It is impossible to understate the seismic shift that has occurred over the past few months in the way our healthcare system is run. The experience of waging an all-out war on COVID-19 has forever altered not just our medical system and all those who are a part of it, but the public’s perception of it as well.
Canadian health ministers, public health officials, ministry officials, and countless others deserve credit for pivoting a system known for its resistance to change so that we were prepared for the worst-case scenario. At the same time, they put in place plans and rallied the public to help us achieve the best possible outcomes.
Policy changes that were viewed as impossible just a few months ago were advanced in a matter of weeks or even days. In many provinces, physicians saw new fee codes introduced to support increased use of virtual care. Pharmacists were given expanded authority to provide patients with prescription refills or emergency supplies of their medications. And restrictions on staff working at multiple long-term care homes were put in place to minimize the risk of spreading the virus.
The challenge, though, with a seismic shift of this nature is that it is impossible for things to go back to the way they were. Many measures that were viewed as emergency actions will likely become permanent. The lines that were intentionally blurred between different health professions to make patient care more seamless will be hard to redraw. And the increased involvement of government in areas such as long-term care will be the new reality.
And that’s just what we know so far. The truth is that this is only the beginning, and our provincial healthcare systems still have a long road to travel when it comes to COVID-19 and its impacts. A vaccine may not be ready for 12 to 18 months and even then it could be many more months until enough is manufactured and distributed to protect most Canadians. Until then, healthcare systems will need to maintain a state of readiness for any spikes in new infection rates while continuing to make further changes to adjust to our new reality.
Public demand is high for more healthcare professionals, increased system capacity, and access to new therapies and technology. But all these things cost money. The public’s tolerance for deficit spending is also high right now, but this won’t last forever. Health spending already demands close to half of government’s budget, and room will need to be maintained for other priorities such as economic recovery and support for the record number of Canadians who have lost their jobs during this pandemic.
Health and finance ministers will need to make hard choices about where to allocate scarce resources. But money won’t solve all their problems, and other changes will require the co-operation of stakeholders or, possibly, the political will to impose solutions on stakeholders who may not agree with a government’s approach. While this list is not exhaustive, here are some of the toughest decisions that governments will face in the coming months:
Long-term care – Higher standards and increased funding will bring improvements, but collaboration with facility operators is also needed. COVID-19 has shown how gaps in standards and staffing put our seniors at risk and may have even hastened death for some. Stronger regulations and more funding are inevitable, but this won’t address all of the issues in this sector. There have been calls to eliminate private, for-profit ownership of nursing homes but the complexity and associated cost make this move unlikely, at least in the short- to medium-term. Governments will need to try to work in partnership with facility operators and health professionals but if a path forward cannot be found through dialogue, imposed solutions and significant new resources may be required.
Acute care capacity – Further system co-ordination and management are needed to create and maintain surge capacity. Pre-pandemic, acute care in many provinces operated at or above 100 percent capacity most of the time. The pandemic has demonstrated the need to build in extra wiggle room to manage unexpected events and to prevent the cancellation of non-urgent surgeries and procedures. Experience, however, shows that additional health capacity is quickly filled up with new urgent patients and maintaining reserve capacity is next to impossible. Maintaining surge capacity and making sure it doesn’t succumb to the regular pressures of the system will require planning, resources, and discipline.
Primary care – Further expansion of primary care is required to reduce pressure on the acute-care system, but buy in from the public will be required. Several governments have increased resources allocated to primary care services, which includes illness and injury prevention, health promotion, and the diagnosis and treatment of illness and injury. Continued investments and further expansion will be required, but this will rarely lead to savings that can be reinvested elsewhere. The real challenge here will be to convince members of the public they do not always need to see a physician when they interact with the healthcare system. Educating the public on the role other health professionals such as nurses and pharmacists can play in managing their health, and allowing those professionals to practice to the full scope of their training will help our health care dollars go further.
Virtual care – Virtual care creates many efficiencies and has many benefits, but increased adoption will also lead to increased costs. In some provinces, virtual care was already moving forward at a steady pace, but the pandemic put this on hyperdrive across the country. Patients today can engage with the healthcare system through their computers, phones, and even email – which many were told was impossible just a few months ago. Now that members of the public have had a taste of how convenient this is, they will not want to go back. But these technologies can have a cost, such as an increase in physician billing as some doctors are able to surpass their regular capacity limits. Decisions about where to reallocate resources to fund these virtual tools will be a challenge. Governments must work with health professionals to manage costs and, more importantly, share the savings that come from efficiencies.
Increased use of health professionals – Using other health professionals such as nurses and pharmacists can increase capacity and achieve cost savings, but diplomacy will be required, as physicians will resist the intrusion into their domain. Allowing select health professionals to provide additional services would streamline care and reduce the workload of physicians. As a bonus, it is often more cost-efficient as well. However, making changes to the scope of practice for one health professional can cause friction among others and requires great care and diplomacy. Governments will need to negotiate changes to allow professionals such as nurses and pharmacists to use their full training, but this process will not be for the faint of heart. Ministers will need to maintain their resolve and push forward where needed to keep the patient and system efficiencies at the centre of all strategies.
New therapies and technologies – Investments in new therapies and technologies will improve the overall system but will require trade-offs. Each provincial Ministry of Health receives countless proposals each month for new drug therapies and technologies that have the potential to improve health outcomes, streamline care, and save lives. However, each of these comes with a cost and forces health policy decision-makers to make hard choices. Investments in therapies that can reduce a patient’s interactions with the healthcare system should be a no-brainer, but budget caps and internal silos mean hard choices are necessary. Focusing on the big picture and where the evidence shows new investments will have the biggest impact is a good place to start. Officials will need to find opportunities to show leadership and prevent silos that are designed to protect existing budgets and turf.
Data and analytics – Significant advances in evidence-based decision-making are possible but will take money and courage. Governments have talked about the opportunity that big data and analytics can provide but building consensus for a common vision across the system has proven to be a challenge, and privacy advocates have often urged decision-makers to go slow to keep risks low. The pandemic required rapid advances in how data was collected and analyzed to allow for complex modeling. New tools for data collection and surveillance will now assume a higher priority, and decision-makers will want to apply this progress to other parts of the system. This is one area where the courage to continue to move forward in the face of critics and cynics will be the critical success factor.
Given the complex trade-offs that governments must consider, how can health stakeholders ensure they will be heard above the noise? They will, of course, need to argue for their funding requests or recommended policy changes effectively and persuasively. But to be successful, their proposals must focus on three things:
- How will the recommended changes make the system more patient-focused?
- How will they allow the appropriate health professional to support patient health?
- And how will they ensure all appropriate therapies and technologies are effectively utilized?
Ensuring proposals are framed so the public interest is at the centre of the narrative will be key, as will the use of data to show how the desired action will result in real progress toward government’s goals.
Ultimately, ministers of health and ministry officials will have many more good ideas to implement than there are resources. While more resources for the health system are undoubtedly on their way, they will never be enough to address all the needs of the system, and hard choices will continue to be required.
Health stakeholders can make those choices easier by creating well-designed, robust advocacy strategies that are executed with precision. Decision-makers are more likely to react positively to those credible groups or individuals who most effectively bring their issues to the forefront of the government’s agenda and who can demonstrate broad support among stakeholders and the public.
This article is part of the The Coronavirus Pandemic: Canada’s Response special feature.