Ontario’s health-care agreement with Ottawa will not fix broken system
The federal-provincial agreement represents more central planning designed to fix problems created by central planning
Published Feb 13, 2024 in the National Post
Prime Minister Justin Trudeau and Ontario Premier Doug Ford congratulated each other last week on signing a $3.1-billion, three-year health-care agreement, ending two years of haggling.
In December 2022, Trudeau had said there’s “no point putting more money into a broken system.” But by February 2023, Trudeau had forgotten his point and signed a $196.1-billion deal with the provinces. It included side deals with individual provinces to be worked out later, which we saw in Ontario last week.
Trudeau is not the only one who changed his mind. Throughout 2022, the provinces fought for a $28-billion increase in transfer payments, with no strings attached. But they settled for $17 billion, with strings to be sorted out later.
Premier Ford seems pleased that his side deal trimmed Trudeau’s strings down to a three-point plan, centred on primary care and data sharing. Health Minister Jean-Yves Duclos had initially demanded five broad and more substantive deliverables.
In a statement, Trudeau’s office said that, “Universal public health-care is a core part of what it means to be Canadian. It is the idea that no matter where you live or what you earn, you will always be able to get the care you need.”
Notice the language here: an “idea” is not a promise or a guarantee. Actual delivery of care is not part of the deal.
Maybe that’s unfair. Perhaps the three-point, strings-attached plan is in fact a promise.
The first string forces an increase in new primary care teams throughout the province. Family Health Teams (FHTs) offer a basket of bonus services patients would otherwise have to pay for themselves. Physicians in FHTs get a small army of helpers funded by government. Is it any wonder everyone loves them?
The second string promises 700 new spots in medical education. If the new physicians are fully trained in Canada, they would need to split the 700 spots between undergraduate and postgraduate training, potentially creating 350 more doctors per year.
Canada has always poached many of its physicians from other countries: one in four physicians have historically been foreign trained. So it’s a nice gesture to try to train more of our own doctors.
However, the gesture will take between 11 and 15 years to help the 2.3-million Ontarians who don’t have a family doctor. Family doctors need four years of medical school, plus two to three years of residency. Even if all the new doctors open a full-time, 1,500-patient family practice, it will take 11 years to close the gap.
But many family doctors carry far fewer patients, and the 350 new spots would probably split between specialists and family docs. A more realistic estimate would generate 175 new family doctors a year, who each care for 1,100 patients. That would create a 15-year wait to meet current needs.
But it gets worse. Many medical students avoid family practice at all costs. In 2023, 100 family practice training positions in Ontario went unfilled. Opening spots in a program that students avoid seems absurd.
In family practice, computers and paperwork have replaced patient care. Family doctors spend 19 hours on paperwork each week. To make matters worse, primary care usually gets hit hard when it comes time for governments to cut fees and funding.
Economic uncertainty is no way to foster growth. To stay sane, most family doctors limit office practice and pursue palliative care, hospitalist medicine, emergency medicine and other areas of focused practice.
The final string includes a promise to upgrade the digital infrastructure in hospitals, capture more data and share it with the federal government. This sounds nice, but the challenge has always been the cost of data collection, and how to determine what to measure. Not everything we measure matters, and not everything that matters can be measured.
Ontario is the fifth province to reach an agreement, after British Columbia, Alberta, Nova Scotia and Prince Edward Island. Each province seems pleased, even with relatively small agreements — like bulls being led by small rings through the nose.
Writing about the fall of communism in 1990, Robert L. Heilbroner, an economist, best-selling author and lifelong socialist, noted that the “system deteriorated to a point far beyond the worst crisis ever experienced by capitalism; the villain in this deterioration was the central planning system.”
The latest federal-provincial agreement represents more central planning designed to fix problems created by central planning. Maybe it’s time to try something new?
How do we get this message across to the public? Why do not all the media sources not share this information and show the misinformation that the governments spin?Physicians knew it takes 10-12 years before increased training spots result in increasing practicing physians. The attrition rates of healthcare providers continues to exceed population growth and the entry of new providers into the system.
Lowering the quality of providers by relying on immigration from unsatisfactory training programs and individuals with different cultural backgroumds is a terrible solution fhf only decreases quality care.
