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Between 1970 & 2019, the number of hospital beds per 1,000 people in Canada went down from 7.0 to 2.5. Between 1993 and 2019, the wait time for treatment by a specialist increased from 9.3 weeks to 20.8 weeks. Our healthcare is in crisis.
INTRO:
Right from the onset of the Covid crisis, we have been hearing about the scary prospect of ‘the healthcare system getting overwhelmed’. The initial lockdown was meant to help us avoid precisely this scenario. The argument that was offered was that if people aren’t moving around, there would be less chance of transmission of Covid, which would help reduce the number of people requiring admission to a hospital as Covid patients.
Nearly two years into the crisis, we are now being told that the so-called ‘anti-vaxers’ are overloading the healthcare system. Every day, we are presented with numbers showing how many new Covid cases are among the unvaxxed. Some people have gone to the extent of saying that we are now in a ‘pandemic of the unvaccinated’. Although it must be noted that as time passed, the number of vaccinated people as a percentage of the total daily cases has risen steadily – but this is also being blamed on the unvaxxed.
With well over 85% of the Canadian population having received both the doses of the Covid vaccine, it is not clearly explained how the remaining 15% or so Canadians are causing such a grave crisis as to require the extension of various restrictive measures.
Leaving those issues aside, today we will focus on one particular aspect of the crisis, viz., that of hospital capacity. Did we have enough of that capacity at the onset of the Covid crisis? I believe this is very important because ultimately, our ability to deal with a health crisis depends on the capacity at our disposal to do so.
Here we must note, with disappointment, that such an analysis has not been made so far in Canada. This is possibly because Canadians take it as an article of faith that we have ‘the best healthcare in the world’. This belief presupposes that the infrastructure / facilities are not insufficient. But a dive into the actual numbers proves the exact opposite. Moreover, it also reveals that this is not a new phenomenon, but rather an ongoing slide for nearly half a century.
In short, we are facing the situation that we have on our hands now because healthcare infrastructure has been neglected for over 50 years. It is only after we acknowledge this harsh reality that we will be able to take the needed remedial actions to bring our healthcare system to a desired level.
CAPACITY BY NUMBERS
One of the most basic factors influencing a country’s ability to deal with a healthcare crisis is the number of hospital beds. I believe that this is at the very foundation of healthcare in a hospital, so this number is of vital importance. Every other form of care that a hospital is able to give to patients is dependent on this crucial number.
According to World Bank data (see link 1), the number of hospital beds per 1,000 of population in Canada went down from 7.0 in 1970 to merely 2.5 in 2019. That is a 64.29% drop over 49 years.
Here it is worth noting that Universal Healthcare was legislated in Canada in 1957, and later again in 1966. In 1960, the number of hospital beds per 1,000 of population was 6.2. By the year 1970, it had gone up to 7.0. From that year onwards, the World Bank chart shows a continuous, ongoing decline for Canada. Barring one year of a tiny increase (from 6.8 in 1980 to 6.9 in 1981), the graph is always headed down.
Canada’s population in 1970 was a little over 21 million. At 7.0 beds per 1,000, this means roughly 149,000 beds. In 2019, Canada’s population had risen to 36.5 million (about 77% increase over 1970). Yet, at 2.52 beds per 1,000, this means that the actual number of beds was about 95,000.
So there was a DECREASE in the actual number of beds by about 54,000.
36% fewer beds for 77% higher population means that availability of hospital beds declined by 2.77 times.
The natural question that arises from this information is, how would the Canadian healthcare system have fared in Covid-era if our capacity was still at 7.0 hospital beds per 1,000 of population?
One doesn’t need to be a rocket scientist (or a healthcare professional) to guess at the answer.
As for our claim of having ‘the best healthcare in the world’, data from the Organization of Economic Cooperation & Development (OECD) shows that when it comes to hospital beds capacity, out of 42 countries, Canada is ranked at #32 (link #2). This is way behind countries like Turkey, Greece, Poland & Hungary. Japan is at #1, followed by Korea, Russia, Germany & Austria. Hungary is at #6.
DENIAL BY DELAY
The low / poor availability of hospital beds, of course, impacts on the timeframe within which patients can receive the recommended treatment. In order to avoid the disruptions caused by the Covid lockdowns, let us look at the number from 2019.
For this purpose, we will look at the report by the Fraser Institute for 2019 (link # 3). Before we do that however, let me clarify one thing: a lot of people have the opinion that the Fraser Institute is a “right-wing” think-tank, and therefore they tend to dismiss anything coming out of the Institute. However, what we have sourced from the report is just the data, so any possibility of an ideological bias does not arise. We can safely take the information in the report at face value.
