Health care in crisis: How do we move forward? 

In Canada, Newfoundland and Labrador has the highest rate of deaths from cancer, the second-highest from cardiac disease and the third highest for stroke. We have the highest level of complex health needs among children, the highest rates of obesity among adolescents, and the highest proportion of older people with three or more chronic illnesses. 

If these facts don’t speak for themselves, we also have the shortest life expectancy — at least 2.6 years below the national average.

Then there’s the climate emergency, giving us extreme weather events and changes that are causing additional problems for health outcomes, particularly for Indigenous communities in Labrador.

If that’s not bad enough, the province’s population is decreasing — in some areas by more than 40 per cent. Fifty years ago we had nearly 200,000 children and 32,000 people over the age of 65. Now we have only 70,000 children and the number of residents over the age of 65 has increased to 118,000. 

The implications for health care are now becoming clear. “The rapid onset of that population shift, linked with outmigration related to the cod moratorium in the early 1990s, was associated with a health system not built to cope with the shift from a focus on younger people with acute illness to older people with chronic illness.” 

That quote comes from Health Accord NL, published in February 2022 after comprehensive consultations with residents, community groups, health-care providers, Indigenous groups, unions, seniors, and others.

It’s an admission by the government that the emphasis on acute care no longer suits our demographics. But the Health Accord goes further and acknowledges that “social, economic, and environmental factors have more influence on [a person’s] health (60%) than the health system (25%) or our genetic make-up and biology (15%).”

This is a game-changer given the province has increased health system spending by 232 per cent over the past 38 years, while social spending — excluding health and education — has increased by just six per cent.

In seeking to address this imbalance, the Health Accord advocates a shift away from the hospital-centered, acute care model for health care we’ve embraced for so long. The objective is to replace it with one emphasizing primary care and a collaborative community care teamwork model where patients have access to multiple perspectives. It is a seismic shift — a positive one.

The collaborative care model

The Health Accord proposes establishing 35 family care teams around the province over a 10-year period. Nineteen are already in place with another four to be opened this year, signalling the gradual abandonment of the family practice model that has serviced the province for decades.

Collaborative care addresses the current crisis that has left 136,000 residents without a doctor by including in the family care teams salaried nurse practitioners who will write prescriptions, order tests, and make referrals. Government intends to expand that authority to other nurses once they have completed specific training.  

Pharmacists will be part of the teams, too, helping to ensure the drugs patients take don’t contradict each other — an important addition given one in four Canadian seniors now take 10 or more prescription drugs. 

The teams will also include other health professionals, like psychologists, dieticians, physiotherapists, and dentists. And then there’s the addition of social workers, who can connect patients with community services that can help them — a long overdue recognition of the link between poverty and illness. 

It’s anticipated that access and exposure to different health care perspectives will influence a ‘culture shift’ in which Newfoundlanders and Labradorians place greater emphasis on achieving and maintaining good health. Rather than seeking to “cure” us, the collaborative team’s mission is to address and respond to the social and economic determinants of our health, including dietary issues. From a medical perspective, it’s hoped this will lead to better management of chronic disease, fewer hospital admissions, and shorter lengths of stay. 

All of this should benefit the province’s long-term finances. Newfoundland and Labrador’s per capita public funding of hospitals was the highest in the country in 2020. Hospital expenditures are a big reason why our province spends 20.5 per cent more per capita on health care than the average across all Canadian provinces. According to this year’s provincial budget, approximately 40 per cent of government spending will go toward health care in 2024.

Hospitals and emergency rooms

According to Health Accord NL, 20 per cent of all acute care beds are occupied by patients who don’t require the level of services provided in an acute care setting. Most are elderly patients. In 2016-2017, seniors accounted for 19.4 per cent of the population in St. John’s, for example, but 58 per cent of acute care admissions. The accord estimates that approximately 300 provincial hospital beds across the province are filled each day with patients who would be better off in a long-term care facility or with home support, if these services were available to them. 

In turn, it proposes implementing a “Frail Elderly Program” composed of interprofessional teams trained in geriatrics. These would be based in hospitals and emergency rooms with a focus on outreach to family care teams and other supports in the community. The objective is to strengthen the ability to “age in place” — one of the most common requests heard throughout the Health Accord engagement sessions.

But there is another problem: overcrowded emergency rooms, particularly in urban areas, caused in part by a shortage of family physicians. In St. John’s, the Liberals have leased and are repurposing the former Costco building in the city’s northeast end as an “ambulatory care hub” for patients who don’t require overnight hospitalization.

As for hospitals in rural areas, the accord recommends relocating some of the specialized services and surgeries to larger hospitals. This will further necessitate the expansion of ground and air ambulance services.

Servicing rural communities

According to the Health Accord, Newfoundland and Labrador has 19 rural health centres with on-call 24-hour emergency room service, most of which have at least a few acute care beds. Unfortunately, they struggle to retain personnel. Between 2018 and 2021, turnover rates for physicians reached 75 per cent in St. Anthony, over 60 per cent in the two Labrador hospitals, and over 50 per cent for Burin, Carbonear and Clarenville. For family practitioners the statistics were equally high. During the same period, turnover rates were the highest in Labrador-Grenfell Health (114 per cent), followed by the rural areas of the Eastern region (76 per cent) and central Newfoundland (71 per cent). Finding locum replacements to fill the gaps has become increasingly difficult. 

