The COVID-19 pandemic exposed long-standing shortcomings and inequities in the Canadian healthcare system. While various publications have attempted to describe the root causes of these challenges, the subject is not new. In 1952, medical columnist Sidney Katz published a report in Maclean’s with a captivating title, “The High Cost of Being Sick.” The same Maclean’s issue also had three other articles by Katz: “The Doctors,” “The Hospital” and “Health Plans,” which provide details of the Canadian healthcare system prior to the introduction of medicare.

In The Hospital, Katz utilized qualitative and quantitative data from the hospital sector to provide an interprovincial comparison of the cost of care delivery in the early 1950s. The article is still relevant today because of its high-calibre policy analysis and the surprising similarities to current Canadian healthcare challenges.

History Repeats 

The Hospital begins with a case study about a young boy, Billy, who underwent a complex leg fracture surgery. Katz describes Billy’s journey through the healthcare system, including the intense use of health human resources (HHR) and the complexity of healthcare delivery in an acute-care setting. The article features a photo that displays 52 people with diverse roles (clinical team, administration and support staff) who have been involved in Billy’s care, with a combined monthly salary of $12,530 (equivalent to $125,655 in 2021). In another case study, Katz described a husband’s challenges dealing with the social and financial aspects of his wife’s hysterectomy, followed by the micro-costing of an episode of hospital stay despite there being no electronic health records. 

The Hospital takes the reader on a coast-to-coast journey and examines the patients’ and healthcare system’s challenges. Katz used surveys and research to portray the key issues in the hospital sector: the high cost of running hospitals, bed shortages, overcrowded wards and scarcity of trained HHR. He quotes interviewees and specifies examples of those challenges: 

• a $400,000 deficit in 1951 at the Victoria hospital (equivalent to $4.15 Million in 2021); 
• a widespread shortage of hospital beds except for small-town hospitals;
• overcrowded corridors; and  
• emergency department (ED) patients being accommodated on kitchen floors before transfer to corridors.

Sadly, the hospital system’s challenges seem to have transformed from acute to chronic. In 2021, the same issues have persisted. 

Katz proposed ten actions (from 1952) to solve those problems, paraphrased and simplified below:

1. Limit people in hospitals by improving public health, preventative measures and early detection. 
2. Achieve adequate hospital financing through private pay, philanthropy and government support.
3. Increase capacity (build hospitals, train staff) based on regional and local needs. 
4. Build functional hospitals that are easy to maintain (some new hospitals are 20 years old when they open!).
5. Reduce hospital operating expenses with better management.
6. Get long-term chronic patients out of the acute-care hospital (chronic-care hospitals should be near the general hospitals to be able to use their facilities but should be focused on rehabilitation).
7. Transition convalescent patients out of the acute-care hospital to less costly settings. 
8. Hospitals must have a homecare program and discharge patients at the earliest possible moment, then continue treatment in the patient’s home. 
9. Invest in welfare services for the incurable, the aged and others who require such care. 
10. Educate the community and medical professionals to use hospital facilities economically.

Analyzing data relevant to Katz’s proposed solutions and comparing Canada with other advanced economies’ healthcare systems may help us better understand the underlying cause of the problems.

Intriguingly, Katz starts his recommendations with public health (item #1). However, since the report was published, the most notable achievement was the enactment of the Canada Health Act (CHA) and the creation of medicare (item #2). Similarly, all provinces have old-age support and services, have enacted home care and long-term care legislations (items #6, 7, 8) and have built infrastructures to provide these services. Hospitals have early discharge protocols, and professional schools have trained many healthcare professionals (item #3). 

Hallway Medicine Persists

With so many critical recommendations implemented, it begs the question of why we still have hallway medicine 70 years after that MacLean’s report. The clue might lie in the availability of HHR and hospital beds: according to the Canadian Institute of Health Information (CIHI), in 2019, 91,000 doctors were practising in Canada. 

Comparing the number of healthcare professionals across Organization for Economic Cooperation and Development (OECD) countries highlights the need for additional recruitment and training in Canada. In 2020, there were 2.8 doctors per 1,000 population in Canada, while the ratio was 4–5/1,000 in Europe. Austria ranked first with 5.4 doctors per 1,000 population. Canada ranked 24th out of 31. Similarly, Canada has a noticeable shortage of nurses. The OECD reports ten nurses per 1,000 population in Canada, while Norway and Germany have 18/1,000 population. 

Furthermore, the healthcare professional’s burnout due to the pandemic has added substantial pressure to the healthcare system that has affected care delivery, exacerbating surgical and diagnostic imaging wait times and cancellations of surgical procedures. Delays in surgeries have profound consequences: as MacIsaac et al. report, emergency surgery delays increase the likelihood of mortality by 56%. According to the CIHI, one-third of operating room (OR) delays were related to HHR. Delays in the OR turnaround time of 25–40 minutes have the downstream effect of increasing OR occupancy by 78% and delaying succeeding surgeries. 

The hospital bed shortage, especially critical care beds, is another serious problem in Canada. Comparing Canada to OECD countries with similar healthcare systems – publicly delivered and regulated – highlights that Canada is lagging its peers in the number of beds available. Despite rapid population growth, the newest hospital to open in Ontario in the last three decades began its planning phase in 2003; it broke ground in 2014 and opened its doors in 2021 (18 years later). The lengthy project’s timeline looks a lot like Katz’s item #4 from 70 years ago.

