Health Care Funding in Canada — Dr. Jennifer Zelmer, Teri Price and Annamarie Fuchs

Avis Favaro

Canada’s ailing health system got a financial boost early 2023. Ottawa increased transfer payments to the provinces and territories by $46.2 billion. That’s on top of the nearly $200 billion for health over the next decade.
And the new money is targeted to helping more Canadians get family doctors or nurse practitioners, beefing up the ranks of health care workers, and helping those with mental illnesses and substance use.
But it comes with some strings attached. And on this episode, we’ll ask what changes could this infusion bring? We’ll get the perspective of 3 guests.
Jennifer Zelmer, President and CEO of Healthcare Excellence Canada.

Jennifer Zelmer

I think resources are an essential ingredient for being able to do the work we need to do.

Avis Favaro

We’ll also hear from Annamarie Fuchs, a nurse and health care consultant.

Annamarie Fuchs

We, in the health system, are tired of waiting for cash to be actioned to produce real change — real, sustainable change.

Avis Favaro

And one of the strings is a commitment to modernize patient medical files and boost the sharing of health data. And for that, we’ll talk to Teri Price. Her 31-year-old brother, Greg, died because of this important gap.

Teri Price

We fully assumed that the information would follow Greg, but the system is really set up so that the information sits in silos in the different organizations.

Avis Favaro

Welcome to the Canadian Health Information Podcast. We call it the CHIP for short. I’m Avis Favaro, the host of this conversation.
One note: the opinions expressed here don’t necessarily reflect those of CIHI, but it’s a free and open discussion, and this episode is all about the new deal on health care. Will this new money and the need for accountability actually make our health system stronger?
Welcome to you all. Part of this discussion is to try and figure out what all this new federal money is going to buy Canadians. Like what are we going to get from this new funding?
So let’s start with the big picture, Jennifer. We know that the provinces and territories were very insistent that they needed more money for health care, and it’s amounted to 46.2 billion in new money over the next 10 years. How significant is this?

Jennifer Zelmer

It’s a lot of money in terms of that period of time. And each jurisdiction, each province and territory has identified priorities that they will work on related to that. So those priorities do change a little bit across the country, as you would expect. We’re not all the same. Our needs aren’t exactly the same. And so exactly what the focus areas will be, within the broad set of priorities determined across the country, will vary a little bit from place to place.

Avis Favaro

Why don’t we go through the key ones that Ottawa wants them to work on. And the first one was family medicine: rural, basic primary care across the country. Why is this a priority for Ottawa?

Jennifer Zelmer

So I think actually, the priorities were identified collectively; not just by Ottawa, but also by the provinces and territories, as part of an overall sort of umbrella set of priorities. And then, within those priorities, each jurisdiction picked the areas that they would focus on specifically.
But if you think about family health services, they’re the first place you go to get care. For some, it may absolutely be a family doctor. For others, it may be a broader team; it may be a nurse practitioner; it may be a combination of folks working together. And we know that having that first point of access and care is so important: someone who knows you and your family and can ensure that you have access to the high-quality care that you need.

Avis Favaro

It’s estimated there are over 6.5 million Canadians, according to Healthy Debate, who don’t have primary care across the country. So the second priority of rebuilding the workforce of nurses and doctors is pretty obvious.
Jennifer, from your position, what do you see in terms of the shortage and how it’s unfolding?

Jennifer Zelmer

People are the core of the health system, so that’s the people who access care but also the people who provide and organize that care. And this isn’t unique to Canada. We know globally that there’s a significant challenge in terms of ensuring that we have the health care providers who are needed to provide services, and that they’re well supported in the work that they do as well.

Avis Favaro

The third priority area is mental health and substance addiction. And every day, we are hearing stories of people dying, record numbers of overdoses, and really long waits for mental health care, so this is an obvious priority. How important is this one, Jennifer?

Jennifer Zelmer

I mean, central to the ways we live our lives, right? We can’t separate our physical and mental health; they go together. And so having this focus and recognition of the priority is really important and actually does continue some work that’s been happening together collectively for jurisdictions for the last few years. But it’s really, to your point, Avis, profiling and prioritizing the work that needs to be done.

