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Five things to know about health-care talks Tuesday between Trudeau, premiers

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OTTAWA — On Tuesday in Ottawa, Canada’s 13 premiers and Prime Minister Justin Trudeau will sit around the same table in person for the first time since COVID-19 hoping to find a path toward a new long-term health-care funding deal.

Both sides are optimistic a deal will emerge but there are some big divides to overcome, including how much more money Ottawa is willing to put on the table, and how much accountability the provinces are willing to put up in return.

The premiers have been asking for a new deal for more than two years. Trudeau kept punting until the COVID-19 crisis was largely over.

That time has come.

Trudeau has been clear a deal is not going to be finished this week. But here’s a snapshot of how we got to this point, and what they’re going to be talking about.

Money, Money, Money, Money

This year Canada expected to transfer almost $88 billion to the provinces and territories for health, education, social supports and equalization. The Canada Health Transfer, or CHT, is $45.2 billion, or 51 per cent of that.

In their 2022-23 budgets, the provinces collectively forecast to spend $203.7 billion on health care. Ottawa’s transfer accounts for 22 per cent of that. The provinces want that increased to 35 per cent, which would mean $26 billion more this year alone.

“There’s been continual demands for an increase in the CHT although I’ve never seen quite as large a demand for an increase as this one,” said Gregory Marchildon, a professor emeritus at the Institute of Health Policy, Management and Evaluation at the University of Toronto.

Trudeau intends to put an offer on the table Tuesday. It will not be an immediate increase of $26 billion, but Ottawa has been silent on where it will land.

While it has existed in its current form only since 2004, some sort of federal health transfer dates from 1957, when Ottawa offered 50-50 funding for health care to provinces that agreed to provide public hospital services based on national standards.

It has evolved and changed at least five times since then, including splitting the federal share between cash and a transfer of tax points — when the federal government cut its income tax rates and the provinces could raise their own in exchange.

In 1995, then-finance minister Paul Martin, desperate to turn around Canada’s debt problems, slashed the health and social transfer by 20 per cent, followed by a 15 per cent cut in 1996. Some provinces have said their health systems have never recovered.

In 2004, a new deal was reached between the premiers and Martin, who by then was prime minister, to see the Canada Health Transfer increased six per cent a year for a decade.

The Conservatives under prime minister Stephen Harper kept that in place, but told the provinces that in 2017-18, the CHT increase would be based on a three-year average of economic growth, but with a minimum increase of at least three per cent.

Trudeau and the Liberals have maintained that.

With economic growth, the annual CHT increase has averaged five per cent since 2017-18.

Over the last 10 years, the CHT has increased 67 per cent, to $45 billion from about $27 billion in 2012-13.

An attempt in 2016 to negotiate a new CHT deal mostly failed, resulting in one-on-one agreements between Ottawa and the provinces and territories to share $11.5 billion over 10 years, beginning in 2017-18, to improve mental-health and home care.

Angling for Accountability

In the split jurisdictional world Canada’s governments live in, provinces are the ones who control health-care delivery. So for the most part, the federal government helps fund it and the provinces get to say how it’s spent.

The Canada Health Act, passed in 1984, sets out the guiding principles for recipients of the Canada Health Transfer, including that health-care systems must be universally accessible. Failing to abide by the principles can, and has, resulted in Ottawa clawing back some transfers.

Trudeau has made clear any increase to federal health transfers must be met with provincial accountability to show results. The federal government has been frustrated at the lack of accountability from provinces over transfers for health care made during COVID-19.

It is adamant that will not be the case with a new funding deal, and is looking at a combination of an annual increase to the CHT and separate deals to target specific problem areas, like health-care worker retention and training, access to family doctors, surgical backlogs, and data collection and sharing.

The 2017 deals on mental-health and home care will be a bit of a model. Those deals saw Ottawa promise $11.5 billion over 10 years for the two areas, but in exchange provinces had to agree to a common set of principles and goals, and to report results.

The Canadian Institute for Health Information was tapped to help collect and publish data. The most recent report in December is still laden with gaps and incomplete data. The reports note it will take time for the reporting to lead to change, and that provinces need to harmonize their data collection in order to better compare statistics across provincial lines.

Marchildon said one of the biggest problems for the federal government in demanding accountability is that measuring health outcomes is difficult, and hard targets are rare.

It’s all about the numbers

Of course, it’s difficult to measure progress if you’re not keeping track.

