Healthcare crisis

The Ontario healthcare crisis

Of all current hot topics in Ontario (in truth, across Canada), the healthcare crisis is “number 1”.
Among recent headlines, a few (paraphrased, for brevity) stand out:

“ 53 per cent of doctors and 75 per cent of nurses reported burnout in 2021, a significant increase since 2017.”
“The healthcare crisis in Ontario system isn’t a seasonal trend – Ontario’s hospitals have been in and out of crisis since 2020.”
“While Doug Ford isn’t responsible for the crisis, he hasn’t helped either.”
“Hospitals and family practices were built to operate at almost full capacity – doctors and nurses work longer hours to meet demand.”
“Health-care workers deliver ‘all-we-want-for-Christmas’ card to Ford.”
“Ontario’s top doctor should provide health-care update”
“Five largest health care unions issue an urgent appeal to the Doug Ford government,”

Listening to, and reading, the barrage of strident protest, replete with exclamation marks, leaves me with an odd mix: amusement, outrage and frustration, mingled with a sense of irony and the recurring impression that mankind’s greatest fault is irrational thought.

Reporters, critics, “experts” – all those involved in the current discourse – ask “HOW?” – How to solve the problem of the healthcare crisis?

No one, it seems, is asking “WHY?” – Why do we have the problem?  

It hasn’t occurred to anyone: the answer to “why” will lead us to the answer to “how”.

BACKGROUND: “WHY”.

The Canadian hospital system never did have built-in redundancy.
The situation in emergency rooms such as the Toronto Western Hospital was not significantly different in 1970: in my time (1969–1974) there were always 3 or 4 patients lying on stretchers in the hallway, “waiting for a bed”.
The main difference, then-to-now, lies in the realm of healthcare staff availability, attitude, self-esteem and income.

History of a healthcare crisis

The notes below were taken from the “Canadian healthcare coalition”, at https://archive.healthcoalition.ca/tools-and-resources/history-of-canadas-public-health-care/,
They outline the history of Canadian healthcare, succinctly; but with sufficient detail.

The Canadian healthcare construct was envisioned by Tommy Douglas in 1947, promoted by Paul Martin (senior) in 1957, experimented with by Saskatchewan in 1962, proposed as a national institution by Diefenbaker in 1965 and tabled/passed into law, over the objections of the Canadian Medical Association, by Lester Pearson’s regime in 1966.
It was signed into law in Ontario in 1972, after the Ontario Medical Association accepted a “carrot on a stick” plan, by which 100% of doctors visits were paid for, in full.
(Previously, doctors would see indigent patients without charge and would accept 90% of their fee from private insurers, often without collecting the unpaid 10% from the patient).

The entire profession was captured in the plan, except interns and residents, who were paid “poverty line” rates, for which often, they had to be on duty in the hospital for 36 out of each 48 hours.
”Thinking” doctors, aware of government management style, were dismayed at the OMA’s acceptance of the proposal.

Notably, the plan would have included dentists, but they rejected it.

The “carrot”, initially profitable for family doctors, was very soon eaten by a combination of inflation and a non-indexed pay scale.

By 1977, the government (then in the care of P. E. Trudeau), reneged on 50-50 cost-sharing in favour of block funding.
By 1978, with the buying power of their income reduced by inflation, the “carrot” was no longer palatable, and many doctors began to “extra bill”.

1979-1982 saw the beginning of the healthcare crisis, with fed up doctors leaving the country.
It was a time when the cost of living increase rose to 14% and house prices doubled, and the government talked the Ontario medical Association into accepting a fee increase for Ontario doctors, of 3.2% in 1980 and another 3.2% in 1981 .
This was a de-facto admission of predatory management by the government, which engendered the disaffection of doctors generally and family physicians in particular.
Those who dared, began to bill patients for “extra” services, such as paperwork.

In 1984, extra billing was banned. Persecution of the profession continued, exacerbated by derogatory publicity in the press and was “brought to a boil.” in 1995, when Paul Martin (Junior) instituted the “Canada Health and Social Transfer”, reducing healthcare spending from 10.2% to 9.2% of GDP.

In 1986, Ontario’s doctors came as close as they have ever been, to forming a union: they staged a 3 week “semi-strike”, in which family physicians worked to rule and specialists accepted only emergency referrals.

1997 brought multiple hospital closures in Ontario, including 3 independent hospitals in downtown Toronto, by then-Ontario-Premier Michael Harris (a golf pro by profession). The hospital closures disrupted the medical practices and income of thousands of hospital-based specialists, with no compensation, no “golden parachute” and no offer of employment elsewhere.

