What does it mean when we talk about doctor shortages?
Provinces, territories have agreed to a deal on health care, but some experts say it doesn't go far enough
Canada's premiers accepted the federal government's billion-dollar health-care funding proposal last month, after months of negotiations, but many policy experts are skeptical about whether it will be enough to fix the current health-care crisis.
Provinces and territories finally agreed to a deal on health care — though the initial reaction was, for the most part, lukewarm.
The federal government has committed to spend $196 billion over the next decade, including $46.2 billion in new funding.
But while that price tag might seem astronomical, provincial and territorial leaders say the new funding is nowhere near what they actually need — even if PC Leader Dennis King calls the cash injection "certainly not insignificant."
"What's lost in the conversation, that we need to continue to focus on, is that it isn't just money we need. We need innovations. We need to change how we deliver health care," King said.
"We've led, maybe, Canadians to believe that money is going to fix this. That is not totally accurate."
Most policy experts interviewed by CBC News for this article agree.
Some are skeptical about a deal that places few conditions on provinces to move forward with the changes needed to fix the system. The majority are optimistic, arguing that the crisis triggered by COVID-19 will push governments to act.
But all agree that nothing short of a radical reimagining of the system can actually fix the issues that have plagued the country's health-care system for decades.
'It's caught up with us'
In P.E.I., much like elsewhere in the country, the health-care system has been under intense pressure since the pandemic began in early 2020.
Islanders are now familiar with long hospital wait times, ER closures, overworked and stressed health-care professionals, and a growing number of people on the patient registry because they have no family doctor or nurse practitioner.
"If you're asking physicians, it's about our lack of access to the tools and the resources that we need to do our jobs to take care of patients. If you ask patients, it's about the lack of access to physicians," said Dr. Krista Cassell, president of the Medical Society of Prince Edward Island.
"Bottom line is, you know, it's been a tough few years with COVID, and then for us here in P.E.I., the impacts of post-tropical storm] Fiona.… We don't have the people to do the jobs, we don't have the resources. And it's all led to a system where everything is backed up."
Health policy experts have been warning for decades about workforce shortages.
"In December, when a lot of people would take vacation and flu season ramped up, you would always have stories of people in ERs, overcrowding and people waiting out in hallways," said Livio Di Matteo, an economics professor at Lakehead University who specializes in public policy.
"We've basically tried to get along sort of a bit at a time — and I think this sort of caught up with us."
One of the priorities emphasized in the new deal is the allocation of funding for the recruitment of primary caregivers. Governments put a lot of focus on family physicians because they're seen as gatekeepers of the system.
"Primary care is the foundation of the health-care system," said Dr. Monica Aggarwal, an assistant professor at the University of Toronto's school of public health. "You can see what happens when the foundation breaks, right? The whole system crumbles."
A doctor shortage?
It might be hard to imagine now, but there was a time when policy experts in Canada believed there were too many doctors. In the late 1980s, governments expected the supply of physicians to outpace the demand that was actually there.
A highly influential report commissioned by the provinces at the time ended with a laundry list of suggestions on reforming the health-care system to cut costs. While the majority of the reforms that were supposed to make the system more efficient were never implemented, those related to slashing the supply of doctors were put into effect.
One-tenth of medical school enrolments and post-graduate training positions were cut, and so were residence spots for foreign medical graduates.
Many health-care professionals say these cost-cutting measures are largely to blame for the system's current fragility.
"We are still feeling some of the impacts that have happened," said Dr. Alika Lafontaine, president of the Canadian Medical Association.
"The most resilient part of our system has always been the people. And that the lack of investment and you know, this hyperfocus on making sure people produce the most at the cheapest cost, really chipped away at that resiliency."
According to Statistics Canada, only 80.5 per cent of Islanders over the age of 12 had a regular health-care provider in 2021. That's compared to 89.2 per cent five years earlier, and it's well below the national average — excluding the territories — of 85.5 per cent of Canadians in the same boat.
Data from the Canadian Institute for Health Information (CIHI) shows that the number of physicians per capita remained largely stable after the early 1990s, growing steadily in the new millennium before flattening in the years leading up to the pandemic.
From 2016 to 2021, the number of family physicians per capita in P.E.I. actually grew from 184 per 100,000 Islanders to 209 during that same period.
"Even though we have the most physicians per capita than we've had in the last 30 years, there still seems to be something like, depending on where you are in the country, 10 to 15 per cent of people without a family doctor. That proportion has stayed relatively stable," Di Matteo said.
"You have more health-care workers, but in a sense they're seeing fewer patients because of change in practice, cultures and work-life balance issues."
Burnout
Historical data from the Canadian Medical Association show the average number of work hours reported by physicians per week, including specialists and general practitioners, has been on a largely downward trend since the late 1990s.
That number did climb back sharply in 2021 at the height of the pandemic, when practising physicians were working more than 52 hours per week — far beyond the hours put in by the average Canadian employee. Medical residents were clocking almost 66 hours a week.
But the number of doctors who reported high levels of burnout also doubled during the pandemic, and about half of physicians say they're likely or very likely to cut their hours in the next two years.
Meanwhile, clinical payments actually fell 3.4 per cent nationally in 2020-21, though they're still higher than they were five years ago.
"We're now at the point where people are unable to keep up with the demands that are currently placed on their shoulders," Lafontaine said.
"The problem is understanding that there's not enough physician numbers, but it's also the demands that have been placed on people's shoulders that have gotten heavier and heavier over the past few years."
Agreement in principle reached
On Feb. 22, P.E.I. became one of the first provinces to enter an agreement in principle with the federal government on the bilateral component of the new health-care deal.
Altogether, the province will receive $996 million over the next decade, including $288 million from the bilateral agreement.
Governments say they share the same priorities on health care. They're now working on a three-year action plan that will set up targets and timelines.
Experts interviewed by CBC News say they hope that plan places conditions on spending.
We're doing things that we actually knew we should have done 20, 30 years ago.— Dr. Alika Lafontaine
In the meantime, both the CMA and the Medical Society of P.E.I. say the priorities outlined in the deal align with theirs, and conditions related to data collection are a step in the right direction.
"I think Canadians should actually be pretty optimistic about the chances in this round that things will actually get better," said Lafontaine.
"We are doing things that we should have done 20, 30 years ago. We're doing things that we actually knew we should have done 20, 30 years ago. Although they may seem very straightforward, we've never had alignment across provinces, territories and the federal government, that you move them forward in the way that we are today."
Di Matteo, however, is wary. He sees parallels between this deal and the Health Accord offered to provinces in 2004, which set the annual Canada Health Transfer hikes at similar levels – though at the time, inflation wasn't as high as it is now.
"A lot of money did not buy transformative change, but incremental change. And now 15, 20 years later, in a sense, you are back where you started in terms of issues of access, and shortages of professionals," Di Matteo said.
"It's the way the system has basically operated over the last 20 or 30 years. Basically, a crisis occurs, here's a lot of funding points poured in, people go back to sleep, and then they wake up five or 10 years later when the problems re-emerge."
I recognize that it's been slow, but I also think that the government can move faster if they wanted to.— Dr. Monica Aggarwal
He acknowledges there has been change over the last two decades, but says it's been incremental and the broader structural change that's needed is highly unlikely.
"I recognize that it's been slow, but I also think that the government can move faster if they wanted to," said Aggarwal, who's been researching health-care reform for over a decade.
"I don't believe in a Band-Aid solution."
This is the first part of an in-depth series by Arturo Chang on how Prince Edward Island could fix its stressed system of providing primary health care. Read the other parts:
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