into your time in the evening. That means that you have to come in early for work, or that means that you don’t see patients during the day, and that that all has obvious impacts for people trying to access a system where increasingly it’s confusing where to go, and increasingly it’s, it’s clear to people that doesn’t have the capacity to meet the needs and demands that people are asking you to do.

Jordan Heath Rawlings How do we create more family doctors? We can’t just make them outta thin air. How can we create them and make them want to go to places where they are needed?

Dr. Alika Lafontaine You know, I, I think the focus really needs to be on working environments, to tell you the truth. It, it’s always been interesting to be a part of these conversations and to see people take elements of supply and demand and ignore other ones. What’s the universal rule for people working in places? We go to the places where we feel treated best. We go to the places where we have meaning, and at the end of our workday, we feel like we contributed and we built something. And so how do we fix it? Well, we, we create better working environments. You know, we, we fix payment schedules. We make it easier for folks to deal with the demands on their time. We, we redistribute. What people actually do in their day. So it becomes more meaningful and more impactful. You know, and this may mean adding additional people to teams. This may mean shifting the types of tasks that family doctors do in the, the scheme of team-based care may mean creating different rules around how people are registered and regulated across the country through things like paning and licensure. So it’s easier to create teams of docs and teams of healthcare professionals who, who work together. But it’s, it’s really coming down to the question. Is what you’re doing going to improve the working environment of the person that, that you’re trying to keep in the job?

Jordan Heath Rawlings I want to ask you about solutions and we’ll, we’ll talk about maybe, proposed solutions in a bit, but first, there are some things that provincial governments have been actively doing, to try to help the system keep going as you put it. And a lot has been made recently, specifically about Ontario’s move following, Quebec and British Columbia to move some surgeries to private clinics. In your mind, is this a potential solution and, and why or why not?

Dr. Alika Lafontaine In in that discussion, it’s really important to be clear on what we’re talking about. I, I think in the discussion about public versus private, which the Canadian Medical Association’s really gonna lean into at the end of the summer through public consultations, is this idea that the presence of pay out-of-pocket versus public care is the actual issue for us to debate when in reality, I think it’s the proportionality, you know, the reason why Canada has an enormous opportunity to maintain equity and improve equity within Canadian healthcare systems is because the core of our financing comes from government. You know, and so as long as that public financing to pay out of pocket ratio remains weighted on the side of public financing, and as long as it’s a high enough ratio, which I think we’re still trying to figure out, international studies do reflect that, you know, you, you do end up having equity in the system, which I think is a core part of the discussion now. The second part is whether or not this is actually gonna solve our problem. Right? We’ve often taken the approach that if we don’t have access, then we just create a new location where people can have access. And I, I think in the context of health human resources right now, the, the fact that there’s not enough family docs to go around or they’re not in the right place downstream, there’s not the specialists and other healthcare providers that kind of support this ecosystem within healthcare. The fact that we, we don’t really track bottlenecks of where people have need of supply and demand in that context. I, I don’t know if this is the actual solution. You know, what, what we really need in healthcare systems across the country, including in Ontario, is a real push from the government to consolidate our understanding of where people are at, what they do, and where they have capacity to provide care. Not every provider is working a hundred percent of the time, 100% of the time, but we, we don’t have any data that that helps us guide. How to, how to help those people know where they can help at what time? And it, it definitely is not in real time. I mean, a lot of these measurements are months to years delayed.

Jordan Heath Rawlings Why don’t we have that? I mean, we have that for restocking products on store shelves.

Dr. Alika Lafontaine You know, it’s, it’s a great question and I, I think one of the reasons why we don’t have it is because, historically, we had health providers just kind of create workarounds. The reason why we really lean into this work longer, work harder paradigm when it comes to family physicians or nurses or specialists or whomever is working in the healthcare system, is because in the past it actually worked that the problem that we have now is that people don’t have any more to give. There’s been so many cycles of, you know, crisis. People are just tired. They can’t deal with the weight that’s on their shoulders anymore. And so that, that’s the reason why it wasn’t created. Now, should it have been created absolutely. But I, I think we’re getting a refocusing this year towards the need for data sharing. You know, some, some things that have happened this year that some Canadians might not be aware of is that with the funding agreements, there actually is a data framework that provinces and territories had to buy into. In order to access that funding you know, there, there was an announcement at the, the end of May on, on how this health framework is supposed to move forward from, you know, Infoway who is responsible for, for helping some of this stuff work in the federal government. I really encourage Canadians to kind of dive into understanding that because, having real-time data on how we utilize people and other resources in the system, I think is something we, we all need to become more literate in, if we’re gonna find our way out the other side of this crisis.

Jordan Heath Rawlings Because you just mentioned the cycles of crisis we’ve been in and their impact. I have to say for three years now, you know, we’ve been talking a lot to doctors, about covid and about its impacts on the system. The one thing that kept coming up even early in the pandemic was burnout and how it was going to impact the system when nurses and doctors who had been pulling extra shifts in, in dangerous places for months and months, finally fell out. Can you give us a sense of how that’s manifesting now that things are maybe a little calmer? And, and what are you seeing as the immediate danger at least recedes?