Government intends to integrate the health centres with collaborative family care teams set up in their areas to produce mutual support. The province is also committing to better connect health centres to hospital emergency departments, ambulance services, and virtual care hubs.  

Virtual care exploded on the scene during the Covid-19 pandemic and is now very much a part of the health care landscape. The government is planning to expand it, particularly in rural areas vulnerable to doctor and nurse shortages. While virtual care can take the form of connection by telephone, the preferable option will be using digital platforms where patients can see the person they’re talking to. But this also comes with important questions. Will older residents be comfortable using this technology? Will the federal government’s commitment to high-speed internet across the province by 2026 be on schedule? What about residents who simply can’t afford the technology?

The good news is, virtual care will be reinforced by connection and outreach from family care teams and, depending on the region, well-equipped traveling clinics. If Health Accord NL recommendations are accepted by government, this could include “allowing paramedics to operate in expanded roles by assisting with primary health care and preventative services to underserved populations in the community.” Government has already committed to modernizing, expanding and consolidating our air and ground ambulance system into one integrated unit, albeit partially privatized.

Creeping privatization

The Health Accord’s recommendations unequivocally support bolstering primary care. Yet, since the accord was released two years ago, our government has zigzagged in the opposite direction by continuing to emphasize acute care priorities. Just months after the accord’s release the Andrew Furey government announced plans to build a new hospital in St. John’s to replace St. Clare’s Mercy Hospital — the third large hospital construction initiated over the last six years. 

Was this really necessary? Is the concept of renovation, prevalent in bygone days (remember the Miller Centre), no longer an option to be given serious consideration?

The Waterford hospital, the Western Regional Memorial Hospital and three recent long-term care home constructions in the Corner Brook, Grand Falls-Windsor and Gander areas were all financed through 30-year public-private partnership agreements with private sector corporations. 

This was done in spite of multiple warnings from auditors general around the country that public-private partnerships are expensive mistakes. That includes the Ontario auditor general’s 2014 finding that public-private partnerships cost that province $8 billion more than traditional public financing. Yet we enthusiastically continue down this road, perhaps because the costs of public-private partnerships can be hidden and passed on to future governments rather than appearing in immediate budgets. Furey has indicated the hospital that will replace St. Clare’s could be financed by a public-private partnership.

We are also witnessing increased business sector involvement in the delivery of health care, with the Liberals expanding air ambulance services through privatization.

And then there’s virtual health care. Many without a family doctor have been assigned to virtual care through Teladoc Health, an American transnational corporation facing a class action lawsuit in New York for allegedly breaching patients’ privacy. Payment for this service, we are told, will be fully covered by government. Meanwhile, if we choose to visit a nurse practitioner qualified to deliver the same service, we must still pay out of our own pocket. One has to wonder what prejudice or special interests drive the government’s hesitation to include nurse practitioners under MCP. 

The Liberals have also chosen to use private travel agency nurses instead of hiring full-time nurses or paying overtime to existing staff. A February Globe and Mail exposé revealed that our province spent $35.6 million on staffing agency nurses from April to August of 2023, up from an average of just over $1 million annually before the pandemic. 

Government has argued travel nurses have been necessary to address the growing nursing shortage that surged during the pandemic. As a stop-gap measure maybe this makes sense, but one wonders how our politicians are going to address the uncomfortable fact that many nurses are choosing to retire early, opt for part-time work, or take temporary locum work outside the province. 

Do our leaders accept that part of the problem might be working conditions? Approximately 26 per cent of nurses in the province feel their workload is manageable. As nurse practitioner Kari Brown explained last year in her Sick & Tired column, too many nurses in our system feel undervalued. How will this be resolved? Relying on recruitment from abroad to resolve these problems, which the Liberals are currently doing, fails to address any of the above.

Health Accord recommendations, but at what cost?

Our health care system is in crisis. On one hand, there’s a shortage of family doctors and nurses that just may continue to grow. On the other, we have an aging population that brings additional demands to the system. How will this be addressed in an affordable manner?

Expanding interdisciplinary collaborative care teams at the community level has long been advocated by health care management, but was always squelched by decision-makers. It’s about time they came around to the idea. Kudos to Premier Andrew Furey and former Health Minister John Haggie, both of whom are doctors, for initiating and accepting the Health Accord’s recommendations. This new model, with its emphasis on better coordination  between hospitals and the different spokes in the system — health centres, primary care teams, virtual care and ambulances — promises to be much more sympathetic to patients.     

But there’s a critical undercurrent here — a predilection on the part of government for private sector business solutions that will ultimately cost us a lot more money, shrink the scope of government, put profits ahead of people, and which don’t address the root causes of our health crisis.

That needs to be acknowledged and reconsidered as we move forward.