According to this report, for 2019, (aptly titled ‘Waiting For Your Turn’) the average wait time between referral by a family doctor and delivery of treatment by a specialist physician was 20.9 weeks (higher from 2018, which was at 19.8 weeks). In other words, in just one year, the average wait time went up by more than a full week. In 1993, this wait time was 9.3 weeks.
This means that in the 26 years between 1993 and 2019, the average wait time for receiving specialist treatment more than doubled. To be precise, it went up by 124%.
The lowest wait time was in Ontario (16.0 weeks) while Prince Edward Island clocked the highest number of 49.3 weeks. That’s almost a year!!
The average wait time for diagnostic tests was also high –
4.8 weeks for CT Scan
9.3 weeks for MRI, and
3.4 weeks for an ultrasound.
The report also shows that in 2019, over 1 million 62 thousand people were waiting for medical treatment. Assuming that each person is waiting for only one procedure, that number amounts to 2.9% of the Canadian population of that year.
As the report rightly notes, these unduly long wait times have a high cost on multiple fronts: the delay causes worse medical outcomes for patients, as well as increased pain, suffering and mental anguish – and some of them may have to suffer a stoppage / reduction in income. We can also add that the worsened medical condition of the patient ends up costing more to the healthcare system.
THE SPENDING SIDE
As we all know, the government spending on healthcare keeps getting ever higher. This is usually explained away as supporting ‘the best healthcare system in the world’. But as we have seen, the performance of that system leaves a lot of room for improvement.
How much is it costing us to keep this underperforming system in operation?
As per the StatsCan report for 2019 (link # 4), out of the total federal, provincial and municipal spending, $ 186.5 Billion was on healthcare (some 23.4% of the total government spending). This works out to $ 4,910 per Canadian. In other words, a typical family of 4 attracts almost $ 20,000 in healthcare spending by all our governments put together.
Are we getting good value for that money?
Let us look at the report from Canadian Institute for Health Information for the answer (link # 5).
(This report gives per capita healthcare spending in Canada at $ 6,448 – about 30% higher than the StatsCan figure; see Page 4. This difference is due to 30% of healthcare spending being done by private insurance coverage & personal funds).
Here are the key findings in the report:
- Healthcare spending increased from 7.0% of GDP in 1975 to (estimated) 11.6% in 2019.
- The OECD average of per capita healthcare spending is 8.8% of GDP (remember that we have some of the worst indices for healthcare in OECD, yet our spending is almost 32% higher).
- In 1975, 45% of the health expenditure was on hospitals, 15% on physicians and 10% on drugs (the total comes to 70%).
- In 2019, 27% of the health expenditure was on hospitals, 15% on physicians and 15% on drugs (the total comes to 57%).
It appears therefore that the spending on hospitals has gone down substantially (40%), while that on drugs has increased by 50%. It is possible to at least consider if we are getting the best outcomes for the high level of spending on healthcare.
THINKING AHEAD
If we go back to the World Bank data on the per capita number of hospital beds per 1,000 of population, it becomes clear that the decline in that number becomes especially steep around the same time when the annual immigration quotas were raised significantly (mid-1980’s). From 6.8 in 1985, it dropped to 5.0 in 1995. This represents nearly 26.50% decline in exactly one decade of higher immigration numbers.
By 2005, there were 3.1 hospital beds per 1,000 people, meaning with another decade of high immigration, there was a FURTHER decline of 38% (compared to 1995).
Overall, in two decades, our hospital beds capacity plummeted by 54.4% (from 6.8 to 3.1).
To me, the meaning of this is abundantly clear: the investment in healthcare system by governments did not take into account its own immigration policy, which should have informed the extent of new capacity required. We can make guesses about the motivation (or practical compulsions) causing this disconnect between two policies of the same government. In the end, however, that would be no more useful than speculation. What matters now is remedial action.
What form should this remedial action take?
I am a big believer in planning by numbers. In our government circles (at all the 3 levels) however, ‘numbers’ usually mean dollar amounts only. It is almost a given that when making any policy announcement, the entire focus of the announcing politician will be on how much money their government has allocated on the proposed measure.
I would go about it the other way around. If we want to restore the glory days of 7.0 hospital beds per 1,000 of population, what all would be required? In what cities would these beds be located, and in what proportion? What would be the requirement in terms of buildings, equipment & other paraphernalia? What would our timeframe be to reach that level of infrastructure?
Once we have the answers to the above, we can the arrive at a dollar figure that would be needed to get us there.