Avis Favaro

The last one was medical records or modernizing health systems, and we’re going to talk about this a little more when we bring in Teri. But overall, when you see this additional agreement and the additional funding, Jennifer, how quickly do you think this is going to lead to some on-the-ground changes for Canadians?

Jennifer Zelmer

I mean I think these are areas that people are working on right now. And there’s also a companion agreement on aging with dignity, so looking at how can you be supported to age well, care closer to home and community. Those are all areas that are super important that — I was just in Halifax last week, for example. They’re working on that today already.

Avis Favaro

So you hope to see results soon. I know there’s a lot of people waiting for a doctor or a nurse practitioner.

Jennifer Zelmer

Yeah. I mean I think we all hope to see the care that we need right now and excellence in that care, and also recognize that it’s not something that you can just — there’s no magic wand, right, to do everything that we need to do straight away. So also that there’s a sustained effort over time, which is why I think it’s helpful that these are longer-term agreements to be able to focus on, how do we actually build the health care we need for the future as well, not just what we need today.

Avis Favaro

So, Annamarie, you have been in the nursing field. You talk to people on the front lines. You’re a consultant. What are the front-line doctors and nurses telling you about this new agreement?

Annamarie Fuchs

What we hear and what I’m hearing is a bit of hesitation and uncertainty. And that may or may not be fair to the government but it’s, frankly, true on the front lines, and for a bunch of reasons.
Provinces acknowledge and clinicians acknowledge the obligation to use those funds in specific ways. But more and more over time, we’re seeing the use of funds to strengthen health care in places that aren’t necessarily high-priority areas for those who have been working and are currently working on the front lines.
So, I guess the larger question is, are those targeted areas and obligations the right ones? Who’s deciding? Are what I believe our most expert people — and I call those, those who are clinicians on the front lines and people in administrative and decision-making roles simultaneously, because there are many individuals who perform those dual roles — are they being asked to determine the right priorities, not only for the country but for their own jurisdictions?
If a priority, for example, is mental health and addictions, how the individual provinces decide to acknowledge and respond to that priority can really vary. And that’s where clinicians, I think, are feeling the frustration.
The decisions about how to proceed tend to be not well communicated or oftentimes not well accepted in various jurisdictions. And that seems to be what I’m hearing and what I’ve been hearing for the 14-or-so years that I’ve been a consultant.

Avis Favaro

Are they at all concerned that the money will be used elsewhere, not in health care?

Annamarie Fuchs

I would say that there tends to be, as you know, a great deal of politicalization around the use of health data and health care. And how health care is rolled out in a province is often determined by elections and that sort of thing. So then clinicians become concerned about, how is the money being used and for what purposes, at what time.

Avis Favaro

So infusion of cash, though, how do you feel about that? What’s the reaction?

Annamarie Fuchs

There’s always a welcome response to an infusion of cash, particularly after 3 years of a pandemic, but the cash, I guess it’s where the rubber meets the road. What we need to see is, and Jennifer alluded to this as well, the more immediate response to those priorities, because we in the health system are tired of waiting for cash to be actioned to produce real change — real, sustainable change.

Jennifer Zelmer

I think there’s absolutely an urgency in terms of people’s needs now and also a recognition, as Annamarie said, that we’ve been passing through this absolutely extraordinary period that has put tremendous pressures on the health system and on health care. And we need to also be looking ahead at what do we need today, yes, but also how do we support people going forward as well, given where we’re starting from right now.

Avis Favaro

Do you know if the money is conditional on it being spent on these priority areas?
Jennifer Zelmer
I mean there’s certainly bilateral agreements, right, for what each jurisdiction is spending the resources on. And there’s also reporting mechanisms that CIHI and others are engaged in. So there’s those kinds of parameters around the resources.

Avis Favaro

One of the priority areas is a modernized health system. And I know that a lot of Canadians are going, what does that mean? Canadians actually think that their health files are shared and, Teri, you know that’s not always the case. This is what happened to your brother Greg. Can you summarize the story of what happened when he started to have symptoms of what would become diagnosed as testicular cancer? What happened?

