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Hunter Prize: Improving end-of-life care is the compassionate and cost-effective solution to Canada’s health crisis

Commentary

The Hub’s first annual Hunter Prize for Public Policy, generously supported by the Hunter Family Foundation, focused on solving the problem of long wait times in Canada’s health-care system. A diverse group of ten finalists have been chosen from nearly 200 entries, with the finalists and winners chosen by an esteemed panel of judges, including Robert Asselin, Dr. Adam Kassam, Amanda Lang, Karen Restoule, and Trevor Tombe. The Hub is pleased to run essays from each finalist this week that lay out their plans to help solve this persistent policy problem. The winners of the first-ever Hunter Prize for Public Policy will be announced on Friday, September 29.

Canada’s health-care system has long been a source of pride, standing as a testament to the nation’s commitment to providing quality medical care for all. However, in recent years, the cracks in our system have become increasingly apparent. 

Wait times across the health system continue to escalate, leaving patients and families frustrated and health-care providers overwhelmed. 

This is further exacerbated by a growing shortage of health-care professionals, especially nurses and personal support workers. 

These factors will soon amount to a perfect storm.

There is one area of health care in which a disproportionate amount of resources are spent, and is intimately tied with patients’ journeys: end-of-life care.

Most Canadians do not want to die in a hospital. In 2020, 54.7 percent of Canadians died in hospital. In addition to contradicting the preferences of most Canadians, the impact of dying in hospital has stark financial and systems-wide implications.

Comparing the last six months of life, Canada’s average hospital expenses (USD $21,840) surpass those of England ($9,352), the Netherlands ($10,936), and the U.S. ($18,500). This cost and care discrepancy in Canada is linked to the heavy reliance on hospitals for end-of-life care delivery, impacting both expense and quality.

The national average hospital length of stay in 2021 was 7.2 days. Patients admitted for palliative care had an average length of stay in hospital of 12 days, and 17 days for those patients with admissions with palliative care. Of these days, patients receiving palliative care remained in hospital waiting for admission to another facility for a median number of 10 alternate level of care (ALC) days per patient. The proportion of admissions with reported ALC days was only 5.8 percent nationally in 2021 (129,764 admissions). Extrapolating from this, patients admitted for palliative care represent a 33.9 percent share of patients with reported ALC days. Nearly half of patients receiving palliative care who were waiting for care in a more appropriate setting died before they could be discharged to one (13). 

Hospices have become an important, alternative level of care setting designed for end-of-life care. Care is provided at hospices with a palliative approach, which has been recognized in literature to increase quality of life and satisfaction with care.

There are significant cost savings when shifting care from an acute hospital bed (~$1000/day) to a residential hospice (~$400/day). These savings are accrued via shortening hospital stays, decreasing the frequency of ICU admissions, and decreasing unnecessary diagnostic tests and treatments. 

While hospices provide a valuable option, the limited availability of hospice beds poses a critical operational bottleneck.

In 2014, the Auditor General of Ontario recommended between 945 and 1,350 hospice beds, yet the reality falls drastically short, and the shortage continues to grow. The shortage of hospice beds is particularly glaring in certain rural regions of the country. 

The 2023 CIHI report found that 49 percent of hospices were always or usually operating at full capacity. Around 50 percent of operating costs are raised yearly by the hospices through charitable organizations, while the other portion is funded by government sources. Hospices also rely significantly on the assistance of volunteers—most importantly patient’s families and friends providing informal care. 

Build more beds

Canada Health Transfers, which are the federal government’s method of funding province’s health-care budgets, should be utilized and earmarked for building more hospice beds. Priority should be given to underserved communities to expand existing facilities and build new ones to meet the growing demand for hospice beds. Such an investment will make hospice care more accessible and reduce the strain on local, acute care hospitals. 

According to Residential Hospice Working Group, in 2010 the average 10-bed hospice had a projected annual budget of $1.6 million, with provincial government support only covering nursing & personnel salaries at $900,000, with non-clinical staff and operational costs covered through donations/fundraising. Some provinces such as Ontario are now recognizing the value of hospice care and are increasing operating budgets.

Per a CD Howe report on palliative care, if the costs associated with end-of-life ALC days in acute care were spent instead on the beds where the patients were waiting for residual care, the savings in Ontario would be $161 million annually, and if extrapolated to the rest of Canada, then $400 million per year, just by moving patients to a bed in the location they are waiting for. While this would not present directly as a cost-saving, we believe that this would relieve in-hospital waiting lists: alleviating burdens in the emergency room, acute medical wards, surgical wait lists, and in-hospital services (radiology, laboratory work, among others) and encourage an acute care system that is more fit for purpose.

Staff these beds

With more hospice bed capacity, the staffing of health-care workers at these facilities needs to increase, too. However, health-care staffing shortages continue to pose a human resource constraint, worsening with increasing reports of health-care worker burnout and attrition. 

To directly increase the Canadian hospice workforce, we should leverage Canada’s progressive immigration policies to make it easier to hire and immigrate foreign-trained health-care workers. Existing preferential skilled immigration programs, like the Government of Canada’s Global Skills Strategy (GSS) can be expanded to allow hospice-focused health-care professionals access to expedited visa and work permit processing. 

By increasing the hospice workforce, we stand to improve wait times in hospitals by reducing the burden of ALC patients and making Canada’s end-of-life services resilient to the demands of an aging population.

