A Primer for Premiers: Some Health System Metrics

 Canada's Premiers are meeting in Winnipeg July 10-12 and along with all the photo opps and media availability sessions, they are also expected to have some discussions on a number of pressing policy concerns including how to spend the forthcoming increases in federal transfers.  Given that none of them have yet submitted plans on the targets and timelines they will use to convert the increased funding into health system improvement outcomes, one suspects it will be some time before the funding increases have any impact. 

 

 

 

Of course, it remains that simply increasing funding alone will not necessarily solve the current chaos as emergency rooms close down during busy summer months, the rosters of people without family physicians grows as physicians retire and nursing shortages lead to delayed or postponed procedures.  As the premiers know, Canada already is one of the biggest spenders in the OECD on health and well above the OECD average both as a share of its economy (See figure 1) and in dollars per capita (See figure 2) .  Yet, as figures 3 and 4 illustrate, this larger amount of spending does not translate into more physicians per capita or more hospital beds per capita.  

 

 

Now these simple types of comparisons can be critiqued on a number of levels.  After all, while we have fewer physicians per capita, our nurses per capita match the OECD average.  Moreover, Canada's physician to population ratio has been rising in recent years and it has been noted that simple physician to population ratios are not always helpful.  Physicians in many other countries sometimes perform a broader range of functions than physicians in Canada which means having more of them per capita is not always an indicator of greater availability.  Yet, if you look at physician consultations per capita, in 2019 - just before the pandemic - Canada stood at 6.6 while the OECD average was 7.0.  

Canadian physician consultations per capita a decade ago were above the OECD average meaning that with fewer physicians per capita and higher consultations, Canadian physicians were seeing more patients than their international counterparts.  That appears to no longer be the case. The case loads of the average Canadian physician have been declining and part of that is a change in practice culture and the arrival of the desire for better work-life balance.  And there are other indicators where Canada does not perform as well - we are below the OECD average on diagnostics such as MRI and CT scans per million population. 

So, throw in the chaos of the pandemic era, and we can see that the current problems are a function both of long term trends in Canadian health system resources, practices and staffing combined with the short-term shock of the pandemic's disruptions.   We are already spending a lot more money than many other countries but we are definitely seeing less health service outcomes with that money.  The per capita statistics also in the Canadian case reflect the fact that there are a lot more people in Canada given recent population growth which when combined with an aging population has certainly resulted in demand side increases too.  The Premiers face quite the challenge.  They will have more money to spend and do need to spend more to deal with the short term supply shortfalls.  At the same time, they need to set up mechanisms to ensure that over the medium to long term, more money does not continue the recent trends of spending more and getting less.

Physician Numbers in Canada and Ontario: Evolution and Ranking

 

The health system in Canada and Ontario is faced with shortages of health professionals in the wake of the COVID-19 pandemic.  Added to this is long-term rising demand for services because of an aging population as well as the impending retirement of large numbers of health professionals given the age distribution of the health work force.  Access to physicians – particularly family physicians - has been a long-standing issue in Canadian health care.  Yet, it remains that despite the constant perceived shortages, physician supply has been increasing.  Figure 1 and 2 present physicians per 100,00 population in Canada followed by Ontario for the period 1978 to 2020.  The plots use data from the Canadian Institute for Health Information/Scott’s Medical Data Base (CIHI/SMDB) and show physician intensity for total physicians as well as specialists and family physicians. 

 

 

 

 

After a period of growth from the late 1970s to the early 1990s, physician intensity showed little growth for nearly 15 years.  Starting approximately 2005, the number of physicians per 100,000 began to increase.  In Canada, total physicians per 100,000 rose from 190 to 242 between 2005 and 2020 – an increase of 27 percent.  Specialist density rose from 93 to 119 (28 percent growth) while family medicine physicians rose from 98 to 123 (a 26 percent increase).  Ontario exhibits a similar profile to Canada except that the 1990s to 2005 saw a more pronounced decline in physician density – particularly in family practice.  Since 2005, the total number of physicians per 100,000 rose from 177 to 232 – an increase of 31 percent.  Specialists grew from 92 per 100,000 to 114 – an increase of 24 percent – while family practice physicians rose from 85 per 100,000 to 115 – a 35 percent increase. 

 

 

 

Ontario was hit harder than Canada by the decline in physician intensity of the 1990s as shown in Figure 3 which plots total physicians per 100,000 population for Ontario and Canada. Up until the early 1990s, Ontario’s physician density was a bit above Canada but since then a persistent gap has opened up.  In 2020, Ontario had about 5 percent fewer physicians per 100,000 relative to Canada as a whole.  But the rest of Canada need not feel too smug.  When compared to the OECD countries or the G-7, Canada and Ontario do not fare particularly well with respect to physician numbers.  As Figure 4 illustrates for the period 2000 to 2020, Canada and Ontario are at the bottom of the G-7 countries as well as well below the OECD average.   

 

 

 

Germany and Italy are at the top of the G7 at 447 and 400 physicians per 100,000 population respectively.  The OECD average is 366.  In 2020, Canada was 34 percent below the OECD average with respect to physician density while Ontario was 37 percent lower. Canada gets by with many fewer physicians relative to other economically developed countries and Ontario gets by with even less.  While there has been substantial growth in physician density in Canada and Ontario since 2005, in Ontario population has also been growing quickly and  actually outstripped physician growth since 2018 actually resulting in a drop in the number of physicians per 100,000. 

