Most Health Care in Canada is Publicly Funded, Privately Delivered

NB: My thanks to Dr. Hemant Shah, who inspired the title of this blog with his statements on health care delivery in Canada.

Well, here we go again. Yet another kerfuffle caused by absolutist ideologues who are so hell bent on forcing their immovable views on the rest of us that they are resorting to fear tactics.

Ontario Health Minister Won’t Rule out Privatization as Option to Help ER Crisis” – screams the headline in the Toronto Star (a newspaper known for its extremely biased reporting on health care). The article comes after Ontario Health Minister Sylvia Jones had a press scrum. The only problem is that’s not quite what she said.

Here’s the tweet from Mark McAllister, who embarrassingly reached a similar conclusion in his summary:

At no point does the Minister say she is going to privatize Emergency Rooms. Her quote is:

“Look, we’ve always had a public health system in the province of Ontario and we will continue to do so.”

Exactly what part of this screams “privatization”? Even the snippet after where she refers to looking at “options” she clearly mentions other jurisdictions in Canada, where, you know, you have public health care.

The reality is that public health care is for the most part, privately delivered in Canada. Take your family doctor for example (assuming you are lucky enough to have a family doctor). Supposing you go to your doctor to get assessed. In Ontario, your family doctor will likely get paid $36.85 (see page A5 on the Schedule of Benefits). Out of that $36.85, your doctor will allot some of it for the receptionist, the nurse, the cleaners, the rent, the computers and so on. The remainder is the profit, which you family doctor will keep for themselves.

Your family doctor is a private business.

The infuriating thing about this kerfuffle is that this kind of absolutist, hyperbolic nonsense has prevented real advances in health care over the past twenty years. Every time there is a new proposal on how to look at health care differently, some nitwit politician screams out that we are opening the door to two tier American style health care. The new idea gets shut down without taking a thorough look at its merits.

It’s the rigid, inflexible thinking by geniuses like Jagmeet Singh that prevent any such exploration of new ideas. Just have a look at our hospitals. We currently have a crisis with our hospitals over capacity and many waiting in ERs for beds. Yet we still do procedures in hospitals that could be done elsewhere, and free up hospital capacity.

For example, there is ample evidence that independently operating cataract surgery clinics are more efficient and can cut cataract surgery waiting lists. In Canada, these clinics would have to be funded by public health insurance. All absolutists like Singh see is that procedures will be done in a “private” clinic, and are therefore un-Canadian and Tommy Douglas must be rolling in his grave to hear of such a possibility.

Fun fact: Tommy Douglas supported user fees for health care.

Singh and his absolutists would rather you go blind on 2 year wait lists than have publicly funded health care done in a way they don’t approve.

To be completely fair, there are some legitimate concerns about doing procedures in independent clinics. For example, there was concern that colonoscopies in outpatient settings were suboptimal. However, those concerns were addressed by some needed changes made by the College of Physicians and Surgeons of Ontario, with the setting of minimum standards and inspections. As a result of that, there was a strong feeling that colonoscopies could be done safely and efficiently outside of hospitals.

And let’s face it, it’s not as if public institutions are without issues either. Remember the time there was concern the Niagara hospital mishandled a c.difficile outbreak? Or the public nursing home that has been shut to new admissions for over a year? In fact there’s a suggestion that harm to patients in public hospitals costs $1 Billion a year.

No matter if public or private, so long as human beings are involved, mistakes will get made. What’s really needed is a way to do appropriate inspection and review of facilities that are funded by the public purse, so that mistakes are minimized. Then let them get on with their jobs.

What I don’t get is how these folk don’t recognize the hypocrisy of their views. In their mind, it is okay for a family doctor to bill OHIP for a blood pressure check, then use that money to pay for their clinic and keep the profit. But it’s not okay for a gastroenterologist to bill OHIP for a colonoscopy in a health facility (which is safe to do), and use that money to pay for their clinic and keep the profit. Or for an ophthalmologist to bill OHIP for a cataract removal out of hospital (also safe to do) pay for their clinic and keep the profit. And they accuse Sylvia Jones of promoting two tiered approach to medicine???

What about the fact that these private clinics charge patients for some things? Um…..have you ever gone to your family doctor for a Driver’s Medical? You know it’s not covered by public health insurance right? And you have to pay your family doctor for it? How about a sick note? An employment form? The reality is that ALL clinics will charge you for things that public health insurance won’t cover.

As our health care system continues to collapse all around us, we need to take a thoughtful, intelligent and open minded look at how we deliver health care. Yes it should be paid for by the public purse. But we need to recognize the reality that appropriately funding private clinics (with levers to ensure high quality care) is the most effective way start clearing the immense backlog of health care cases.