Teri Price

We were absolutely sort of in that bucket where we assumed that the system had sort of modernized along the same pace as other industries that we have more experience in than we had in health care. And so what happened with Greg was he eventually was diagnosed with testicular cancer, but it was a really slow, delayed diagnosis for a whole number of different reasons. There’s multiple points in his care where the ball was just dropped. He sort of fell through cracks and time was lost, which was really critical in what should have been a treatment that is actually typically very successful. Testicular cancer is very treatable.

Avis Favaro

You and your family produced a film, Falling Through the Cracks.

Teri Price

Yeah. And that was after Greg died, we started asking questions. We ended up connecting with the Health Quality Council of Alberta. They did an investigation and the lead investigator, Dr. Ward-Flemons, he wanted to be able to share Greg’s story with the medical students when he was teaching the importance of patient safety and teamwork to the undergrad medical students. And we were excited about the idea of being able to share Greg’s story to sort of have an impact and thought that sort of having those conversations with the next generation of doctors would be one way to have an impact.
We’ve done more than 550 screenings, and Dad or I, or the combination of two of us, have joined almost all of those screenings. There’s only a handful that we haven’t participated in a post-film discussion.

Avis Favaro

So one of the key things in Greg’s story was that the doctors didn’t have medical records that they could share and pass on with each other; a lot of the material was passed on by faxes. And so things were botched because he didn’t have his medical records.

Teri Price

Yeah. We fully assumed that the information would follow Greg, but the system is really set up so that the information sits in silos in the different organizations, the health technology that they choose to have. Greg saw multiple different physicians and really, each of those physicians had their own record and that there was no way for the information to flow between those physicians.
So Greg, sort of, he was a private pilot, so he interacted with a physician who did his pilot’s medical. They sort of flagged one symptom. Greg started having back pain, went to a different walk-in clinic, and so that information sat in a different health information system. And that walk-in clinic physician didn’t see any of the record of the symptoms from the original appointment. And so even that, having back pain and those symptoms, if those two pieces of information would have been together, the connection to testicular cancer would most likely have been made at least a lot earlier than it was.
And so, it’s absolutely critical that that information flows, and we fully believe that the advancements in technology, that it’s possible.

Avis Favaro

So when you heard that Ottawa made this a priority, what did you think?

Teri Price

I mean it should have been a priority a long time ago and there has been a lot of people working on it. I feel like there is more momentum right now. The more people that are actually — and more sort of levels of the health care system that are focusing on this, the better, because it is, it’s a significant issue.
We really believe we need to be able to create the conditions for safe care and believe that being able to work in teams is part of being able to deliver safe care. And you can’t work in teams if there’s no way to communicate or share information.

Avis Favaro

Would this have saved Greg’s life?

Teri Price

I think so. If we don’t have like the metrics that actually matter, the data that actually can help us make the right decisions, then we’re going to continue to be not confident in the decisions that are being made, that they’ll actually have the right impact on the system and be able to enable some of the things that we want to see in the future of our health care system.

Avis Favaro

So, Annamarie, what are your thoughts?

Annamarie Fuchs

When Teri talks about silos, we’re talking about legislation and policy that is influencing the custodial model. And by that, I mean individual physician groups or clinics hold on to data because they have this expectation that privacy can only be preserved if they hold on to the data. And so there’s a hesitation or there has been a hesitation to share data.
As a result, individuals like Teri’s brother didn’t have information following him in the way that it should have and, in many cases, the information simply didn’t go where it needed to go.
So when we back up and look at information problems, we have to look at legislation, and we have to look at privacy legislation and release some of those or at least clarify the expectations on custodians for the appropriate use, collection, and sharing of data as a means to improve patient care.

Avis Favaro

So, Jennifer, this would seem to be also an urgent issue, if lives are at stake because of the siloed information.

Jennifer Zelmer

There’s just no question about that. So, if you’ve got the information available to you at the time that decisions need to be made — available to you, to Teri’s point, as an individual, to your family, and also to your broader care team — that’s when you’re going to get the best care.
And so, I think we saw that loud and clear during the pandemic. And I think now, we’re seeing that real focus with the new interoperability roadmap that was just announced in terms of how do we make sure that it’s not just access, to Teri’s point, to pieces of information one by one, you having access, for instance, to information in the hospital or information from a clinic or elsewhere, but how do you get actually integrated access to information. That’s really what it’s about.