Growing Old in a World without Personal Services

 

The retail reopening in Ontario this last week prompted my wife and I to go shopping for new mattresses given our decade old ones were a little worse for wear.  We went to one of our local “big box” furniture stores in Thunder Bay.  There are only three here so as a skill testing question,  if you want to know the one we purchased at, its name translates into Italian as il mattone.  It was a pleasant experience and efficient and unlike some of the other purchases we have made over the last few months, this product did not appear to be stuck on a container ship in the Suez Canal and arrived within a few days. 

 

The delivery people came while I was out foraging for food, and my wife took the delivery.  The delivery people were polite, quick and efficient and took out the old mattress and box spring for disposal.  We were told in advance we had to place them into the prepared bags provided.  The large heavy-duty plastic sheeting provided was reminiscent of the crime programs where a serial killer planning a nefarious murder lays out the material on the floor in order to dispose of the body, but I digress.  In any event the delivery went smoothly, and I actually arrived as the delivery people were leaving.  Upon entry, I found the new mattress and box spring were still wrapped, and we were required to unwrap everything – providing us with a new supply of heavy-duty plastic sheeting for any future crimes – and then put everything in place.  Which we did.

 

My point? My wife was surprised the delivery people did not unwrap and place the new mattress and boxspring when asked  – as was I. The reason?  As she was home alone, she expected the delivery people to do so.  There is a delivery fee after all and the instructions we had on a sheet dated March 2021 that were provided with the bill of sale even stated:

 

“Mattress & Boxspring will be unwrapped and placed in frames or on bedroom sets.”

 

Moreover, after checking, something similar is also stated on the company’s web site.  And yet, the delivery people stated that due to COVID-19 precautions they did not do set up of mattresses as part of their delivery.  The salesperson at the time of sale did not mention this was not done.  You can say we did not ask but really why would you?

 

My wife and I are still able bodied and given that we had to wrap the old stuff up for removal, we were quite capable of unwrapping and placing the new.  That is not the point of course. My wife was on her own at the time and could have used the help. As for COVID-19 precautions as the excuse, the delivery people apparently arrived without masks on and inquired if my wife would like them to wear masks before entering. It was nice of them to ask but so much for not setting up the mattress because of pandemic precautions.  They were obviously quite willing to work without masks if you allowed it.

 

In the end, if policy has changed on delivery and removal, salespeople need to state it at point of sale.  Of course, one understands reasons why not mentioning it might be an optimal business strategy.  After all, once mentioned we likely would have checked out a few more stores to see if they did full service when delivering.  Everyone wants a sale.  And during COVID one suspects a lot of companies like delivering with minimal effort because it saves money during a tough time. They will probably continue doing this because it saves money. This type of behaviour does reduce sympathy for all the businesses who have been clamouring for assistance, complaining that the pandemic has hurt business.

 

However, this is also not the real point. The problem here is the following.  If my wife had been a little 80 year old widow, they probably would have done the same thing – drop off the mattresses and leave her to her own devices.  Which brings me to the real point of this story.  There is an aging population and not everyone has a lot of young able-bodied friends or children living nearby to help out on a lot of personal services.  Even if you do, it would help to be told in advance you need to do something like setting up furniture on your own especially when a reasonable search of company documents says they are going to do it.  And even for the non-aging population, there are a lot more people on their own these days. The single largest household type in Canada now  is a single person rather than a more traditional two partner household.

 

I find the general lack of accountability a lot of businesses practice once they have made their sale pretty deplorable.  The long-term implications are pretty stark.  We are often told about how we need to have more home care and aging at home strategies and remain longer in homes by paying for services.  However, it turns out that there actually is not a lot of commitment to personal services in Canada and the few that there are tend to be quite pricey whether it is assistance with personal care, home maintenance, lawn care, snow removal and now by our experience, the delivery and installation of large heavy bulky furniture.   The problem will likely get worse.  Personal service is labour intensive and the pandemic seems to have made growing labour shortages worse given the substantial disincentives to work provided by easy government cash.

 

Of course many will counter that this is just the rant of a privileged boomer with multi-million dollar real estate  assets who just wants more.  However, I have always found demographic stereotyping of this nature rather odd because my demographic timing at the very tail end of the baby boom always seemed to give me more in common with the bust generations of the latter 60s and early 70s than the duck-tailed front end of the baby boom.  Whether it was job opportunities or housing or access to programs and services for the kids, it always felt like getting to a wedding reception at about 11pm. Sure there was dancing and a buffet but the substantial main course had been served a while ago.  

 

And as for the real estate, well I like a lot of other people do not live in Toronto or Vancouver.  If I liquidate my real estate, the assets are enough for a ten percent down payment on something equivalent in one of those cities.  And, good luck generating income to pay for services from any assets in retirement given the low interest rate policies being pursued which have essentially created a landholding aristocracy in major urban centers.  But there is always a silver lining.  Given the rather lack lustre defined contribution pension my university has,  I suppose upon retirement,  I may have a future providing personal services as an old family retainer to some suburban aristocrat in the GTA in return for room and board and a little cash for books.