One might fault the wait times, especially surgical wait times, on funding policies. The hospitals’ global funding model disincentivizes hospitals to increase surgical volumes. Whatever the cause, the cumulative lack of timely investment in training healthcare professionals, bed capacity and modern technology is a vortex that will pull the system into deeper troubles. 

Furthermore, advancements in medicine and technology have helped people live longer. However, people unavoidably fall ill, and, often, their ailment becomes a chronic condition. The Government of Canada reported that the prevalence of common chronic conditions, such as diabetes, cardiovascular disease and neurological and psychological conditions has substantially increased over the past three decades. 

The perceived solution for chronic disease management has been increasing or creating services within the acute-care setting. Frequently, patients with chronic illnesses have long, and often unnecessary, hospital stays, creating another problem. About 12 to 15% of hospital beds are occupied by patients waiting for alternate levels of care. Unnecessary hospital stays start a chain of events, including EDs’ inability to admit patients and hallway medicine; surgeries are delayed until post-op beds become available; hence, unacceptable surgical wait times bring us to items #1 and #9 on Katz’s list. Increased investment in the most expensive location to deliver care – the hospital – may not solve current systemic problems. Admittedly, hospitals have always been in fiscal crisis mode. The solution, according to Lundberg, is to shift care out of hospitals and out of the healthcare system. 

In the absence of a fundamental shift in care delivery from a hospital-centric model to a patient-centric model, the current problems will persist

Additionally, one of the core principles of the CHA is equity. Although the healthcare system custodians are doing their best, the rapid changes in demography and Canada’s large landmass make equitable access to care, especially for subspecialized care, even more difficult. 

Rapid, Agile Policy is Possible

In response to the COVID-19 pandemic, policymakers rapidly adopted new policies driven by societal pressure and urgent needs. For example, for decades, enabling technologies and secure communication channels existed for remote patient management (RPM). One of the barriers to the widespread use of RPM was physician fee codes.

During the pandemic, almost all provinces swiftly created physician payment codes to facilitate RPM, which many stakeholders, including patients, have asked for over the past decade

RPM is not just convenient; it is timely, safer and readily accessible when performed appropriately with the right patients. RPM makes specialty and subspecialty care equitable.  

An extension of this concept is robotic-assisted surgery. The equity and quality of surgical procedures are not consistent in all regions. The most experienced surgeons often practice in large hospitals with the latest technologies available, which are not as ubiquitous in hospitals located outside urban centres. One solution to improve the efficiency and accuracy of less experienced surgeons is the use of robotic-assisted surgery, which can democratize access to high-quality, specialized surgeries. In the past few decades, robotic-assisted surgery has advanced enormously. Unfortunately, the adoption of robotic-assisted surgery has been delayed by misinformation and often inaccurate health technology assessments (HTA). For example, a report from Health Quality Ontario in 2017 questioned the value of robotic-assisted surgery in prostatectomy. The report’s retrospective analysis of published literature found equal outcomes between robotic-assisted surgery and conventional prostatectomy. However, a major difference in the review process for advanced technologies compared to conventional HTA (e.g., pharmaceuticals) is the operator’s learning curve and, more importantly, change management for the surgical team and OR processes. Over time, the outcomes of surgeries improve, complication rates decline and efficiencies increase. Interestingly, an Alberta HTA in the same year included real-world evidence in its analysis and concluded that robotic-assisted prostatectomy is excellent value for money with better outcomes. 

Of note is that the traditional evidence review process of HTA agencies does not consider healthcare system limitations, such as those previously discussed (e.g., HHR and capacity). The practical implementation factors, including equity in access to advanced care, are missing from these reports. Furthermore, in a patient-centric healthcare model, the outcomes of a procedure should focus on what is important to the patient. For example, a recent study showed that prostatectomy patients are more concerned about the complications of the procedure (e.g., impotence and incontinence), while HTAs focus on mortality rates.   

A vision for the future 

We need a transparent and open discussion with the owners of the healthcare system – the people. The healthcare decision maker must define the current system’s advantages and a few disadvantages inherited from the past decades. Following Katz’s approach, one could envision a future where the following happen:

1. Hospital 3.0 has flawless connectivity, fluid processes and budgets (breaking down silos), and optimal use of advanced technologies to improve patient outcomes and reduce dependence on human resources. 
2. Substantial investment happens for short- and long-term care at home: there are new policies, funding and investments to leverage current technologies in this field. Canadians benefit from integrating advanced technologies at home, such as digital home platforms, monitoring devices and data management systems to reduce the disease burden on patients and caregivers. 
3. The investments in the healthcare system use the return-on-investment principles and cycles: rationale and objective investments made today save tomorrow.
4. The “digital native” generation, including healthcare professionals, transforms healthcare. The concept of privacy for “digital natives” is different from that for the previous generations. They expect seamless and easy digital access to health data. 
5. A close collaboration between the health industry, policymakers and administration fosters an agile, patient-centric, need-based policy and investment. In this context, as an integral part of the healthcare ecosystem, industry will be a solution provider and perhaps the most promising group to collaborate with to achieve systems’ financial goals.

After all, who thought a completely new vaccine could be manufactured, evaluated, approved, and globally distributed and administered in less than a year?  

Conclusion

Solving the Canadian healthcare systems’ chronic difficulties requires an objective, bold mindset that puts equity and timely access to quality care at the forefront of patient-centric healthcare policies. Seventy years after the Maclean’s report, the Canadian healthcare system still faces the same challenges. However, today, advanced technologies, including remote care, minimally invasive surgeries and artificial intelligence that facilitate access to care and improve efficiencies, can provide concrete evidence-based solutions to some of Canada’s healthcare challenges.

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