This is the second instalment in a multi-part series. Read Part 1 here; watch for Part 3 on Wednesday.
Sometime in the next few weeks, Ontario’s vaccination campaign will be essentially complete. It will not end, because there will be stragglers and new people aging into eligibility. But the main effort is only weeks away from completion. We will move into what military commanders would call the “mopping up” phase — the main fighting will be over, even if some skirmishes continue for some time.
This may not represent a final victory — we will need to remain vigilant against new variants that may defeat our vaccines. For now, at least, a return to something much more like normal is possible. Only time will tell what that new normal looks like, and that’s a topic for future analysis. The challenge (and opportunity) before us right now is different: What does this next phase look like? These coming weeks and months? What should we do right now, as we exit this long crisis?
In the coming days, TVO.org will present interviews with a variety of experts who were all asked some variation of this question: What happens next in your field, and what must we do immediately?
Today: Anthony Dale, president of the Ontario Hospital Association, on what the health-care system must do to recover from this terrible ordeal.
Matt Gurney: Anthony, I watch the OHA’s Twitter feed every day, and I see the intensive-care unit occupancy numbers coming down steadily every day. It’s great to see. It was doing the opposite a few months ago. So things are improving and will hopefully, probably, continue to improve. What do our hospitals do next? What can they start doing now?
Anthony Dale: The first thing we need to do is find as many ways as possible to support our health-care workforce and give them a respite. They need it. They’re exhausted. These individuals have given everything. They need to recover. That means, hopefully, some time off and some well-earned rest.
But at the same time, there’s a huge amount of planning that has to take place to deal with the surgical-procedure and diagnostic-imaging backlog. The Financial Accountability Office recently created an estimate for the backlog for both and it’s … [sigh]. It’s just breathtaking. Its scale is enormous. People don’t appreciate it. There are existing wait-lists for some of the services. Cancer and cardiac care, in particular. But for a lot of these procedures, we’re using previous years’ volume and estimating. There aren’t always wait-lists. We have thousands of people in this province who don’t know that they’re sick. They don’t know that they need to see their family doctor or a nurse at their family health team or any number of primary-care professionals to start the process of keeping well. This is going to be an enormous hidden challenge. I was speaking recently with Matt Anderson, the CEO of Ontario Health. This is the paramount short-term issue on his mind. We need to do planning and put in motion steps to get thousands of people access to care that was cancelled, postponed, or never scheduled in the first place at all.
At the OHA, though, we think we also need to step back and take stock of two key pieces of legislation to see what worked and what didn’t: the Emergency Management and Civil Protection Act and the Health Protection and Promotion Act. Both acts were created in the aftermath of the SARS crisis. There are many individuals who can look at themselves in the mirror and say, “I did everything I could, in the control that I had, to help this province succeed through this pandemic.” But let’s look at the systemic underpinnings of both those bills and in the ancillary regulations and policies and learn from them.
Gurney: Is this something the OHA itself can do? Or someone else?
Dale: It should be an independent review. An independent review of the statutory underpinnings of pandemic and crisis management in the province and public health is necessary in order to prepare for the future. Kieran Moore, the new chief medical officer of health, is ideally positioned to look at all of that through fresh eyes and help lead us in the dialogue about what needs to change.
But then there are actually bigger, long-term questions we need to think about. Where does this health system go? Having experienced this pandemic and having learned enormous lessons about the value of moving quickly, of integrating personnel and services to support long-term-care homes and any number of areas, there are some profound lessons here about how siloed and fragmented Ontario’s health-care system is.
We have seen what this system can do when it has to move and adapt. Now there’s an opportunity to do it better. We can make it easier for trained workers to cross silos and work without barriers. Long-term care is still facing big challenges; so is home care. There are shortages in Ontario’s hospitals, and the workforce in general is exhausted. We won’t have new graduates entering the workforce for years, even with new investments we’ve made. We need to think boldly and creatively about how to make even better use of our fantastic health-care professionals and workers to serve the needs of patients and residents in various settings across the province. These are huge challenges, but there are also huge opportunities if we’re brave and if we’re bold.
