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Hunter Prize: The prescription to end hallway medicine once and for all

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.

Health and long-term care (LTC) systems across Canada are struggling now more than ever, and it’s negatively affecting the health of every Canadian. There’s simply not enough support available for everyone who needs care at home or in LTC homes. 

In Ontario, there are currently over 14,000 people on the continually expanding waitlist for home care and over 39,000 people on the waitlist for LTC homes. Many of these individuals, who can no longer reside safely in their own homes, have ended up living in hospitals instead. These and others, who no longer require hospital care, are politely labelled as “Alternate Level of Care (ALC) patients”, but are essentially being held hostage by the current lack of LTC services as they wait for appropriate care to become available back in their own homes. 

Currently, there are 4,514 patients ALC patients occupying 13.6 percent of Ontario’s hospital beds, with 48 percent waiting for LTC home placement and 13 percent of them waiting for access to in-home care. In its overcrowded hospitals, Ontarians are now waiting a staggering 17.9 hours on average to be admitted to an inpatient bed from emergency departments. Furthermore, limited beds only serve to additionally delay timely access to elective surgeries. 

While Ontario’s current government was elected on a promise to end hallway medicine in 2018, the truth is that it’s never been further from this goal. Its proposed solution was to build and redevelop 60,000 LTC beds by 2028, but has only managed to open 1,934 new or renovated beds while only another 5,071 are under construction. While the government has further responded to this by more than doubling its construction funding subsidies from an average of $240 to $560K per bed, or $14 to $34B overall, to help further incentivize and accelerate the building of LTC beds to meet its 2028 goal, it remains highly doubtful this can be achieved.    

So how can we actually end hallway medicine? 

We are proposing that Canada significantly reorient from its current preference to provide LTC services in LTC homes to within the actual homes of Canadians, for which we currently only allocate 31 percent of our LTC spending. While LTC homes must remain an option for some, home care services can be ramped up more rapidly. Furthermore, by lessening the need for more institutional forms of care, we can avoid the significant infrastructure costs that are associated with warehousing vulnerable people. 

However, we don’t just need to provide more home care, but also implement more integrated and intensive ways of delivering this care such as through our proposed “Virtual LTC @ Home Program.”  Such an approach would enable integrated teams, comprising local home care, community services providers, primary care providers, and community paramedics to offer a more robust, flexible, and cost-effective mix of home care services to enable LTC home-eligible individuals, including the nearly 52,000 Canadians awaiting LTC home placements, to live in their own homes for as long as possible. This is also what nearly 100 percent of older Canadians have said they actually want. Furthermore, these teams would have to work with the same level of funding it would cost to care for these same individuals in an LTC home.

While our proposed prescription might sound unrealistic, it is both inspired and informed by the United States and Denmark, which have successfully developed more robust home care programs, to improve care outcomes and reduce the strain on hospitals and overreliance on LTC homes. In fact, Denmark, which has been championing its progressive Ageing-in-Place Strategy since 1988, now allocates only 36 percent of its overall LTC spending to care for individuals in LTC homes, compared to 69 percent in Canada. As a result, Denmark has achieved an almost non-existent 1 percent ALC rate—compared to Ontario’s rate of 13.6 percent—through a strong emphasis on providing adequate home care services that enable patients to be appropriately discharged quickly from hospitals when they no longer need care in them. Denmark also avoided building any additional LTC beds over two decades and closed thousands of hospital beds as a result of its strategy.

In the United States, Program for All-Inclusive Care for Elders (PACE) models currently support approximately 51,000 LTC home-eligible individuals 55 years and older across 31 states to live safely at home for as long as possible with the support of one of 260 PACE programs that provide robust home care services—which receives the same amount of funding per enrollee as would have been given to care for them in an LTC home. Finally, one study showed that after three years, 85 percent of PACE enrollees were still able to live in their own homes.  

Our call to action

Given predictions that Canada will need to more than double its current complement of LTC beds by 2035 to meet the needs of its ageing population, our proposed Virtual LTC @ Home Program offers a high-impact, cost-effective, and politically desirable policy alternative to building more LTC homes that can effectively address health-care wait times and other health-care delivery challenges. 

In its 2023 budget, Ontario announced that it would inject an additional $569M this fiscal year for the provision of more home care. Rather than pursuing more of the same approaches with this funding, it’s time to embrace more innovative and robust solutions. We are thus proposing that Ontario use a small proportion of its new investment to launch up to 10 Virtual LTC @ Home Demonstration Programs. These programs could support up to 150 clients per year with up to $67,510 per enrollee per year (the current annual per-resident cost to provide a year of care in an Ontario LTC home), for an initial three-year period of funding. While this would represent an investment of $100M a year, as part of Ontario’s overall $14B LTC services budget, we think we cannot afford not to test our evidence-informed solution that could begin to finally put an end to Ontario’s debilitating hallway medicine and waitlist crisis once and for all and show a way for Canada to better meet the needs of its ageing population.  

Sean Speer: We no longer need the CBC

Commentary

This past weekend, I was a guest on the CBC’s weekly call-in show, Cross Country Checkup, to discuss and debate the question: do we still need the CBC?

I was there in particular to make the case that the news media market has evolved over the past decades such that a public broadcaster of the size and scope of the CBC is no longer justified. Others argued in favour of preserving the CBC. And then there was a combination of callers and experts who found themselves somewhere in the middle. 