Data — or the lack of it — is a long-standing weakness of Canada’s federalized system, with 13 separate health-care systems working alongside one another but not necessarily in tandem.

In his first public overture to open negotiations with provinces on health funding in November, Health Minister Jean-Yves Duclos told provincial health ministers the federal government would increase the Canada Health Transfer if provinces agree to work together on a “world-class health data system for Canada.”

“It is the foundation for understanding what we’re doing, who’s receiving services, whether we’re making improvements,” said Kim McGrail, a professor with the University of British Columbia School of Population and Public Health.

McGrail was one of several experts the federal government tasked with reporting on what a “world-class health data system” would look like in Canada.

Gaps in Canada’s data tripped up the national health responses in dozens of different ways during the pandemic, from tracking the number of COVID-19 cases to reporting adverse effects from vaccines.

The same is true of tracking surgical backlogs and other information about how well, or not, the health system is working.

“Data informs every part of the way we think about health,” McGrail said, which includes the health of individual patients.

Canadians who move from one province to another can’t easily access their records because the technology isn’t compatible.

It’s a problem that exists even within provinces, as incompatible technology makes records inaccessible between hospitals and clinics.

“We need those technology systems to be able to talk to one another, to be able to to move data back and forth or to send messages back and forth in some way,” she said.

It’s an expensive problem to fix. Just last week, Nova Scotia government signed a $365-million contract to bring new electronic health-care records to the province, which may or may not be compatible with other provincial systems.

McGrail said investments will pay off if important information about the health of Canadians stops falling through the cracks.

The expert panel delivered a report last year that will likely serve as a road map for improving data sharing in Canada. It includes 31 recommendations, starting with provinces, territories and the federal government agreeing on a shared national vision for health data.

Ontario and Quebec have indicated a willingness to work with Ottawa on data, though other provinces have been less firm about it.

Aging gracefully

Provincial leaders have been able to agree with Ottawa on the need to reform Canada’s long-term care homes, though exactly how to accomplish that is still up for debate.

Duclos has said helping Canadians “age with dignity” is one of Ottawa’s priorities for a new health-care deal, and long-term care plays a major role in that.

So does home care, and the 2017 bilateral deals already began to advance improvements on that front.

Long-term care is an entirely different story.

The pandemic cast a glaring light on the dismal conditions in care homes across the country, when COVID-19 outbreaks led to thousands of deaths and inhumane living conditions for seniors. The military and the Red Cross were summoned to help.

In the early months of the pandemic, Canada had the worst record for COVID-19-related deaths in long-term care of the world’s wealthy countries.

Meanwhile, residents were isolated from the outside world and workers struggled to provide basic care and ensure dignity.

Experts and advocates say the problems long predate the pandemic, and have gone largely ignored until now.

“Given the devastation that we’ve seen in the COVID-19 pandemic and the impacts on our health-care system … we’re seeing this unprecedented moment where finally there’s some hope of collaboration,” said Dr. Amit Arya, a palliative care physician and founder of Doctors for Justice in Long-Term Care, which advocates for an overhaul of Ontario’s long-term care system.

Governments are now scrambling to improve the conditions, as the number of people who need specialized care grows every year and the number of workers willing to provide that care dwindles.

Several provinces have already announced plans to increase the number of hours of care residents receive per day and build new spaces for the growing number of seniors who are living longer with more serious cognitive and physical impairments.

The federal government created a $1 billion “safe long-term care fund” during the pandemic to help pay for immediate infection prevention and control measures to stop the spread of the virus.

The government also set aside $3 billion to help provinces bring homes in line with national standards for the design and operation of long-term care, though specific agreements with provinces haven’t yet been signed to deliver that money.

Those standards were publicly released last week but are unlikely to factor into the health-care talks.

Still, there is plenty of work that needs to be done if provinces have a hope of meeting the standards, especially when it comes to the workforce.

“I think we’re stepping into a crisis,” said Dr. Joseph Wong, the founder of Yee Hong Centre for Geriatric Care, the largest non-profit nursing home in the country.

He said Canada will need upwards of 100,000 new personal support workers to provide care over the next 10 to 15 years in order to provide adequate care to residents.

“It is a time bomb,” he said.

Essential Workers

The same could be said of the health system at large.

None of the lofty goals of the federal or provincial politicians will be possible if they don’t find a way to persuade workers to stay in hospitals, clinics and long-term care centres across Canada, said Linda Silas, president of the Canadian Federation of Nurses Unions.

“They don’t have the staff to do the job,” she said.