As for absolutists who snarl at the mere mention of the phrase “private”. While everyone with a modicum of intelligence recognizes that Star Trek is a much better franchise, let me leave them with this from the other, weaker franchise:

What is Going on at Sunset Manor?

Full Disclosure: Sunset Manor is a public, long term care facility in Collingwood, Ontario. I don’t have patients at Sunset Manor. The only interaction I have with Sunset Manor is when I am on call. My personal experience is that the nature of those calls from them has been no different than those from other long term care homes. All the information in my blog is based on what has been publicly reported in the media (with links attached as appropriate).

In June of 2021, the Ministry of Long Term Care issued an order to stop admissions immediately, to Sunset Manor in Collingwood. According to the CTV News Barrie report:

  • The Ministry stopped admissions because of a belief “that there is a risk of harm to the health or well-being of residents in the home or persons who might be admitted as residents.”
  • Sunset Manor received “several written notifications and compliance orders” for not following requirements highlighted after inspections between July 2018 and April 2021.
  • What shocked me the most – the Ministry stated “There are reasonable grounds to believe that the licensee cannot or will not properly manage the long-term care home or cannot do so without assistance.”

Bureaucrats generally tend to use bland, inoffensive language to avoid controversy. That last sentence jarred me. I’ve lived through some pretty bad health care facility situations in my time and have never seen a sentence that strong.

As I write this blog, Simcoe County’s website lists Jane Sinclair as the General Manager of Health and Emergency Services for Sunset Manor, which would make her the admin person in charge of the place.

The CTV News report stated:

  • Jane Sinclair called the ministry’s report “excessive,” adding,  “We don’t agree with the level of severity of these ministry findings.”

Over a year later, Sunset Manor still isn’t allowed to accept new patients, and an exclusive article on Collingwood Today suggests why. You can read the whole article for more details but briefly, Sunset Manor is alleging that the investigations were tainted because an ex-employee of Sunset Manor, Katy Harrison, was part of Ministry Inspection team. Jane Sinclair swore out an affidavit that she told the Ministry the termination of the ex-employee was “not amicable”. Sinclair further states she complained to the Ministry in 2019 about having an ex-employee do an inspection of the home stating she “could not conduct a fair and impartial inspection of the home.”

However, the Ministry elected to have her continue inspecting Sunset Manor as a “junior” member of the team. They state the allegations of bias are “spurious and unsupported by evidence” and that multiple officials inspected Sunset Manor, not just Harrison.

There’s a whole set of details about the inspection process in the Collingwood Today article that I won’t bore you with. But I will note that the article points out there have been four further inspections of Sunset Manor since last June, none by Harrison, and the facility remains closed to new admissions.

Generally speaking, the admin person at an LTC would report to the representative of the owners (in this case the County of Simcoe) to inform them how things are going. As I write this blog, the County of Simcoe’s website indicates that person is one Mark Aitken, the CAO. The website further states one of his responsibilities is overall management for Long Term Care and Seniors Services. Yet another wrinkle thrown into this mess is that Mark Aitken is married to Jane Sinclair. (Yes I know it was a letter to the editor, but it has gone un-retracted which the press would do if it was challenged).

In summary, Sunset Manor has been repeatedly investigated by the Ministry of health over the past four years. One of the investigators was an ex employee whom the Manor feels was biased. As a result of investigations, Sunset Manor has not been allowed to admit new residents to the facility for over a year. The Administrator answers to the owner (or in this case, the owners representative) who happens to be her husband. The response of the owners is to sue the ministry alleging the inspections were biased and unfair.

Here’s my take.

1) I think it was wrong of the ministry to allow ex-employee to investigate Sunset Manor. I’m in no way suggesting that Miss Harrison acted inappropriately. The reality however, is that optics matter. If you’re going to level the most serious punishment possible to a long-term care facility you need to make sure that there’s absolutely no margin for people to think that that punishment is anything other than completely justified.

2) Similarly the administrator of Sunset Manor should not be reporting to her husband. The Administrator may have handled the situation perfectly, but again optics matter. The public needs to be reassured that if the Administrator made a mistake, appropriate action would be taken, and people won’t believe that if your spouse is your boss. (ADDENDUM: While the Simcoe County Website continues to list Mr. Aitken as the person responsible for LTC – please see the first comment below from Mr. Manary – who wrote the initial letter stating Mr. Aitken and Ms. Sinclair were married. At this time I’m simply putting the information out there, but if there is a factual correction to be made by someone in authority at County of Simcoe – I will do so).

3) You know how there are people like Dr. Samir Sinha who write articles that we must stop private nursing homes? Or that tweet the incessantly that public long term care facilities are better? Sunset Manor is public.

This situation has been allowed to drag on for over a year to the point where according to Collingwood today there are now 43 empty beds at Sunset Manor. While four compliance orders have been lifted, the home was fined another $5,500 for failing to comply with medication management.

