Last week, The Hub‘s executive director Rudyard Griffiths spoke with leading author and journalist David Frum at a live event at the Gardiner Museum. The two discussed what we learned about Canada since Hama’s attacks on October 7th and the consequences for our social cohesion and national identity. Here are three key insights from their conversation.

1. Rebuilding a national security culture in Canada

“Canada faces a deep internal security problem that the country isn’t prepared, not only to cope with but even, to think seriously about. Canada does not have a substantial national security culture. All problems of security are seen through domestic political prisms. There are so many examples of this including espionage from the People’s Republic of China, an assassination by a foreign government on Canadian soil of a Canadian passport holder, etc. All of these things were interpreted through the prism of immediate political needs for one political party or another without the apparatus and the method to think about them from a national point of view. And we have seen that very much since October 7.

Canada is an amazing immigration success story. When you pull people from all over the world, one of the things that you owe them is a clear message about what the rules of engagement on this new land are going to be. There are things that if you liked them, they were welcomed in your old place, but you can’t do them in the new place. There are many benefits to life in the new place. But the new place has its own customs, its culture, and its rules. And these are the things that have to be done. Although you try to communicate that in the nicest possible way, there also is an enforcement arm where you have an apparatus that is capable of detecting radical and potentially violent activity, and either thwarting it or punishing it. That has been sorely missing including the lack of clarity.

I’m not going to criticize what the Canadian government has said about events in the Middle East. But the lack of clarity about events in Canada and expectations in Canada is really alarming. Those expectations need to be clear, and they need to be backed up by an apparatus with the skill, the technology, and the legal power to protect Canadians from extremism and potential violence at home.”

2. An intellectual self-defence of Canada

“I think it reveals that Canada is in the grips of an ideology that is very dangerous to the health and safety of Canadians. If it’s true that people who identify as Indigenous have the right to murder people who they identify as settlers, that isn’t a principle with a lot of bite, not just in Israel [but here too].

If you have systems of belief that are defenceless to explain why that is wrong, why the whole concept of indigeneity is meaningless, and why the whole concept of settlership is equally meaningless, if a country like Canada can’t explain that, then a country like Canada lacks the wherewithal for an intellectual self-defence. Canada has been on that slope for some time.

That makes it very difficult for Canadians to say ‘I’m proud of this country’s history.’ It is blemished as every country’s history is, but less blemished than just about anybody’s. And as for the blemishes, there’s a process for correcting them.

Canadians need to feel pride. Canadians need to not only feel it but to assert it. If you’ve discovered their fellow citizens who don’t feel that same pride, the majority who do feel it should have ways and arguments that can say in a forthright way ‘You are wrong; it’s a free country, you can have that view, obviously, no one’s going to prevent you from having the view. But at the same time, the majority that have the view of affirmation and pride are not going to be bashful.’”

3. The risks of voting for the Leopards Eating People’s Faces Party

“There’s a common internet joke about ‘I never thought the leopards would eat my face said the lady who voted for the Leopards Eating People’s Faces Party.’ What we’ve seen in Canada and in the United States is, for a long time, there’s been a culture where people say things that other people take offence to and then there’s this massive campaign of suppression not by the government, but by society, to hold them accountable—to give them economic and social consequences including directly targeting their careers.

What has happened since October 7 is that because the majority of Canadians and the huge majority of Americans abhor Hamas terrorists, the people who have been seen to make excuses for them are suddenly discovering they voted for the Leopards Eating People’s Faces Party. Now the leopards are on the prowl, and they’re being devoured.

We’re seeing a social pushback where people are saying ‘We disapprove of people endorsing terrorism on the public dime,’ or people who have honoured positions of instruction are teaching contempt for human life and gleeful disregard for the suffering of families that have loved ones in captivity.”

Listen to David Frum’s full interview with The Hub’s executive director Rudyard Griffiths on the audio player below or on your favourite podcast app.

If you enjoy Hub Dialogues, be sure to check out more insightful commentary on The Hub’s YouTube page:

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.