Staff shortages have been the common theme among some of the most serious issues underlying the public-health crisis in Canada.

Dozens of emergency rooms have been forced to close temporarily or reduce hours because there weren’t enough staff to treat urgent injuries and illnesses. The Canadian Medical Association estimates nearly five million Canadians don’t have a family doctor. And hundreds of thousands of Canadians are sitting on wait-lists for backlogged surgeries and diagnostic tests.

Health unions and professional associations want a national strategy to keep doctors, nurses and personal support workers in their jobs as well as train new staff to bolster their ranks.

Silas said after years of burnout and moral distress over not being able to care for their patients properly, nurses in particular have said, “I’ve had enough.”

Nurses in Ontario have also balked at a law limiting pay increases to one per cent a year.

Data from the Canadian Institute for Health Information shows that because of new graduates, the supply of nurses is still growing. However, many have chosen not to take full-time positions, and existing staff are increasingly eyeing early retirement, Silas said.

The heavier demands of the job since the pandemic, combined with fewer and fewer people to do the work, has created what even the federal health minister calls a crisis.

“We need to stop the bleed,” Silas said.

This report by The Canadian Press was first published Feb. 5, 2023.

 

Mia Rabson and Laura Osman, The Canadian Press

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Older patients, non-English speakers more likely to be harmed in hospital: report

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Patients who are older, don’t speak English, and don’t have a high school education are more likely to experience harm during a hospital stay in Canada, according to new research.

The Canadian Institute for Health Information measured preventableharmful events from 2023 to 2024, such as bed sores and medication errors,experienced by patients who received acute care in hospital.

The research published Thursday shows patients who don’t speak English or French are 30 per cent more likely to experience harm. Patients without a high school education are 20 per cent more likely to endure harm compared to those with higher education levels.

The report also found that patients 85 and older are five times more likely to experience harm during a hospital stay compared to those under 20.

“The goal of this report is to get folks thinking about equity as being a key dimension of the patient safety effort within a hospital,” says Dana Riley, an author of the report and a program lead on CIHI’s population health team.

When a health-care provider and a patient don’t speak the same language, that can result in the administration of a wrong test or procedure, research shows. Similarly, Riley says a lower level of education is associated with a lower level of health literacy, which can result in increased vulnerability to communication errors.

“It’s fairly costly to the patient and it’s costly to the system,” says Riley, noting the average hospital stay for a patient who experiences harm is four times more expensive than the cost of a hospital stay without a harmful event – $42,558 compared to $9,072.

“I think there are a variety of different reasons why we might start to think about patient safety, think about equity, as key interconnected dimensions of health-care quality,” says Riley.

The analysis doesn’t include data on racialized patients because Riley says pan-Canadian data was not available for their research. Data from Quebec and some mental health patients was also excluded due to differences in data collection.

Efforts to reduce patient injuries at one Ontario hospital network appears to have resulted in less harm. Patient falls at Mackenzie Health causing injury are down 40 per cent, pressure injuries have decreased 51 per cent, and central line-associated bloodstream infections, such as IV therapy, have been reduced 34 per cent.

The hospital created a “zero harm” plan in 2019 to reduce errors after a hospital survey revealed low safety scores. They integrated principles used in aviation and nuclear industries, which prioritize safety in complex high-risk environments.

“The premise is first driven by a cultural shift where people feel comfortable actually calling out these events,” says Mackenzie Health President and Chief Executive Officer Altaf Stationwala.

They introduced harm reduction training and daily meetings to discuss risks in the hospital. Mackenzie partnered with virtual interpreters that speak 240 languages and understand medical jargon. Geriatric care nurses serve the nearly 70 per cent of patients over the age of 75, and staff are encouraged to communicate as frequently as possible, and in plain language, says Stationwala.

“What we do in health care is we take control away from patients and families, and what we know is we need to empower patients and families and that ultimately results in better health care.”

This report by The Canadian Press was first published Oct. 17, 2024.

Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.

The Canadian Press. All rights reserved.

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Alberta to launch new primary care agency by next month in health overhaul

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CALGARY – Alberta’s health minister says a new agency responsible for primary health care should be up and running by next month.

Adriana LaGrange says Primary Care Alberta will work to improve Albertans’ access to primary care providers like family doctors or nurse practitioners, create new models of primary care and increase access to after-hours care through virtual means.

Her announcement comes as the provincial government continues to divide Alberta Health Services into four new agencies.

LaGrange says Alberta Health Services hasn’t been able to focus on primary health care, and has been missing system oversight.

