For decades, the triangle of “triple constraint” has been a familiar framework for anyone managing a project. The theory suggests that products and businesses grow differently depending on what we deem most important, and how we balance three things: quality, speed and cost. Want quality and speed? You’ll have high cost. Speed and low costs? Quality suffers. Quality and low cost? Everything takes longer.
Yet federal, provincial and territorial governments have long promised an idealized future state of health care that flies in the face of this theory: service that’s high-quality, accessible and cost-efficient. Even for the most responsive, talented and skilled teams in any industry, this is a state nearly impossible to reach in the real world. Yet today we remain in this shared delusion that all three are possible at once in health care because we continue walking the same path we always have.
That doesn’t mean we cannot achieve the health care we want. We just have to shift our gaze from what’s ideal to what’s necessary. We should be proud that our 13 provincial and territorial health systems survived the stress test of past COVID-19 waves – but we also must acknowledge these systems are now collapsing under the weight of backlogged health services, providers with epidemic-level burnout and insufficient health human resources that all operate in an outdated delivery of care model.
We don’t need to look too far for evidence of this. According to the Organization for Economic Co-operation and Development, Canada spent 12.9 per cent of its GDP on health care in 2020, compared with an OECD average of 9.7 per cent, ranking second behind the United States. Yet we lag behind on availability and timeliness of care, now sitting below the OECD average. The result of today’s status quo? Just go to any hospital or try getting an appointment with a primary care provider. Long queues, unprecedented wait times and unreasonable work environments are now things we accept as normal.
Decades of trade-offs are now coming due, and it’s clear that what governments have prioritized in the past will not bring us into a brighter future. A constant and long-time focus on keeping costs low, coupled with a system that is resistant to change and has not meaningfully adjusted to Canadians’ evolving health care demands since Medicare was conceived in the 1960s, have brought us to the precipice. We have leaned into innovation to save costs, instead of improving care. Eventually you cross a threshold where there is nothing left to give, and no people to resource more capacity. Bottom line: Health workers and patients have been left to fend for themselves, without the leadership required to make the hard decisions that are necessary.
But there is an enormous opportunity now across provinces, territories and the federal government if we truly embrace our similarities. Working together, we can build – for the first time since the dawn of Medicare – a health care system that is integrated, co-ordinated and collaborative. Pan-Canadian licensure could simplify the registration of Canadian-trained and internationally-trained health care providers whose mobility could supply the desperate need for health human resources. National collaboration on virtual care could democratize access and embed convenient, appropriate access to care with in-person health care. A national health human resources plan could leverage the training capacity we currently have with regionalized needs now and in the future.
The Canadian Medical Association recently released an analysis of health spending and the required collaboration between various levels of governments, which appears to be the sticking point these days. In reviewing the provincial and territorial government health budgets, there were two insights that I found interesting. The first was that despite the insistence that our 13 provincial and territorial silos have their own unique challenges, there are commonalities in the priorities that they are funding, such as mental health, care of older Canadians and surgery backlogs. The second – closely related to the first observation – is that despite the premise that federal priorities do not and should not influence provincial and territorial health care system priorities, past federal priorities have been prescient; past federal governments have spoken to then-emerging issues that are now our present crises.
We do not get the health care systems we aspire to; we get the health care systems we design. Lack of leadership, investment and new thinking means we have built fragmented systems where siloed decision-making results in redundancies, subpar outcomes and an unpleasant experience for providers and patients. Addressing the foundational issues and prioritizing quality – of experience, communication and collaboration – is a path we must take.
Leadership means choices. And it is time for those who hold the levers of powers – our governments at all levels – to choose that path we have yet left untravelled. Canadians are ready for a truly integrated, co-ordinated and collaborative health care system.
Dr. Alika Lafontaine is president of the Canadian Medical Association.
This commentary originally appeared in the Globe & Mail on Friday, Oct. 14, 2022.