Dignified, comfortable, and compassionate

As our society continues to age, the demand for end-of-life care will only intensify. By prioritizing hospice care, building hospice beds, expanding the health-care workforce, and increasing funding transfers, we can transform the landscape of end-of-life care in Canada. This initiative is a call to action that will usher in meaningful change, improving wait times and ensuring a dignified, comfortable, and compassionate journey for patients nearing the end of life. 

Rick Firth, the president and CEO of Hospice Palliative Care Ontario notes, “While there is a growing understanding of the complex needs of the dying and their families and how quality of life can be extended to last breaths with appropriate hospice palliative care, we still have much work to do to truly demonstrate the compassion and humanity of our society by caring for families in a most difficult chapter of life”.

Richard Shimooka: Canada’s military is being left behind

Commentary

Looking back, one of the most difficult periods for the Canadian Armed Forces in recent history was the late 1970s and early ’80s. Successive governments had cut into the military’s budget, downsizing and reorienting the forces while also delaying modernization. By the 1980s the CF faced obsolescence in the face of significant advances by Warsaw Pact forces. 

But while downsizing had cut the military’s standing forces, it still retained a capable administrative system with enough institutional memory to execute the new programs. By 1990, the military had replaced a number of its key systems with platforms (like the CF-18, CP-140, and the Leopard 1) with other major ones, like the Halifax Class frigates and the North West Warning system that was on the cusp of delivery. 

On the surface, Canada today looks like it is in a similar situation to the 1980s, and may even seem to be on the same trajectory if 2017’s Strong Secure, Engaged is executed as envisaged. Unfortunately, looks are deceiving. The reality is far worse now than it was then.

Many of the same systems we acquired in the 1980s are now far beyond their rust-out date and are not anticipated to be replaced for another decade or more due to failing program execution. While defence spending has increased over the past eight years, much of it has gone to operational accounts due to growing international commitments. This has masked the growing dilapidated state of the military’s capital base.

In other words, our system of procurement is fundamentally broken. Deliveries of major capabilities can now be counted in decades where years should be the norm. The Remotely Piloted Air System (RPAS) program, which will deliver a medium-altitude unmanned aerial vehicle, is about to enter its 17th year of existence without delivering a platform. By comparison, many of our allies, such as the U.K., Germany, and France have brought equivalent systems into service in under four years.

These failures have occurred at an inopportune moment, as the international security environment has deteriorated rapidly in the wake of Russia’s invasion of Ukraine and China’s destabilizing efforts in the Indo-Pacific. Our allies have increased spending and launched broad modernization of their forces, whereas Canada’s efforts have largely stalled by comparison. 

The system of acquisition is fundamentally misaligned from the focus of delivering critical defence goods to our soldiers. Over the past four decades the system has become progressively slower and less able to meet our national defence needs due to several factors. First has been the increase in non-defence objectives in procurement, most notably delivering economic and social benefits to Canadian society through these purchases. Second, a number of perceived failures, such as the initial cancellation of the F-35 acquisition in 2012, resulted in ill-considered reforms. It added layer upon layer of unnecessary processes, diluting individual accountability, and increasing costs and delays in programs.

While our present situation is suboptimal, the real cause for concern is the CAF of the future (which in reality, is already here). Reflecting the rapid and fundamental evolutions our societies are experiencing due to the confluence of new technologies, warfare is undergoing a similar shift. What I outlined earlier reflects a 20th-century approach to war fighting and procurement. Canada must move into the 21st century. 

A core consideration is the information dominance strategy. In the United States this exists under the Joint All-Domain Command and Control approach, or JADC2. Simply put, this doctrine seeks to aggregate and integrate information from all available sensors, then analyze and disseminate it to units that can affect action. Canada’s major allies, including Australia, Germany, and the U.K. are implementing similar approaches and have already drastically affected force structures and doctrines among all of their services. On a granular level, a platform’s connectivity and integration to existing networks and command and control systems are often as important as its physical attributes.

Canada has not adjusted to this new reality. While Strong, Secure, Engaged did contain verbiage that acknowledged joint intelligence surveillance and reconnaissance’s utility for the battlefield, the Canadian Armed Forces has lagged far behind its allies in this area. For example, when we look at RPAS, the misalignment of focus is clear. The procurement was largely focused on its physical capabilities while minimal consideration was given to how the platform would play in a broader networked environment. It would be akin to buying a top-of-the-line smartphone and only using it to make phone calls. 

In many ways this shift, when it comes, will be a fundamental one for the department and the government. Its implications will be profound and widespread, affecting not only military operations but how we procure systems. For some systems, such as software-enabled capabilities, how we develop them will directly affect their military utility. It requires procurement approaches that are flexible and innovative, delivering capabilities rapidly to our soldiers in order to face unanticipated new threats. 

If there is one point to start, we need to develop a strategy and doctrine that clearly identifies the importance of this emerging revolution in warfare. While, ideally, this should have occurred in the Defence Policy Update, even some level of guidance would be a start. By identifying these first principles, the military, the Department of National Defence, and the government as a whole can start the process of aligning its thinking around this problem. That is the crucial initial step that must be taken before further reforms can follow.

The 21st-century battlefield is already here. It’s time our leaders seriously engaged with what that means. We must enable the military to field the systems it needs to operate and succeed there. Nothing less than our security and global standing are at stake.

This article was adapted from remarks given as testimony before the Standing Committee on National Defence. A recording of the remarks can be viewed here.