Dr. Alika Lafontaine The most, scary part about cycles of crisis is that the, the same pressure, even lower pressure feels just as heavy, as previous, you know, cycles. So I’ll use my own personal example. So in, in March of 2020, that that’s really when Covid became a focus for a lot of healthcare systems. That was the beginnings of, you know, the first wave where people remember lockdowns, et cetera. I, I remember it pretty clearly myself. I was sleeping in my garage. Because I was afraid this unknown airborne pathogen, you know, spreading it to my family. I was, at a moment’s notice ready to rush off to the hospital because I, I didn’t know the kinds of support that my colleagues had, but in the institution, I was worried about patients. I was sitting on a variety of different committees and by the fourth or fifth wave, you know, a lot of us started to recognize that the problems that we had pointed out over and over and over again, were not actually getting solved. We are still responding to a lot of these problems in the exact same way that we did in wave one, and a lot of us started to feel like it wasn’t useful for us to be around those tables. It wasn’t a good use of our time. It wasn’t a good use of time for the patients or colleagues that we were trying to support. And as a result, some of us started to check out. Like I, I still remember getting a call kind of in that, that third wave and thinking to myself, do I really wanna spend another eight hours trying to explain this to a another group of people when, when I’ve explained it, you know, hundreds of times. And I, I think when you look at cycles of crisis, people get tired of seeing things not change. And whether it’s covid or whether it’s our health, human resource crisis, which we’ve actually been in before in the late nineties. people lose faith in institutions because they do not act on the things that they know they need to do. And that’s the big challenge of, of moving through this in the next few months and years, is will the federal government, province, and territories sit down together and actually chart out that path to what comes after. And are they gonna support people who are telling them what needs to change, whether that’s patients or providers. And I, I think that we have to start showing that we’re responding to what needs to get done and showing that things are actually getting done. In order to restore that trust action is the best way to restore loss of faith.

Jordan Heath Rawlings Obviously that’s not gonna happen overnight, but you’ve released this letter, you’ve issued the call. The premier’s meeting is next month. We can’t solve all the issues. What is there that could happen at that meeting or immediately afterwards that would be a good first move that would, be an easy win that would actually have an impact. I’m not talking about, you know, an awesome statement about how we care so much about healthcare and we’ll fix it. What’s something that they could tell you or show us that there’s a plan here?

Dr. Alika Lafontaine Yeah. So, so just as you mentioned, one thing that is not going to take us the next place is get another statement with reassurances without action. But I, I think that action is, is something that is happening across the country, but we need to lean in it and, and, really accelerate and magnifying, you know, ever since the agreement that came around, the different types of funding within the health transfer that happened in, in, you know, February and March. There, there are folks coming together, gathering resources, and starting to figure out ways to deploy it. What we really need right now is, is to take the monies that have been set aside, and we actually have the largest nominal investment by a federal government since 2004 into the healthcare system. You know, and, and in 2004 when this happened, it wasn’t as big a of amount, but that, that led to big changes in the system. You know, we got the Wait Times Alliance out of this. We started to look at something called Clinical Pathways for the first time and reorganizing the system around patient flow and patient needs. You know, and, and I, I think the lesson that can be learned from the 2004 investment in everything that came after is that as long as people sit around the table and remain focused, On the same problem, and they actually listen to people who are going through the system as patients or as families supporting patients or you know, the providers who are working on the frontline change will happen, you know, but, but we need to see the federal, provincial, and governments sitting around the table remaining seated. It’s the getting up and walking away. That’s of greatest concern right now. Then I’ll say this as having managed hundreds of crises over my 12 years practicing as anesthesiologist and you know, all those years of training, you eventually make your way through things. You know, this crisis will eventually end. The challenges now to make sure that, that when we make it through, we’re in the best position to not fall into crisis again. You know, if we can stabilize healthcare systems. We can then move to that next step of, of rebuilding and, and making sure that we expand and, and support services again. But until we are sure that things are stable, which they are not right now. We, we have to remain focused on, on being there for, for people who need it.

Jordan Heath Rawlings Dr. Lafontaine, thank you for this and and I guess we’ll see.

Dr. Alika Lafontaine Thanks for having me.

Jordan Heath Rawlings Dr. Alika LaFontaine, president of the Canadian Medical Association. That was The Big Story. For more, you can head to TheBigStorypodcast.ca. You can listen to all of our reporting on the healthcare system through the pandemic. We did an entire week on it last fall. You will be interested to note that while some changes have been made, a lot of the problems Dr. Lafontaine identified still exist, and some of them are worse. You can find us on Twitter @TheBigStoryfpn. You can talk to us anytime by writing us an email hello@TheBigStorypodcast.ca, and you can always give us a call and leave a voicemail, (416)-935-5935. You can find this podcast any place you get ’em. And as always, I’m Jordan Heath Rawlings. Thanks for listening. We’ll talk tomorrow.