Avis Favaro

So one of the other interesting points of this agreement is that there’s a hook or a string to it, where Ottawa is basically saying, we’ll give you the money for these things but we want from you, data. Why is the data important, Jennifer?

Jennifer Zelmer

Data helps us to understand the current situation, what’s working well, so that we can share it with others and learn from those experiences, and where we have work to do.
And one of the things that I think is interesting is there’s nowhere in the country, there’s nowhere in the world that I can see that’s figured it all out. Right? We’ve all got things that we can learn from other people, we’ve all got things to share, and the data helps us to identify what those things are to be able to track our progress towards the goals that we seek and to be able to understand, who can we learn from; how can we make progress more quickly.

Avis Favaro

Do you know what kind of data specifically Ottawa wants from the provinces and territories that they aren’t providing right now?

Jennifer Zelmer

Well there’s a series of indicators have been identified that link to these priority areas but that also build a foundation for the kind of more real-time information we need. So I think that was something that became really obvious during the pandemic about the importance, not just of data, but of data in near real time, so that we can dynamically adapt and adjust as we need to going forwards as well.

Avis Favaro

Now, Annamarie, you have some concerns about data, what data, who chooses what data is collected. What are your concerns?

Annamarie Fuchs

When I saw that report or that announcement, my first question was, what data? What are we doing? And then, ultimately, my last question would be, how are we going to collect the data and avoid duplication?
We have ministries of health, health quality councils, health authorities, research agencies, primary care networks, various organizations across the country, all collecting data. Much of it is similar. Much of it cannot be compared and benchmarked appropriately so that we can stop being mired in analysis and actually action change that we can compare with and against each other for progress and growth so that patients could benefit in the long run.

Avis Favaro

Interesting points. Do you want to respond to that, Jennifer?

Jennifer Zelmer

I mean I think with anything that we do, right, we always need to look at, where’s the value. We need to make sure that the data that we are investing in, that we are investing in collecting and in processing and in using, actually helps to drive change and helps to drive the work that we do to make the health system safer, more equitable, higher quality as we go forward as well.

Avis Favaro

You are now seeing a number of provinces moving to private delivery of health care, private clinics. So when it’s run — when different data’s controlled by a private agency, how will we know that they will be able to adequately share the information? Annamarie?

Annamarie Fuchs

So when we talk about data sharing and data transparency, whether it’s inside a hospital on one street, or inside a private surgical clinic designed to reduce wait-lists and manage outcomes for patients in a mall further down the street, a health data charter, which has already been contemplated and we know that — it’s based on the Universal Declaration of Human Rights around health — a health data charter that everyone has to sign off would be one step or an important step in the process of creating full transparency and, I would add, accountability, to all providers, whether they’re working in the hospital down the street or the clinic, that surgical clinic in the mall.
So you need a bunch of legislative and policy change to make private clinics work collectively and appropriately alongside what the public sees as the public system. The public system is still supported by these clinics and they’re opening up all over the country. We certainly are seeing them in Alberta. But a common expectation when we modernize data, that a health data charter is signed off by everyone and that the Pan-Canadian Health Data Strategy, which contemplates some of this as well, is also actioned, will help reduce some of the risk that you’re speaking of, Avis, I think. At least that’s my opinion.
It’s one thing to jump on the priorities that are existing now and I am 100% in favour of reducing waitlists and getting people seen and cared for. I would also say that we need policy and legislative change so that 5 or 10 years from now, we haven’t created a bigger problem in trying to react to issues. We need to respond to issues and create a system that is more transparent and more legislatively sound. It’s simply not there yet.

Avis Favaro

So going back to the overall arching question, do you think this agreement is eventually going to buy Canadians better health care? Jennifer?