Gurney: [long pause] Well … like … uh, oh? [laughs] Sorry, man. But I’ve lived in this province my whole life. If the solution rests on being brave and bold … well, we’re [expletive deleted]. Let me ask you a very Ontario question. I don’t want to discourage boldness and bravery, but I’ve been covering this stuff for a while. So … what’s the modest and incremental version of this?
Dale: Yeah, yeah, I know. Look. If we leave everything alone and shrink back into how things were before the pandemic, we are staring at a long-term-care sector that has been smashed to pieces because of the impact of COVID-19 and its aftermath. You have the findings of the long-term-care commission sitting on a shelf where nothing has happened, despite the fact that it’s abundantly clear to all that residents of long-term care have far more complex and far higher acuity than the system was originally designed to care for. So if we shrink back and we ignore the findings of that commission, shame on us, because we are ignoring the lessons of this pandemic and ignoring unbelievably compelling evidence and information about what we have to do, what we have to change, to provide better care and more appropriate care for frail seniors.
If you turn to home care: the home-care workforce has been hollowed out through this pandemic. Many home-care companies, whether they’re not-for-profit or for-profit, are finding it increasingly difficult to meet various care requests that are coming in by the thousands every day through the provincial administrative system for allocating home care. If we don’t act, and we don’t buttress both those sectors, in particular — again, shame on us, because it’s the frail seniors in this province who will continue to pay the price. That would mean systemic resistance to acting in support and in care of the most vulnerable people in our province.
Gurney: I don’t mean to be too reductive here, but how much of the problem we’ve had over the last year and a half has been a hospital system that’s just too damn small? Are we going to just need to build three or four more huge hospitals in the GTA and a bunch of small ones elsewhere?
Dale: I’ll tell you, for 15 or 20 years, we have been calling for something that won’t win a lot of votes but has been a huge omission, a huge kind of gap in our health-care system. We simply need to get serious about long-term health-service-capacity planning. We also need to find ways, not just as a province, but as a country, to invest in health services outside of the hospital setting. We have among the lowest hospital-beds-per-capita in the OECD, among our peer nations. So evidence suggests we’re at the outer limit of what’s appropriate in terms of hospital capacity.
But, look, look at our system pre-pandemic — one in six patients in our primary hospitals didn’t need to be there. They’re called “alternate level of care,” or ALC, patients and they’re ready to be discharged into a more appropriate health-care setting, but there’s no capacity there to take them. They can’t be discharged into a bed that doesn’t exist. So if we’re prepared as a country really to make some choices about how we support our frail seniors, in particular, we can make some powerful changes.
Gurney: This is an issue I’ve written about a lot at TVO. Bottlenecks in LTC homes, rehab hospitals, and wait-lists for community care for mental-health care and addictions services leave people stuck in hospital beds they don’t need to be in. It could be fixed, but only by making huge investments in all these other parts of the system.
Dale: And to do that, we’re going to need federal help. We need the government of Canada. They’re the only ones with the fiscal capacity to do this. People don’t generally appreciate how complicated funding for health care is in Canada. Physician care and hospital care — that’s publicly insured, period. Many people may think that home care, for instance, in Ontario is publicly insured, but it’s not. Many people think that long-term care is a publicly insured health service, but it’s not. The province of Ontario does fund those health services. But that’s not the same as the universally covered hospital funding system. This is a big part of why the system remains so dependent on hospitals.
Different leaders have been trying to address this for decades. But the reality staring us in the face as we went into the crisis of COVID-19 was that we had hallway health care. It was a deepening issue; there were huge amounts of congestion and overcrowding in our hospitals because of the imbalance that I’ve described — not enough capacity outside of the hospital setting to care for our frail seniors.
So now the pandemic’s over, and we’ve seen how we can mobilize personnel, we’ve seen how we can mobilize resources — what lessons are we going to learn? Are we going to find new ways to strengthen capacity and build capacity in other parts of the health-service continuum? Or are we just going to continue to plod along using the same approach that, frankly, has underperformed for so many years?