Who ae going to be the mentors?
Burned out physicians who are already overburded!
Don — great points!
The pool of unattached patients grows quickly
We don’t have capacity to accept a ton more trainees
And people are fleeing family practice!
Yes, very few seem interested in scratching beneath the surface of these announcements.
1. We need more care.
2. Governments must decide who’s in charge.
3. We need to get serious about appropriateness — we can’t cover everything
4. We should let provinces innovate. Friendly interprovincial competition would help identify better ways to function.
Thanks for posting!
The truth will always remain the truth. Family physicians are woefully underpaid , especially given the reality that the costs of maintaining an office, competent staff, and updated computing systems far exceed the government’s “ funding” of the typical Family Practice. This problem remains after this funding to the Provincial Government.
No one wants to point to the obvious . Family Physicians are underfunded. Until this is corrected , the problem will worsen; and the crisis will deepen. Senior citizens ( of which I am one) will have diminished access to care.
“Poaching “ foreign graduates will mitigate this only marginally (at the price of disadvantaging their country of origin from their services in their culturally familiar system of training : an ethical issue which seems to be ignored). Training more home grown Canadian Physicians has always been the correct approach … but the numbers suggested here will fall short .
So what is the real problem. When you offer “free services “ in a market economy with infinite demand ( and rising) , society will not be able to afford the costs , even collectively.
The Canada Health Act must be amended to allow for a hybrid system of private and government funding. Until that happens, nothing will change. Government officials that say otherwise are either uninformed , misinformed, or less than honest about the truth. I will let you draw your own conclusions.
Fantastic comments, Charles. (I arbitrarily added paragraphs to your comment to make some of the points jump out more … I hope that’s ok)
Underfunding = fewer doctors + fewer services
Poaching is not a longterm solution
All-you-can-eat care must be rationed somewhere. In our current system, it is rationed behind the counter: smaller plates, fewer plates to choose from, long lineups at the buffet.
Changing the CHA from “must” be publicly administered to “may” be publicly administered would help. But the feds still think they can meddle in Section 92 issues (that is, they bribe provinces to change behaviour). This is a constitutional issue. You cannot have two cooks making the same stew.
Thanks for reading and taking time to post a comment!
Shawn
🙏
What is the tipping point that leads to
meaningful change?
Most all of my colleagues retired early ( withdrew from practice) years early. Let’s say twenty highly experienced family physicians retire in a community (the one I practiced in) , each having 30 or more years experience. That represents a loss of 600 physician-years of experience and put 30,000 patients with reduced care alternatives. You cannot replace this with a few more medical school enrolements or by parachuting some Foreign Medical Graduates into town.
What is the government thinking ? Perhaps the answer is in the question( Government Officials, are not thinking … they are also fundamentally bankrupt; and that is to be intended in all nuances of the word)
I am happily retired(early) My former patients are not quite so happy with the outcome. Many inexperienced and early career physicians avoid patients requiring complex comprehensive care . These patients end up in crisis and in Emergency Departments.
The Ministry of Health is the author of its own problems. The Canada Health Act is the precursor to all this. Politicians are afraid to change the Act because it may lead to loss at the next election. It is necessary to have courage , honesty, and character to tackle this dilemma. Unfortunately, most politicians do not demonstrate courage, honesty, or character. It is easier to blame healthcare workers.
This will change … only after the entire system collapses ( and that collapse will be blamed on healthcare workers) … The fix will be a hybrid system. Healthcare workers will be blamed. The political class will claim innocence. The world will continue. Many patients will pay the price in grief, uncertainty and loss. That is the truth. Politicians don’t really care until their loved one is ill. The general population is unaware of the problems until they or a family member needs care. We need honesty and character in our leadership. We don’t have that at the present time.
It is sad to watch.
Another set of excellent comment, Charles — thank you! (I added paragraphs again to make your points pop out … I hope that’s ok)
You, and docs like you, have powerful stories to tell. For example, “Most all of my colleagues retired early ( withdrew from practice) years early.” Most people aren’t aware and do not care (why should they?) until their own access to medical care is compromised.
Our society promotes envy as social virtue. We repudiate everything from the past. Voters WANT to see a fancy car and nice office when they visit the lawyer: Must be a great lawyer! But they rankle when their doctor drives anything nicer than a new Honda.
