The Cost of Caring for Canada’s Health Systems — Stéphane Robichaud

Alex Maheux:    

Hello, and welcome to the Canadian Health Information Podcast. I’m your host, Alex Maheux. In this program from the Canadian Institute for Health Information, we’ll be analyzing Canada’s health systems with qualified patients and experts. Stay tuned as we’ll go beyond the data to learn more about the work being done to keep us healthy.

CIHI has released the first report on health spending during the pandemic, which shows that we will exceed $300 billion this year, a new record in health spending. To help us understand what this means for the health of Canadians, we’re speaking with Stéphane Robichaud, Executive Director of the New Brunswick Health Council. Hello Stéphane, welcome to the podcast.

Stéphane Robichaud:    

Hello, thank you for the invitation.

Alex Maheux:    

How are you today?

Stéphane Robichaud:    

Things are going very well. The weather is nice.

Alex Maheux:    

The weather is nice, perfect! I have to admit I was really looking forward to talking to you today on our podcast. We’ve talked a lot so far about the impact that COVID has had on our health, on our well-being in Canada, but 1 thing we haven’t really talked about on the podcast is the burden that COVID has had on our economy and our government budgets. First, I’d like to start by asking you how you experienced the pandemic in your role. It must have been a very difficult time.

Stéphane Robichaud:    

It was easier for the Health Council than it was for health service organizations. So we have an annual budget, if that budget is not otherwise affected, even during a pandemic given the fact that we are not service organization, it was essentially savings for us, if you will. Meaning that there was no daily travel, no meetings, all those things. So from the Health Council’s perspective, it was relatively straightforward. But from our health care systems’ perspective, it was a different story.

When you put yourself in the context of that spring of 2020, it’s pretty unreal that the whole planet just stopped. We were mainly seeing decisions related to health services or, at least, where we saw the needs at that time. The context was not the same depending on where you were in Canada at that time. In 2020, the reality in New Brunswick was different than that of many regions in the country. If we look at Toronto and Montreal, the major centres where people came and went much more frequently, the virus could spread more easily. The impacts of the cases on hospital services were different from what we saw in New Brunswick. It took a long time for these cases to affect us.

So, in the New Brunswick system, we had a bit of an anomaly where we only had a small proportion of people who were busy 7 days a week. We know that many surgeries had to be delayed among other things and people couldn’t do anything for a while. So there was a big anomaly in those first months in that sense.

Alex Maheux:    

Certainly. Let’s dive into the details. CIHI recently released a report on health spending during the pandemic that showed an increase of about 12% from the previous year. This is about 3 times the usual amount from one year to the next. The provinces and the federal government obviously needed to spend more money to ensure that Canadians had access to the care they needed. Can you tell us a little bit about what you’ve seen in the last 2 years from a financial perspective? What do you think we’ll happen in the next few years?

Stéphane Robichaud:    

Well, there are 2 parts to your question. 2 years is much too short a period in terms of the financial situation, the increases, the expenses. From the very beginning, our public financial services in Canada had gaps that were never addressed. Therefore, when we have cost increases and decreases, it is a result of fiscal pressures. We had constraints in the 90s. In the early 2000s, with the Romano report, it was decided to increase spending toward the end of that 10-year agreement. We realized that the increases were not yielding results, so we decreased the budget. So we’ve gone up, down, up down, and it’s always been part of the cycle. It’s not surprising that during the pandemic many shared a common feeling … and that’s the main tool our policy-makers have, increasing and decreasing spending.

So, if it were not for increased spending, I feel like people would not have known what else to do in response to the crisis. We must also remember that people across Canada did not react in the same way. In New Brunswick, we did not increase spending as much during that time. But as a reaction to a very drastic situation, we increased spending. Over the decades, this has been the main tool of decision makers, to increase or decrease spending. In a general budgeting approach where we have a very poor understanding of our expenses, this is pretty much the only tool available to our leaders.

You talked about increased spending to improve access. I think we have to ask ourselves whether we met the need or not? It is important to ask this question. We agreed to spend because that is the tool we know best, which is to spend more. But will we, at some point, have a better understanding of the impact on those who did not have access to the care they needed? If we were to look at the next 2, 3 or 4 years, I think we’re going to see a rubber band effect. Let’s take knee and hip operations, where people’s situation continues to deteriorate for various reasons during the waiting period. This means that when we return to a so-called more normal way of meeting these needs, we risk facing an increased demand, not to mention the mental health situation. And that’s the demand or pressures the system will be facing.

But at this point, we can’t really appreciate how well the need is being met because the needs were not being properly analyzed before the pandemic. If that is the case, do we really believe that we will be able to address those problems adequately?