The Alberta government’s dismantling of the health agency is expected to include two more organizations responsible for hospital care and continuing care.

Another new agency, Recovery Alberta, recently took over the mental health and addictions portfolio of Alberta Health Services.

This report by The Canadian Press was first published Oct. 15, 2024.

The Canadian Press. All rights reserved.

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Experts urge streamlined, more compassionate miscarriage care in Canada

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Rana Van Tuyl was about 12 weeks pregnant when she got devastating news at her ultrasound appointment in December 2020.

Her fetus’s heartbeat had stopped.

“We were both shattered,” says Van Tuyl, who lives in Nanaimo, B.C., with her partner. Her doctor said she could surgically or medically pass the pregnancy and she chose the medical option, a combination of two drugs taken at home.

“That was the last I heard from our maternity physician, with no further followup,” she says.

But complications followed. She bled for a month and required a surgical procedure to remove pregnancy tissue her body had retained.

Looking back, Van Tuyl says she wishes she had followup care and mental health support as the couple grieved.

Her story is not an anomaly. Miscarriages affect one in five pregnancies in Canada, yet there is often a disconnect between the medical view of early pregnancy loss as something that is easily managed and the reality of the patients’ own traumatizing experiences, according to a paper published Tuesday in the Canadian Medical Association Journal.

An accompanying editorial says it’s time to invest in early pregnancy assessment clinics that can provide proper care during and after a miscarriage, which can have devastating effects.

The editorial and a review of medical literature on early pregnancy loss say patients seeking help in emergency departments often receive “suboptimal” care. Non-critical miscarriage cases drop to the bottom of the triage list, resulting in longer wait times that make patients feel like they are “wasting” health-care providers’ time. Many of those patients are discharged without a followup plan, the editorial says.

But not all miscarriages need to be treated in the emergency room, says Dr. Modupe Tunde-Byass, one of the authors of the literature review and an obstetrician/gynecologist at Toronto’s North York General Hospital.

She says patients should be referred to early pregnancy assessment clinics, which provide compassionate care that accounts for the psychological impact of pregnancy loss – including grief, guilt, anxiety and post-traumatic stress.

But while North York General Hospital and a patchwork of other health-care providers in the country have clinics dedicated to miscarriage care, Tunde-Byass says that’s not widely adopted – and it should be.

She’s been thinking about this gap in the Canadian health-care system for a long time, ever since her medical training almost four decades ago in the United Kingdom, where she says early pregnancy assessment centres are common.

“One of the things that we did at North York was to have a clinic to provide care for our patients, and also to try to bridge that gap,” says Tunde-Byass.

Provincial agency Health Quality Ontario acknowledged in 2019 the need for these services in a list of ways to better manage early pregnancy complications and loss.

“Five years on, little if any progress has been made toward achieving this goal,” Dr. Catherine Varner, an emergency physician, wrote in the CMAJ editorial. “Early pregnancy assessment services remain a pipe dream for many, especially in rural Canada.”

The quality standard released in Ontario did, however, prompt a registered nurse to apply for funding to open an early pregnancy assessment clinic at St. Joseph’s Healthcare Hamilton in 2021.

Jessica Desjardins says that after taking patient referrals from the hospital’s emergency room, the team quickly realized that they would need a bigger space and more people to provide care. The clinic now operates five days a week.

“We’ve been often hearing from our patients that early pregnancy loss and experiencing early pregnancy complications is a really confusing, overwhelming, isolating time for them, and (it) often felt really difficult to know where to go for care and where to get comprehensive, well-rounded care,” she says.

At the Hamilton clinic, Desjardins says patients are brought into a quiet area to talk and make decisions with providers – “not only (from) a physical perspective, but also keeping in mind the psychosocial piece that comes along with loss and the grief that’s a piece of that.”

Ashley Hilliard says attending an early pregnancy assessment clinic at The Ottawa Hospital was the “best case scenario” after the worst case scenario.

In 2020, she was about eight weeks pregnant when her fetus died and she hemorrhaged after taking medication to pass the pregnancy at home.

Shortly after Hilliard was rushed to the emergency room, she was assigned an OB-GYN at an early pregnancy assessment clinic who directed and monitored her care, calling her with blood test results and sending her for ultrasounds when bleeding and cramping persisted.

“That was super helpful to have somebody to go through just that, somebody who does this all the time,” says Hilliard.

“It was really validating.”

This report by The Canadian Press was first published Oct. 15, 2024.

Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.

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