The premise behind the episode was that there are a few big developments looming over the CBC that threaten its ongoing existence. The first is that Conservative Party leader Pierre Poilievre has promised to defund the CBC and seems committed to delivering on his commitment. It remains one of the most popular applause lines in his speeches to party supporters. 

The second is growing polling evidence that CBC is not only losing its salience with the Canadian public but that even a majority of non-conservatives believe that the public broadcaster has an anti-conservative bias in its news reporting. 

The third is the broader disruption in the media industry itself including the decline of legacy news media organizations and the rise of web-based start-ups that are experimenting with new and different business models to reach their audiences and sustain their operations. 

In light of these developments, there were various arguments put forward during the episode in favour of the CBC including the need for a single public institution to connect Canadians from coast to coast, that it represents a bulwark against the rise of so-called “misinformation” and “disinformation”, and that its listeners and viewers like its content. 

Due to the number of guests and callers, I didn’t have the opportunity to address these arguments as directly and fully as I would have liked. Let me respond to them now. 

The first one speaks in part to a conservative concern that in a world of growing fragmentation and diversity, there are few sources of common citizenship and identity in Canada and the risk is a gradual drift from what Rabbi Jonathan Sacks has referred to as a “home society” to a “hotel society.” That is to say, in an absence of common stories and shared understandings of ourselves and the country, the danger is that we devolve into a loose collection of individuals merely living in the same geography. 

This is a legitimate concern that we’ve written about and discussed at The Hub. Yet the notion that the CBC is a key source of common identity belies the facts—including its relatively small audience, divided public opinion about its ongoing purpose, and growing tendency towards micro-narratives at the expense of a broader national story. 

The latter point is worth addressing more fully. Although the CBC should be lauded for concerning itself with diversity and representation within its organization and content (including news reporting), there was a sense among many of the callers that it has overcorrected for the historical underrepresentation of different stories and voices. 

This is consistent with my own experience as a listener and viewer. The network’s emphasis on identity issues can cause it to lose the forest for the trees. It has increasingly contributed to a narrow and unrepresentative conception of Canadian civic life that undermines its ability to still play a nation-building role.  

The next argument that the CBC is needed to contest misinformation and disinformation (which has been advanced by CBC’s president and CEO Catherine Tait herself) isn’t a self-evident one. It may be that these issues ultimately require some form of collective response—though the past several years have demonstrated the risks of groupthink and so-called “established narratives”—but it doesn’t necessarily follow that it requires a public broadcaster in general or the CBC’s current size and scope in particular. 

One might even argue that the right lesson is that centralization and consolidation are a threat to overcoming misinformation and disinformation. They can cause bad ideas and wrong information to calcify in the public discourse and undermine the ability of others to challenge them. The COVID-19 “lab leak” story is a powerful example. The CBC (which referred to the lab leak theory as a “conspiracy theory” and “one of the most persistent and widespread pieces of disinformation during the COVID-19 pandemic”) and other major media organizations plainly got it wrong. Smaller, less established, and typically less liberal outlets were generally the ones prepared to pursue the story and its facts. 

The key point here is that today’s fragmented and more decentralized media landscape may be messier and more complicated than the old one, but it’s not obvious that the trade-offs are inherently bad or that it necessitates an ongoing role for the CBC. 

The final case that the CBC’s content is good and well-liked by its audience members was both the most common one cited during the episode and the most counterintuitively unpersuasive. No one doubts that the CBC produces good programming or that some Canadians enjoy listening to or watching it. But that’s not a justification for the current level of public resources dedicated to the CBC or a public broadcaster in and of itself. 

There are a lot of claims on the public purse that might be popular but that doesn’t make them a good idea. Public policy needs to be rooted in something more principled than “Some people like it.” Even the show’s host, Ian Hanomansing, who deserved credit for his fairness and neutrality, seemed to miss this point. 

During the conversation, I observed that The Hub’s podcast is the eighth most popular Canadian-based one in the “culture and society” category and that six of the seven ahead of us are CBC productions. It strikes me as an odd use of scarce public dollars since it’s hard to argue that there’s a market failure in the production of podcasts. 

Yet Hanomansing’s reaction was that the relative popularity of CBC’s podcasts is somehow market proof that its content resonates with Canadians and therefore a justification for its ongoing role. The reality is that the CBC has a huge financial advantage (which is based on public subsidies rather than market competition) and is able to cross-promote its content across its well-established channels, including its internet, radio, and television assets. That of course doesn’t mean that its podcasts aren’t good or worth listening to, but it does mean that it’s not a fair measure of the CBC’s true competitiveness or a compelling case for maintaining it. 

I don’t mean to be presumptuous but I’m reasonably confident that if we received $1.24 billion in annual public funding (which suffice to say is considerably more than The Hub’s total budget), we could probably climb to higher than the eighth-most popular Canadian-based podcast in our category. We wouldn’t presume however that it was necessarily evidence of our real public support or entitled us to ongoing government resources. 

I guess the upshot is that while I was glad to participate in the conversation and think it generally speaks well of the CBC that it permitted such a discussion on its network, I came away no less convinced of the case in favour of “right-sizing” and even defunding the CBC. What that means in practice is still an open question and, as I said on the program, there will soon be a growing onus on Poilievre and the Conservatives to bring greater definition to their plans. But their basic instinct is right as a matter of principled policymaking.  

Do we still need the CBC? My answer is still no.