Doctors naturally want to help patients; they get intrinsic rewards from solving a puzzle, doing something worthwhile, and receiving appreciation (in the past) from patients. Then if we add some social plaudits and a remuneration structure that rewards outstanding effort (evenings, nights, weekends, long hours, etc), then doctors will literally work themselves to death. They get a dopamine hit from offering the service PLUS a shot of reinforcement when they get paid next month.
But we’ve destroyed that. Medical care is an entitlement. Patients are angry and suspicious that you are holding something back. They resent the fact that you have to do 19 hours of paperwork — “Why wasn’t your office open when I needed to see you?!” Voters assume doctors are loaded simply by working 37.5 hours per week. And the coup de gras, the government and regulators assume doctors are basically knaves: professional criminals who will cheat the system at every turn if we don’t have strict rules controlling as much behaviour as possible.
And then society clutches its pearls and gasps, “But where have all the family doctors gone? Why are medical students avoiding primary care?!”
Thanks again for your comments — they inspired a rant in me. 😀
Cheers
We have been poaching family physicians from other countries for decades–darn good doctors by the way. This has not solved our shortage of physicians.
Training more Canadian physicians is an obvious part of the solution, but back in the 1990’s governments decreased the number of medical school spots in Canada. Why? To save money. The government considered physicians to be part of the problem of funding medicare. It was said that each physician produced $400,000 of costs to the government healthcare system. This was not for the physicians’ incomes, but this was for the blood tests, diagnostic procedures and surgeries generated. That’s right, physicians were blamed for “creating” costs by treating patients. The assumption seemed to be that we dragged people off the street, made them patients and then ordered tests, referred patients and made patients have surgery. I wonder if the government considered the fact that patients might really need medical care.
Politicians were forced to create a health care system that was free, cheap and unlimited. The politicians were forced to promise this but creating it was impossible. In my mind the only feasible way to “save” Canadian Medicare is to redefine it: its purpose and what it can deliver.
Brilliant comments, Gerry.
“In my mind the only feasible way to “save” Canadian Medicare is to redefine it: its purpose and what it can deliver.”
Precisely. Once we sort out who’s in charge (governance) by either following the Canadian Constitution Act or amending it, we must talk about purpose and appropriateness.
Currently, medicare is a redistribution program (as Romanow called it) that promises all you can eat of everything you can lobby the government to provide. This is not sustainable.
Thanks again!
Hi Shawn,
Central planning …. eh comrade ???
The soviet system used it extensively.
Decentralization in the form of a European hybrid system is the only solution,I believe.
Portugal,France,Germany are reasonable examples.
Better for patients and doctors.
In the meantime …. Nero(our politicians) fiddles while Rome(our patients and docs) burns.
Well said, Ram
Hybrid works. This is not a debatable point. Only blind ideology blocks us from trying anything different.
What gets me worked up is all the political pretending that any 3- or 5-point plan will fix it.
Great to hear from you!
Cheers
Hi Shawn,
As usual the only important people that would benefit most from what you wrote, I am speaking of, Premiers Ford and Trudeau won’t read it and likely wouldn’t understand the core principles and they certainly wouldn’t know what to do. Unfortunately their advisers don’t seem to understand the basics of managing the delivery of health care. I am not an expert on that matter either but could understand a good plan and do understand what you have talked about. Many people know the system is broken and pouring more money at it without massive changes will not work. That has been the action taken for at least 30 years. As Trudeau said so clearly Universal Public Health care is an idea in fact I would add a great idea but will always be an idea because it will never become reality in Canada.
Great point, Graeme.
Those who know cannot speak. Those who have the power to make change do not seem to have time to learn.
I think it comes down to first principles: do we believe that governments offer the best, fairest, most efficient way of doing things? Or do other approaches exist?
Thanks for taking time to post a comment!
Cheers
Be careful when you use the “fair”. “Fair” is defined in the eye of the beholder. “Fair” is a word used to promote an agenda.
Agree!
