Over the next few weeks, The Hub will be expanding upon the top five submissions for the 2023 Hunter Prize for Public Policy, which asked for proposals that would tackle the problem of Canada’s lengthening wait times for medically necessary care. In each of these dispatches, readers will get a closer look at the issues at play, as well as analysis from experts in the field.

Health care in Canada was facing challenges even before the pandemic, but since 2020, the system has been under an even greater strain. Wait times for medically necessary care are longer than ever, and staff are increasingly exhausted, with many either leaving the profession or seriously considering doing so. Combine these issues with a population that is, on the whole, unhealthier, and access to care has become more limited.

In a submission for the 2023 Hunter Prize for Public Policy, Ayeshah Haque, a midwife and researcher, suggests that the creation of mobile, integrated health-care teams capable of conducting home visits could help free up space in hospitals and improve the work-life balance of health-care workers. 

Under Haque’s proposal, paramedics, nurses, midwives, and internationally trained personnel would be eligible to form a home-visit team. A manager would be assigned by a hospital, and the hospital would cover the costs of salary, benefits, mileage, equipment, supplies, and insurance. The teams would meet twice a day, either in person or remotely, with case reviews to refine program protocols and processes. 

Haque anticipates that home visit teams would receive $50 an hour in addition to the equivalent of 10 full day’s pay. Staff would be permitted to maintain seniority, and would not be considered to have left their home-care team. 

Easing pressure on emergency rooms

To demonstrate how a home-care team would work—and relieve pressure on emergency room and other hospital staff—Haque invites readers to consider a scenario in which someone feels unwell and goes to the emergency room, perhaps waiting several hours for care that could have been provided elsewhere. She notes that this patient’s needs could alternatively be met through a prompt assessment by a home-visit team. This could potentially pre-empt an unneeded emergency room visit by determining whether or not the patient truly requires that level of care.

Haque presents a second scenario: one in which a patient has been struggling with her mental health and has not eaten for days. Her family calls for emergency services. The home-visit team could offer to assess the patient at home and provide supportive care. At the same time, the team could craft a care plan with a nurse practitioner or physician to be used until a hospital bed or psychiatrist is available. 

In the two examples above, Haque demonstrates how pooling health-care providers into home-visit teams can lessen the burden on emergency rooms by diverting non-urgent patients away from the hospitals. 

“Expanding community paramedicine programs into interdisciplinary teams that provide home visits and link community and hospital settings can address prolonged ER visits, [and] improve outcomes and experiences for patients while providing continuity and culturally safe care,” says Haque, pointing out that treatment for conditions such as asthma and information about birthing procedures can be provided via home care, thus shortening wait times for these services.

As evidence for why this model could work, Haque cites the ability of midwives to provide high-quality services outside of hospitals; she also points to the link between nursing home visits and reduced ER waits and hospital readmissions. 

Helping exhausted health-care workers

Staff burnout was an issue in Canadian health care before COVID-19 began to spread, but exhaustion brought on by the pandemic led to thousands of medical personnel leaving their jobs due to physical and mental strain. 

Data from the Government of Canada in 2022 found that 95 percent of health-care workers felt their jobs had been impacted by the pandemic and roughly 87 percent were more stressed; one in four nurses planned to quit their jobs within three years. 

“These care providers are seeking better work-life balance and/or [are] unable to work in their current models,” writes Haque. 

She notes that the data on health-care staffing shortages, while limited, suggest that many skilled health-care workers have not exited health care completely; rather, they are inactive or not working in clinical environments. Her proposal suggests that members of home-visit teams would have the option of casual or part-time work, and would be able to pick up shifts when the emergency room is busier than usual. This flexibility could address some of the concerns raised by health-care professionals about the demanding nature of their work.

In line with these observations, Shawn Whatley, a physician and Munk senior fellow in health policy at the Macdonald-Laurier Institute, emphasizes that health-care professionals enjoy patient interaction but are often overwhelmed by administrative tasks. 

“I’ve never seen them retire because they really got sick of patients. They get sick of everything else. They get sick of the administrative burden or the bureaucratic environment or the top-down approach to infection prevention and control committees,” he says. 

Home teams could present communications challenges

Emmanuelle Faubert, an economist at the Montreal Economic Institute, believes home-visit teams would be a great preventative measure, and agrees they would free up space in emergency rooms. One concern, however, is that hospitals are already short-staffed and that implementing these teams would require more trained personnel for roles such as communications. 

“As it is right now, [the hospitals’] lack of flexibility is making their staff leave,” she says. “The flexibility inside of the hospital settings should probably be addressed before we give them the responsibility of managing these community teams.” 