A capitalist-oriented monopsony

From the standpoint of one whose memories of working in the Ontario healthcare system began in 1969, the Canadian government has consistently shown itself to be typically capitalistic in its management of healthcare.
The system instituted a monopsony, in which the price for goods or labour is set by the buyer.
In a monopsony, as in slavery, the disadvantaged employee has no recourse, the system is permitted to exploit its workers ad libitum and no decency is required of the business.

Thus, the healthcare system has exercised the basic principles of capitalism in its dealings with healthcare workers, viz: the all-powerful owner, whether an individual or a corporation, extracts maximum effort from workers, for minimum expenditure.

As an example, I was granted a license to practice in British Columbia in 1993, only to be told in writing, in the letter of approval, that the British Columbia healthcare system “would be happy to pay you 50% of the fee schedule”.

In 2018, the Ontario government introduced Bill 124: The Protecting a Sustainable Public Sector for Future Generations Act, limiting all compensation increases to 1% across the public sector for years. It defined compensation broadly to include all “discretionary non-discretionary payments”, and benefits – including vacation and sick days.

This was no worse than usual, but it did result in the departure of some nursing and technical staff from their jobs.

Nevertheless, the system persisted, admirably supported by altruistic doctors, nurses and ancillary staff, until December, 2019.
The Covid 19 pandemic began in 2020, quickly flooding the underequipped and underfunded, understaffed emergency rooms, hospitals and clinics to the point at which a majority of doctors, nurses, technicians, and general workers are burned-out and incapable of further effort. Doctors have continued to work because they have no recourse, but many nurses have sought employment outside of healthcare.

SO HERE WE ARE.

The answer to “why” lies in the general disaffection of government healthcare workers, outlined in “background”, above.

The answer to “how”, as is to be expected, is much more complicated than the answer to “why”.
It involves reconfiguring the entire system, so as to ensure non-replication of our current impasse:

• The “bricks and mortar” of the system should be redundant, in some degree, allowing for disaster response.
• Said bricks and mortar should be located outside of potential disaster zones, with multiple access routes, built-in emergency power supplies, in-house clinical test facilities, self-sufficient laundry and maintenance units, etc.
• We should not have four huge hospitals such as Toronto general, Mount Sinai, the Women’s Hospital and the sick Children’s Hospital, all within half a kilometre of each other, where one good earthquake, or a couple of bombs, would get rid of all four simultaneously.
• Long learning/training curve personnel should be redundant, to a degree commensurate with training time.
• Salary scales should allow “equal pay for work of equal value” as compared with non-government employment and should be standardized, country-wide:
  No longer should our doctors, nurses and technicians relocate to the United States of America for financial gain.
  No longer should administrative staff balloon, in the face of increasing bed closures.
  No longer should hospital-based specialists have to face the fact that the hospital manager earns more than they do.
• Attention should be paid to the social value of the healthcare professions:
  – a nurse relocating to a different hospital should not be forced to begin at the lower end of the pay scale.
  – medical qualifications should entitle our intensively trained professionals to work anywhere in the country, without subjection to insulting local licensing requirements and arbitrary pay-scale manipulation.
• Professionals (doctors, nurses, and others) immigrating to Canada can reasonably be required to complete our licensing examinations, but otherwise, should be made welcome.

IN OTHER WORDS

(1) Train more people than we need in uneventful times.

(2) Treat healthcare employees, professional and nonprofessional, at least as well as commercial enterprises do.

(3) Make sure that our hospitals and their emergency rooms have sufficient capacity for catastrophes.

(4) Make sure that our hospitals are equipped to handle all aspects of their operation.

(5) Don’t pay the hospital manager more than the cardiac surgeon and neurosurgeon.
(6) Ensure that seniority-based salaries and perquisites are transferable, in the event of staff relocation.

(7) Realise, and advertise to our citizenry, that our deficiencies hark back to the beginnings of the Canadian healthcare system in the 1960s and that correcting our current deficiencies will take time.

IN PARTICULAR, INCREASE AVAILABLE FUNDS

Reorganize the tax system, so that the wealthiest among us pay their fair share of taxes: thus, enable this country, which is arguably the best in the world, to live up to its promise for all our citizens.

Is anything going to change?

Put it this way, they don’t get it, and they’re still doing it: despite surging cases and reports of overwhelmed EDs, the government’s 2022 Fall Fiscal Update offered no new healthcare funding – keeping total spending at its April level.
That spring budget offered hospitals $68.414 billion, up slightly from $65.103 billion in 2021, a below-inflation increase, along with temporary covid-19 funds.
But don’t blame Doug Ford, or any other individual politician: our society is based on “dog eat dog” and the problem with healthcare is the difficulty from which employer–union relations has always suffered.