Alex Maheux:    

You mentioned that in part because of the pandemic, there has been an increase in demand because of cancelled surgeries and increases in mental health needs. We’ve seen all of this in CIHI reports that show how people have used our health systems. But at the same time, because of the big expenses we had during the pandemic, there are many people who are now talking about needing to decrease spending because of the last year. How can we reconcile these 2 things?

Stéphane Robichaud:    

It wouldn’t be the first time we experience budgetary restrictions, if that comes to be. I think that for those who are in each of these cycles, the long-term perspective is somewhat lost. Basically, the main tool we have is to increase or reduce spending. But we rarely ask ourselves whether we are getting what we want in exchange for these increases in the same way that we cut spending. Often what we see is that decisions are put off until later. Pressures are increasing while the proper spending is not being done. I think that this puts us in a situation where we absolutely must improve our approach to planning and using resources in the Canadian context.

For the Health Council, it became very clear early on, not only in New Brunswick, but across Canada, that there is no proper understanding of the health needs of the population we serve. Therefore, we distribute our resources as if everyone had more or less the same needs. So, we don’t fully understand some target populations, for example the proportion of people that have chronic diseases. This is where aging becomes an important issue. We’re also not doing a very good job understanding the outcomes in terms of quality of health service, the results that we’re getting. Do we have good results? There is work to do on that level. 

Third, we have a very poor understanding of our resources. We know how much we spend in general, but are our resources being distributed fairly? Is it done in such a way as to meet the needs of our populations geographically, for example? Our understanding of that is very poor. When the pandemic started, there was this big debate in the first few months about respirators, for example. It would have been nice if someone simply said: we don’t know exactly how many we have in the public health system. We just don’t know. And if someone had said it early on, perhaps it would have helped us collectively identify one of the important elements to address once the pandemic or the crisis end.

Alex Maheux:    

There is a lot of talk about the perfect storm that our health care systems are now facing. This includes our aging population, our depleted and shrinking health care workforce, and of course the COVID-19 pandemic. It’s a lot to digest and discuss. Let’s start with the aging population that now needs more care, more complex care. In fact, I heard the other day that the population aged 75 and over is expected to grow 6 times faster than the available workforce. Do we need to re-evaluate where we put our efforts and spending to improve both the health of our seniors and also the efficiency of spending?

Stéphane Robichaud:    

I think that aging is probably the perfect subject to highlight possible solutions to improve our health care system. It may be a training challenge for the health sector because the health sector doesn’t think about people, but rather in term of diseases, conditions and all that. So a term like aging is automatically associated with higher service needs, when that is not necessarily the case. I believe this is not the case yet for the majority of the population. But the chronic diseases that you mentioned, that’s the issue. This was highlighted back in 1974, in the Lalonde report, which really made me think. Already back in 1974, the report stated that with the aging of the population and the increase in chronic diseases, it was crucial to change the way we managed our health services. It said that prevention was as important as the treatment of acute conditions. And that was in 1974. 

So what is it? Is it a lack of education in our health sector? Are people not educated enough to understand this? I doubt it, it’s probably one of the fields where people are the most educated. I think that the problem is a vision that is too short-sighted. Aging, first of all, is one of the successes of our society. Aging is not a problem, it is not a challenge. But in terms of health, the target issue is not aging, but rather the population for whom aging leads to a gradual deterioration of health. It starts with a chronic illness that is managed poorly which in turn leads to other conditions, etc.

So could we better target that sub-population? And from the perspective of planning and managing our services, make it a priority group. This is not to the detriment of everyone else in society, but by not addressing this group of people in a timely and serious manner, they are disproportionately consuming our health services. We need to look at this and perhaps, at this point in our history with the increase of seniors in that situation, perhaps this will push us in the right direction.

The other issue is resources. We have a huge amount of health care professionals who will be taking a well-deserved retirement over the next decade. And maybe it will help us to see the health care sector as more than just hospitals and doctors.

Alex Maheux:    

You touched on the subject, but I’d like to go a little further. It is clear that we are going to have a shortage of resources in the health workforce because of aging and also because of the exhaustion caused by the pandemic. So with that in mind, what changes do we need to make to attract and retain health care workers? And not only that, but how can we better support the people who support us and all the other people in our society?

Stéphane Robichaud:    

I’m happy you ended your question that way. At first, I was about to ask where we got the idea that we don’t recognize our health care professionals as people. I would ask this: how can we value our health care professionals without really understanding the results they should be achieving with regards to the population they serve? When our health care professionals feel valued, they are no different than any other economic sector. When we make their work easier, we can really see the positive impact of their daily actions. In the case of health professionals, is the goal to improve their reality or to improve the health commission and the quality of services for the population we serve? It’s pivotal.

Too often, in Canada, when we put the emphasis there, we tend to say: that it’s hard for our professionals and all that. Yes, the situation is difficult, but for the vast majority, the hardest thing for them is that we are failing to serve the public. If we improve our services to the public, it will be better for them.