The frustrating thing is it it should never have come to this. It’s a travesty when we have so many people waiting for long-term care beds. I recently had a patient wait over 90 days in hospital for one. Getting Sunset Manor open again would really help our community.

I don’t know who’s right and who’s wrong here, but hopefully whatever needs to be done there gets done, and our seniors can once again get the care they deserve, in the location they need.

Crisis at Trillium Health Partners Demands an Intervention

Over 20 years ago, I and a number of other physicians were involved in a significant dispute with our local hospital administration. The specifics don’t really matter now (it’s ancient history). But in general terms physicians like myself felt strongly that we were fighting for patient care against an administration that didn’t value our input or opinion. Administration at the time undoubtedly felt differently. Eventually, both sides became entrenched and the Ministry of Health had to send in a team to sort this out, after we went public with our concerns. The MOH bureaucrat even fashioned a new phrase, referring to their team as “Interveners”.

All of which is to say I still get nightmares when I hear of in house disputes at a hospital being made public, most recently at Trillium Health Partners in Mississauga. Not working at that hospital, all I can go on is what CTV News reported. 40 physicians at Trillium Health Partners have hired a lawyer alleging:

  • physicians “are targets of an abusive and unprofessional behaviour of the hospital administration.”
  • “terrified for their livelihoods”
  • “fearful to go work”
  • a physician was called “crazy”
  • “a toxic culture rooted in harassment, intimidation and threats”
  • an environment where “physicians are afraid to practice medicine”

All of this certainly brought back my own PTSD at the events that led myself and my colleagues to take action over two decades ago.

As mentioned, I don’t know the specifics there. But I can say a few things in general from not only my previous experience, but from other institutions where I’m aware of doctors speaking out.

First, doctors in general hate speaking to the media and going public about internal conflicts. It’s one thing to talk about medical issues that pertain to the health care needs of the population as a whole. But to go out and air dirty laundry? It’s not in their nature. For something to reach this point, it usually means that every possible avenue has been exhausted, and there is a real concern for patient care.

Second, every hospital has multiple processes for addressing concerns. There’s a Medical (or Professional) Staff Association that advocates for the needs of their professional staff. There are numerous committee structures and depending on the concern the issues can be brought there. There are internal complaints processes and various Human Resource department protocols. There are chiefs of departments whose role includes addressing concerns fairly. Basically a lot of ways to bring problems to the attention of the higher ups.

Third, doctors in general put up with a lot of bureaucratic non-sense just so they can get the job of looking after patients done. Whether it’s ludicrously difficult hospital IT systems, policies that require us to duplicate our efforts, or any number of roadblocks, physicians complain privately about the working environment, but put up with it because we want patients well looked after.

In that context – to see physicians do what they’ve done, and write to the Minister demanding she appoint a supervisor (essentially someone to take over the administration of the hospital) signals a complete failure of all of the internal processes, and a dramatic escalation. This only happens when the two sides are entrenched.

What next?

What’s Likely to Happen:

Usually, administrations in such a situation tend to circle the wagons and go on the defensive. Attempts are made to minimize the concerns or denigrate the physicians as a small group not representative of the whole. Evidence is produced suggesting the concerns were appropriately reviewed and dealt with.

As an aside, Trillium has already done this by having their own lawyer investigate the complaints and, surprise surprise, the lawyer Trillium pays found Trillium did nothing wrong. I would have thought for issues of this magnitude it would be appropriate to bring in an external person to review. Maybe Trillium didn’t do anything wrong. But surely having an external person say that would carry more weight.

Then, if physicians make enough noise, the issues continue to percolate, the general public expresses concern and politicians get scared. In our area, the issue became so toxic that enough physicians decided to resign their privileges and our Emergency Department was in danger of shutting down part time.

After months of agony, somebody at the MOH (plus/minus political intervention) realizes they have to do something and appoints a third party with the power to actually do something and make some necessary changes.

What Should Happen:

Why go through additional months of grief? There’s clearly a crisis there. The residents of the catchment area of the hospital must surely have concerns about the care they will receive when they read the articles from CTV News. Having doctors who are fearful of the working environment simply cannot contribute to good patient care.

The MOH appointed their “Intervener” in my hospital and the Intervener had the power to tell both Administration and Physicians when they were offside. I personally got told I was going too far offside by him during the process, and I know Admin was also told they had to back down on some things. At least he was fair.

I don’t know who’s right and who’s wrong at Trillium, but patients at Trillium need to know that something is being done to address these concerns and ensure there is safe environment for the caregivers. To that end, the MOH needs to appoint an independent third party to help the situation sooner, rather than later.

For a link to CTV News’ follow up report on the issues that includes comments from yours truly, click here.