Similarly, for wait times, one would need to drill down on why they are so high, and what is causing them to creep ever higher.
What would we need to do in order to restore the wait times that prevailed in 1993? How much would it cost, and in what timeframe can we manage that cost?
If we put our minds together along these lines, we can, as a first priority, stop the ongoing decline in our healthcare system, and in the second phase, try and make it better. If we are sincere in this effort, we will perhaps be able to regain the glory of our long-gone past.
OBSTACLES
Before we attempt any remedial action, we must identify and address the obstacles that are going to impede our efforts along the way.
I see two main obstacles here: denialism and partisanship.
Canadians are so steeped in the belief that we have the ‘best healthcare in the world’ that they get emotional when someone points to its shortcomings. Here are the arguments that I encountered when I tossed out my initial findings on Twitter:
- A lot of medical procedures that used to require hospitalization in the past are now done in the outpatient category. This naturally means that fewer beds are required in hospitals.
- Advances in medical knowledge, technology and methods of operation such as day surgery and preventative medicine have made it possible to shorten the hospital stay of patients considerably. Therefore, there is higher turnover of patients for each bed, thus requiring fewer beds.
But as we have seen already, the actual number of beds went down by roughly 60% (on a pro-rata basis adjusted for total population) and went down by 64% in terms of beds per 1,000 people. Neither of the above two arguments help us understand how better working and reassignment of in-hospital patients to outpatients can achieve such a huge reduction in the capacity required.
On the other hand, we have the well-known phenomenon of ‘hallway medicine’. We see it being reported in the mainstream media from time to time. If all the above improvements justified the hospital capacity that we now have, we wouldn’t have ‘hallway medicine’ (or double the wait time for specialist treatment).
Additionally, one major factor impacting on the requirement for hospital infrastructure is the general state of health of people. Just as the improvements reduce the demand for hospital beds, poor health among the general population increases that demand. In this context, we already know that obesity and drug addiction are at alarming levels and on the rise. There is therefore reason to at least investigate how much additional hospital capacity become necessary due to such factors.
Another factor here is that compared to 1970 (and the immediately following periods), Canadian populated is much older. This increases the requirement for healthcare infrastructure, including hospital beds.
Finally, we need to remember that in the list of 42 OECD countries, we are at number 32. Instead of arrogantly assuming that the 31 countries ahead of us haven’t incorporated modern improvements and technology in their healthcare (or have poorer general health of people than Canada), we need to reflect on whether there is a need for us to improve our hospital beds capacity.
Unfortunately, our ideological adherence to believe that we have ‘the best healthcare in the world’ gets in the way.
If, after much strenuous effort, we are able to convince Canadians that there is something wrong in Canada that needs remedial action, the other obstacle that I mentioned above kicks in – many people instantly take recourse to the government(s) – past and present – of particular political parties. Here are some examples:
“Harper reduced healthcare funding.”
“Justine Trudeau is sending our money overseas instead of helping Canadians.”
“Paul Martin slashed healthcare funding and gutted the system.”
“Mulroney ran insane deficits forcing the Chretien government to slash & burn services.”
“Pierre Trudeau set us on a disastrous path by his reckless spending from which we have never recovered.”
As will be instantly obvious to an objective observer, none of the above takes us even a nanometer in the direction of a solution to the mess we are in.
The answer, I believe, lies in ridding ourselves of partisan loyalties and obsession with the past. The only thing that should matter is how to get out of the mess that we find ourselves in.
There is a widely shared opinion in Canada that we should aim to have a population of 100 million.
Let us remember that increasing our population from 21 million to 37 million has resulted in a 60% reduction in hospital capacity. What will be the consequence of adding another 63 million to the population of Canada?
Links:
- Hospital beds per capita in Canada, per 1,000 of population down from 6.9 in 1976 to 2.52 in 2019. World Bank data https://data.worldbank.org/indicator/SH.MED.BEDS.ZS?locations=CA
- Canada is at #32 spot out of 42 OECD countries in hospital beds per 1,000 of population: OECD data https://data.oecd.org/healtheqt/hospital-beds.htm
- Wait times in 2019: Fraser Institute https://www.fraserinstitute.org/studies/waiting-your-turn-wait-times-for-health-care-in-canada-2019
- Government spending on healthcare for 2019: StatsCan https://www150.statcan.gc.ca/n1/daily-quotidien/201127/dq201127a-eng.htm
- Percentage spending analysis of healthcare budget: CIHI https://www.cihi.ca/sites/default/files/document/nhex-trends-narrative-report-2019-en-web.pdf