Krystle Wittevrongel, a senior policy analyst with the Montreal Economic Institute, likes Haque’s proposal, but she, too, has some concerns about communication. How, she wonders, would communication between patients, home-visit teams, and ER physicians (if required) work? 

“There has to be some way of considering this within implementation, as well as how this would be funded,” Wittevrongel says. “Would the liaising with the doctor be remunerated the same way as if they had seen the patient in person? If so, the system is effectively being charged twice for the same patient, and this would ultimately increase costs.” 

Questions about funding remain 

Hospitals in Canada are currently funded under the global budgeting system, in which an annual budget is allocated based on the level of services provided and number of patients treated during the previous year. A number of other countries have adopted activity-based funding—a system in which hospitals are funded according to real-time needs, with government entities setting the prices for the services and procedures provided. 

“With global budgeting, hospital-funding this would be problematic, in my opinion, as you aren’t going to have the carve-outs for these services appropriately when needed,” says Wittevrongel. “Combining [this] with activity-based funding would be useful.” 

Wittevrongel wonders if hospitals would be willing to dedicate parts of their budgets to the home-visit teams rather than in-hospital work. 

Nadeem Esmail, a senior fellow of the Fraser Institute and former director of Health System Performance Studies, has similar questions. And like Wittevrongel, he believes activity-based funding would be better suited to hospital-run community teams. 

“What is the incentive for the hospital to do it? Why would a hospital today be interested in creating this whole program to spend a bunch of money on services?” he asks. “From a hospital’s perspective with activity-based funding, if I don’t have as many patients coming who can be treated effectively at home, then the hospital can take more complex patients and treat them more rapidly, which…increases revenue.” 

Esmail also notes that hospitals don’t necessarily have to be the only managers of the community teams. “It could be run by general practitioners in multidisciplinary practices, it could be run by hospitals, it could be run by health regions.” 

Regional differences 

Shawn Whatley notes that versions of community-based teams have worked well in urban settings. 

“Definitely in downtown Toronto, I think it’s worked very well, where you can have a team not travelling very far,” he says. “The person is just in the home, they’re in the apartment building literally across the street from the hospital, and you have a team that walks over, sees the patient, and does whatever they need.”

As a province-wide system, however, Whatley says it will not have the same effect. 

Wittevrongel says that needs in rural areas can also be addressed by increasing funding for nurse-practitioner (NP) clinics. Nurse practitioners are health practitioners who can work alone, or with other health-care personnel, to deliver care. 

“NPs can do much of the same as family doctors,” says Wittevrongel. “Having funding options available for these clinics can also be extremely effective for rural and remote areas.” 

Nurse practitioners do have a role in Haque’s proposal. She suggests that one would be assigned by the hospital to supervise patient flow and care plans for the home-visit teams, as well as evaluate the implementation of the home-visit team and its impact on emergency rooms and the community. 

Additionally, Haque says that nurse practitioners practicing home visits in the United States have already demonstrated that their services reduced emergency room visits and hospital readmissions. 

Four days after the October 7 attack by Hamas that killed 1,200 people in southern Israel, mostly civilians, Israel’s war cabinet vowed to wipe Hamas “off the face of the earth.” And yet, despite one of the largest military mobilizations in the country’s history, and the rapid encirclement of Gaza City by the Israel Defense Forces (IDF), experts are skeptical about whether Israel can fully accomplish its objective. Some are also beginning to doubt that the predicted regional escalation will come to pass.

Janice Stein, the Belzberg Professor of Conflict Management in the Department of Political Science at the University of Toronto, does not believe the IDF has met its objective, which was to disable the capacity of Hamas to organize and launch attacks on Israel. 

Despite the fact that the IDF has managed to kill several of the October 7 attack’s ground commanders, Hamas’s senior leadership remain far away from Gaza in safer locations, such as Qatar. As well, rockets have continued to be fired at Israel from inside Gaza, with Hamas claiming responsibility for an attack aimed at Tel Aviv on Monday. 

“[This] suggests that there is still military capacity,” says Stein. “There are certainly reports from the IDF that infrastructure has been identified, attacked, and dismantled. But there was no way of knowing what proportion of the infrastructure or whether these are the most important pieces.” 

Stein says that though it cannot be confirmed if it is Hamas who is launching all of the missiles—as opposed to groups such as Islamic Jihad—the underground tunnel system built by Hamas in Gaza is still largely intact, as the IDF is only operating in the northern part of the city. The tunnel system is crucial to Hamas’s military strategy, as it enables them to stay hidden from Israeli air strikes while remaining operational. In the past, Hamas has also been able to extend the tunnel system into Israeli territory beyond the border fence with Gaza.