Alex Maheux:    

These are really big questions. You talked about the way our systems are organized, and that maybe there are ways we can do better. Can you elaborate a bit on some of the ideas you have?

Stéphane Robichaud:    

Well, for me, I think there’s a pivotal concept that has become more important over the last 12 years of our work in New Brunswick. It centers around a subject that unfortunately comes up far too often and it’s perhaps because it’s so common that it remains unaddressed. Our system is not at all people-centred and we need to make that shift. For example, during this pandemic, there is a lot of talk about investment in technology and the advances that this will bring. Why is there such a need to emphasize that technological advances represent productivity or performance improvement opportunities? Why do we feel this need? We’ve known that forever, so why do we feel in times of pandemic that this is the time for technology?

For me, the real question is will we succeed in clarifying the desired results in terms of quality of services and population health? Will we be able to clarify outcomes to guide our investments whether in technology, human resources and so on? When we had the 2004 to 2014 federal–provincial agreement, one of the main observations of the Health Council of Canada at the very beginning was that, once again, the strategy did not identify the results we wanted to achieve. For the Health Council of Canada, this was an insurmountable obstacle. It was impossible for them to report publicly on the performance of the agreement if we had not identified what the agreement was supposed to achieve in terms of results.

In 2021, nothing has changed. We are launching initiatives, for example, investments in technology and artificial intelligence, but we still lack an intelligent management approach. We must once and for all focus our decisions, planning and management on the clientele we serve.

Alex Maheux:    

That’s a really interesting way to look at things. We’re talking about spending, we’re talking about investments, based on what you’ve just said, how can we improve spending or financial resources to accomplish this?

Stéphane Robichaud:    

It’s sort of a trick question, you know? We need to consider the reality, diversity and levels of health services, promotion and prevention. If we accept everything that is being said in terms of balance and so on, the question is not which area deserves more investment, but how can we improve our approach regarding our spending? It comes down to the same thing.    

In New Brunswick, for example, when we look at trends in population health and then the use of our services and the results obtained, we can see sub-populations where it would be a great advantage for them, and also for the system, to establish better targets. I think that in terms of spending, it’s about being more focused and defining what success is. So, if we look at certain populations, and we saw this back in spring in New Brunswick, in our consultations, transportation here. New Brunswick is a rural province with a small population distributed over a very large area. You can’t complain about that, but what it does highlight is that there are barriers. Barriers often related to money, transportation, and so on. That’s not trivial. When we look at the burden that people with certain chronic diseases place on our system, we need to address the barriers that prevent them from achieving optimal outcomes.

Alex Maheux:    

I think the underlying theme in all your questions is the importance of learning more about the population we serve. That is 1 thing our listeners need to remember from this interview. Stéphane, during your career in the health sector, you have surely faced ups and downs. What would your final piece of advice be for health policy-makers?

Stéphane Robichaud:    

It’s important to understand the industry you’re working in. In any organization, we need to understand what our decision-making processes are. You have to be in it. In Canada, we do not have a health care system, but jurisdictional systems. Many will tell you that these are not systems. They do not necessarily work in an integrated fashion. Our system is public, fundamentally. There is a governance issue that our provinces and territories must find a way to improve. There is a dual governance between the elected government, which is always changing, and our boards of directors. It must be shared. We never discuss that issue. In 12 years, there hasn’t been a conversation reflective of the challenge that this represents for us in Canada. So, this needs to be addressed. This caused of a lot of frustration for me.

The other part is that on the other side of governance, there is the operational element. In our institutions and organizations, there are 3 levels. We have health professionals, the health organizations that they work for and then in each of our jurisdictions we have a ministry or something more global, higher up. That’s the operational side. Once and for all, in each of our jurisdictions, we need to reinforce the decision-making processes, because without that, we don’t know where we’re going.

I’m going to give you 1 last example. I held 70 virtual consultations during the pandemic, and it was very interesting to hear so many different perspectives. The common thread was that everyone felt outside the decision-making cycle. Everyone, without exception. So it became clear that there is no such thing. If everyone feels outside the decision-making cycle, there isn’t one. I think all Canadian jurisdictions need to work on formalizing the decision-making processes. It is the only way we can improve them. This absence has been a cause of much frustration for me the last 13 years.

Alex Maheux:    

Stéphane, thank you for your time and thank you for your insights today.

Stéphane Robichaud:    

You’re welcome. Thank you very much for the opportunity.

Alex Maheux:    

Thank you for listening. Come back next time when we will be discussing other exciting health topics. For more information about CIHI, visit cihi.ca. If you enjoyed today’s discussion, please subscribe to our podcast and follow us on social media. This episode was produced by Stephanie Bright and Angela Baker and by our executive producer, Jonathan Kuehlein.

This is Alex Maheux, see you next time.

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