Thanks, Gerry
Thanks Shawn so much for creating a “platform” for all of us particularly for those of us too “old” to create our own. My final comment this time around: The decline in Health care services especially primary care started about 1985 when there were no longer any doctors that work for their patients. That was the time all clinical doctors including me worked for “the Government”. Up til then I was able to practise “fee-for- service” accounting with my patients. (outside of OHIP, yr approx).
Thank you, Graeme for sharing you wisdom.
I agree that 1984-86 put the nail in the coffin of medicine as a profession, in the original sense of being a professional.
Only 1.3% of physician remuneration came from so-called ‘extra-billing’, as the media and leftists called it (docs, as you know, called it balanced billing: the ability to make up the balance of what the government had initially promised but then refused to pay).
Journalists laughed and made fun of doctors for going on strike in 1986 for such a puny amount: 1.3%! How absurd!
Of course, doctors were not on strike because they were losing money. They went on strike because they were having their profession usurped by government. The ability to bill — even if that ability was RARELY exercised — was the last vestige of what it means to be a professional. Thereafter, medical fees, services, volume of services, management of services, and everything else to do with medical care was either directly determined or heavily shaped/regulated by government.
The whole concept of a professional had been redefined, as it applies to medicine.
… best not to think about it too much. Although it’s clear in hindsight, it is painful to think about.
Cheers
1984-86 were the years that I was betrayed by a Public that never understood that I was not in medicine to make a fortune but to help society. My personal finances were supposed to be something that were just an aside. I made that decision in high school. I took the Public’s attacks very personally. I continued to do my best for patients but never felt the same about my career.
I went on strike in 1986 so that years later I could tell my younger colleagues that I tried to prevent the disaster that is now our healthcare system. I am only surprised that it took so long to collapse. Or maybe I should say that our healthcare system collapsed about 20 years ago, but the majority of Canadians did not realize it until later.
Gerry
THIS is key: “I took the Public’s attacks very personally. I continued to do my best for patients but never felt the same about my career.”
Physicians respond foremost to the drive that comes from inside them. Curiosity. Challenge. Compassion. Friendly competition. The desire to do meaningful work. The passion to excel. The joy from a job well done. Revelling in the respect society (once) offered.
These are intrinsic motivators. Physicians bring the drive, passion, and curiosity to the job (similar to nurses and others in the caring professions). The system either PROTECTS and FOSTERS those vital elements (drive, passion, curiosity), or the system crushes them.
“I continued to do my best but never felt the same about my career.”
Governments, politicians, civil servants, and administrators fundamentally misunderstand this. They are blind to the idea. You cannot crush someone’s drive and hope to get it back. Once gone, it is not recovered (or only very rarely).
Thanks again for posting. It breaks my heart to have seen so many bright, eager students slowly extinguish after a few years of rules, union grievances, useless meetings, frivolous complaints, covering your butt instead of caring for the patient, promotion of incompetence, and on and on. What’s worse: the pundits blame this process on the people who work in the system (us). WE ruin the new ones, not the system. It reminds me of Mao’s Great Leap — we need to get rid of the old so that they don’t poison the new.
It could be SO much better, if the planners restrained their lust to fiddle.
Hi Shawn and all those that have left comments,
I appreciate very much this discussion because it outlines clearly why our health care system is failing. we also know why it is not going to get better because no understanding by those designing the system as to the root cause of the problem. “The Client/Patient” is expected to take some responsibility for the provision of their own health care……. Go from there remembering that individual is the most important person. Pretty simple!
Thanks for this, Graeme.
I’m glad you mentioned individuals. I’d add ‘relationship’.
Whenever you need anything — legal advice, accounting help, even plumbing services — you ask your friends whether they “know a guy” who can help. We all want to know someone, so that we can call them when we need help (accountant, dentist, doctor, mechanic, etc.).
At the bedside, I see three separate things:
1. A patient (someone in a vulnerable state)
2. A promise to help or heal (made by a clinician)
3. Action taken to fulfill the promise (care)
Planners do not see this. They see technological services and the cost of delivering those services. If the service cannot be measured (e.g. “You do not need surgery at this time”), they struggle to assign any value to it.
I agree that patients have agency. And they are in a state of vulnerability (not the same as being weak or powerless).
The only way to address agency and vulnerability, at the same time, is within a relationship built on trust. Again, planners cannot put this into a spreadsheet.
Thanks again for posting,
Cheers