Joshua Krasna, a former Israeli diplomat and a senior fellow at the Philadelphia-based Foreign Policy Research Institute, says that Israel’s goal of completely destroying Hamas is unrealistic. While this may be a popular position among the Israeli public, he points out that it is very difficult to annihilate a group like Hamas, which possesses a strong ideological component. Nevertheless, he believes Hamas’s ability to strike at Israel will be greatly diminished when the war ends. 

“We’re destroying their capabilities. We’re killing their fighters, we’re destroying their infrastructure,” he says. “It will not be easy for them to rebuild what they’ve lost, because if there’s a political order in Gaza afterward—and we hope it’s going to be significantly different— it won’t be easy for them to covertly build back these capabilities.” 

On Tuesday, Israeli Prime Minister Benjamin Netanyahu’s cabinet approved a four-day pause in the war in exchange for the release of Israeli hostages. Some Palestinian prisoners will also be returned to Gaza. Although Netanyahu has vowed that the war will continue after the truce expires, Stein says pressure from the United States may push Israel towards a full ceasefire. 

“How long it is going to go on is largely a function of the pressure that the United States is going to put on,” says Stein, who expects the fighting to end by Christmas. “There’s a long history of this in virtually every war in the modern history of Israel—the United States eventually intervened to stop the fighting. And there’s nothing that makes me think this will be an exception.” 

Krasna also predicts that this conflict will resemble previous wars waged by Israel, and believes that nobody in Israel wants the war to go on for a full year. 

“It’s going to be shorter than Israel would want, and we’re going to achieve less than we want,” he says. “But that’s been true in every operation in every war that Israel has had.” 

Regional escalation seems unlikely

Since the early days of the war, there has been speculation about regional escalation, especially on the northern Israeli border with Lebanon, where Hezbollah, an Iran-backed terrorist and militant group, has a strong presence. Estimates suggest that Hezbollah currently possesses 130,000 rockets, and it is described by the Washington, D.C.–based Center for Strategic and International Studies as the most heavily armed non-state actor in the world. 

Iran is Israel’s top strategic rival in the Middle East, and the two countries have been waging a proxy conflict for decades. In fact, says Krasna, prior to October 7, there was an impression in Israel both strategically and publicly that Iran and Hezbollah were a greater danger than Hamas. 

He says Netanyahu had been presenting Iran as Israel’s greatest threat for years while downplaying Hamas’s capabilities—a narrative that was bolstered by the effectiveness of Israel’s Iron Dome missile defence system, which intercepts and destroys most rockets launched from Gaza. Israel’s border fence with Gaza, and the perception that Hamas would moderate in order to pragmatically govern Gaza, also lulled Israel into a false sense of security. 

Although Krasna says he was as surprised as anybody else when Hamas launched its attack in early October, he had always considered Hamas to be the bigger threat. 

“In my view, the enemy is always going to be the person who kills the most of your people, not the person who theoretically could pose the greatest strategic threat,” he says.

While there have been sporadic clashes and artillery exchanges between Israeli and Hezbollah forces, they have not precipitated a full-scale war—and some experts now feel that regional escalation may not happen. While Krasna says that Hezbollah has an interest in “keeping that border hot,” and as such, are perceived as helping the Palestinian cause, they are not interested in a full-scale conflict.

Jeffrey Feltman, former U.S. assistant secretary of state for Near Eastern Affairs, also thinks a regional escalation is unlikely. Speaking to the Brookings Institute, he said that Hezbollah’s military buildup is intended to deter Israeli military strikes against Iran, and questioned whether Iran and Hezbollah would want to use their arsenal in support of the Palestinians. He also noted that the international narrative is already working against Israel, without any escalation from Hezbollah or Iran. 

“Horror and anger over the civilian toll in Gaza transcend the initial outrage and sympathy over the October 7 butchery and abduction of Israelis,” he said. “Hezbollah and Iran take much satisfaction with Israel being branded the aggressor and may not want to complicate that impression.” 

West Bank concerns

The outbreaks of violence between settlers and Palestinians in the West Bank have not received as much media attention as the war in Gaza, but Stein says the volatility there should not be underestimated—as evidenced by President Biden telling Netanyahu to put a stop to the provocations that Israeli settlers were engaging in there. She says there is evidence that Hamas members are currently present in the West Bank. Captured Hamas fighters have revealed that they were hoping to link up with Hamas members in the West Bank to provoke a general uprising.

Netanyahu’s centre-right Likud party is not closely linked to the settlers, unlike Likud’s more hardline coalition partners, whose leaders hold key cabinet positions in Netanyahu’s government. 

“It may not be fully within the capacity of Netanyahu to stop this, but if he allows this to continue, he does so at his peril,” says Stein.