Jennifer Zelmer

I think resources are an essential ingredient for being able to do the work we need to do. I think also, as these agreements recognize, we need some other things around them. Right? So we need data around them, for instance.
If you think about the aging with dignity work, there’s been sort of complementary work that’s been done in terms of standards in long-term care. We also need to do the kind of work in terms of moving forward with change so the tools and supports to actually make change happen, with and for patients, with and for front-line health care providers.
So we need all of these ingredients to come together to do the kinds of really from-the-ground-up changes that we’re all looking for, for the future because the health system we’re going to need 10 years from now is not the same as the one that we need today.

Avis Favaro

Teri, are you hopeful with what you’re seeing?

Teri Price

Yeah. I think we are. I think there’s more conversation around change and even just when we are having conversations across the country, there’s lots of people that are interested and wanting to collaborate and contribute to this change. And I think that is different now, 11 years after Greg’s death, than it was sort of in the first few years after Greg’s death and for a whole number of different reasons, including the pandemic. But it does make us optimistic that we are building some momentum for change.

Avis Favaro

What would you hope in 5 years, ten years, when this agreement is done, that the difference would be for patients?

Teri Price

For patients, you would be able to see your own information and be able to share it with your care team, regardless of where your care team is, and be able to, if you want to include your family member, if you want to include another health care provider, that they would be able to access that information and collaborate and work effectively as a team.

Avis Favaro

Annamarie, what do you want Canadians to watch for as this agreement unfolds over the next 10 years?

Annamarie Fuchs

I think we need to watch as — I’ll put myself in the role of the public. I need to watch for a real change that makes sense to me. So what I mean by that is, well, Avis, you can go on your phone, your laptop, your PC, or to a debit machine at 7-Eleven and see your bank balance. There’s a governance and legislative model behind the modernization of financial data that has made it simpler for you and me to manage that information.
My health is far more important to me, at least I hope it is, than the money I have in the bank. So the public needs to watch for and hold our elected officials accountable to modernize the system in a way so that, if you break your leg in another place and you happen to have a chronic underlying disease, or you’re injured and you can’t speak for yourself, that data is readily brought up so that the provider has the information he or she needs to support you and ensure that you get the care you need. It’s happening elsewhere outside of health; it can happen here.
And so the public needs to watch for that kind of change. The public needs to be part of the solution because privacy legislation was originally embedded to protect the public. Sure, to some degree, it may protect the public; it’s actually harming the public because that custodial model is what caused those silos to occur and to prevent the information from following Greg where it needed to follow.
There has to be a point where health becomes a basic human right and our political leaders are accountable to simply be stewards of what we’re delivering so that the public benefits in the long run. And we need to stop the ebbs and flows of funding announcements that sometimes occur and sometimes get stopped when another leader comes into power.

Avis Favaro

It’s such an important issue and that’s why we were trying to break down this latest funding announcement to help people understand.
I want to thank all 3 of you for being a part of this discussion. And I just want to make note that Teri and her family have a website. Can you tell us about that, so that if people want to look at the film and the issues that you’re trying to raise with Greg’s story, where can they find that?

Teri Price

Yeah. So the website’s just gregswings.ca and we do host monthly public screenings of the film. We haven’t posted it anywhere that you can just Google it and watch it, and we’ve intentionally done that because we really do believe in the importance of the conversation after the film.

Avis Favaro

Well I want to thank you, Teri, for your advocacy. Not only did you endure a tragedy, but you’re trying to turn it into a positive for Canadians coast to coast, so thank you on that.
Thank you, Jennifer, and thank you, Annamarie. And I think we should have this podcast in 5 years to see how the funding is going and if we’ve made any progress in these key areas. But thank you all for coming.
As you’ve heard, there will be many eyes on this new federal health funding deal watching for the innovation, the flexibility, and the increased accountability that will show how the provinces and territories are delivering good and timely care to Canadians across the country.
Our executive producer is Jonathan Kuehlein and a shout-out to Alya Niang who’s the host of our French CIHI podcast.
If you want to learn more about the latest Canadian Institute for Health Information data, please go to cihi.ca that’s C-I-H-I-dot-C-A, and subscribe to the CHIP wherever you get your podcasts.
I’m Avis Favaro. Talk to you next time.