Gurney: You mentioned before that we need to do a legislative review of how the laws and regulations performed. What about just an operational review — an after-action report by the hospitals themselves on how all this went?
Dale: Every hospital in the province has its own emergency-management systems and planning. And, without doubt, when the smoke clears, there will be examination of how each individual hospital performed. And hospitals are deeply focused on continuous performance improvement. So no doubt, there will be significant learning and findings across the entire province at the individual level. And we already have the LTC report, of course. But as far as I’m aware, there are no other reviews anticipated or planned.
But, you know, after the auditor general’s report on the pandemic response last year, we did write to the leadership of all the political parties in the province. I think some of the auditor’s report is debatable, but between that and the LTC commission’s report, there are clearly issues that warrant and merit further discussion by legislators. And those issues should be discussed and reviewed in an independent manner. And this is no doubt something that will be happening across the globe, as all sorts of jurisdictions learn from this crisis. We will probably do that at the federal level, as well.
So I think we should take pride in the hard work and enormous effort that so many people have brought to fighting this pandemic, but also be prepared to constructively criticize what hasn’t gone well, build on what has gone well, and embed changes to prepare us for the next pandemic. Because as the experts have been warning us for so long, this won’t be the last. And this has been the most serious civil emergency in the province’s history. There will be further crises ahead. There may be pandemics, there may be other crises, and I think it’s in the public interest to conduct that kind of evaluation at the macro-system level.
Gurney: I want to throw you a curveball question here, and it will sound like a personal question, but I have a point with it. Think back to last year. When did you have your real moment of, uh oh, this is really going to happen. Mine was in February, when it popped up in Seattle and then New York and was ravaging Italy and Iran. I went to Costco and did a huge run. I was way ahead of you all on the toilet paper rush. But what was your moment last year?
Dale: Yeah. Through February 2020, the OHA was being called to different meetings, different forums, called by the province to start planning for the pandemic. None of us, anywhere, had ever experienced something of this magnitude. I had this feeling that things were happening fast, but I couldn’t put my finger on exactly why. On the night of March 11, I had some discussions with colleagues in the hospital sector, with the government and elsewhere in civil society. And we really did conclude that more urgent action was needed. Events were moving far quicker than we as a province, collectively, all of us together, were moving. So we called an emergency meeting of the board of directors. And we prepared a letter that went to Premier Ford on Friday, March 13, recommending effectively that the province immediately implement the Emergency Management and Civil Protection Act and a series of cascading recommendations to prepare for what became the biggest domestic homefront emergency in our history.
So we went from feeling uncertain about the risk to very, very quickly realizing that the risk was very, very high. And that was primarily a consequence of the command tables, where estimates were being shown to us that laid out what would happen if we didn’t take immediate action. These included fatality projections. And … well, they were catastrophic. It galvanized all of us into moving quicker than we ever have in our entire lives. That meeting and those few days will stay with me forever.
Gurney: Yeah. I remember in those first days, we were thinking, well, okay, this thing is killing, like, 3 or 4 per cent of people it infects — that was an overcount, because we didn’t know how much asymptomatic cases were a thing with COVID. And I was doing mental math. Three million people in Toronto. Say a quarter of people get it. That’s 750,000. Four per cent of them die. That’s 30,000 dead. We realized pretty quickly it wasn’t going to be that bad — the scenes in Italy were horrific, but it was the first time we had useful information from a country where we could trust their reporting. But those early days were terrifying.
The reason I asked that is that we think this is almost over. But we’re not quite out of the woods. And all the reviews you’re talking about above, they’re going to take time. If a new variant emerges that defeats our vaccines, God forbid, or if God really has a dark sense of humour and some entirely different virus mutates on us and we’re staring down a crisis like this again, what’s your first call? What’s your first action this time — if we have to do this all over again before the reviews are completed?
Dale: I think all jurisdictions have a culture of their own. And in our system and culture, we have a system of deference and of listening to the highest authority — in our case, usually the parliamentarians and legislators. And a big lesson for the OHA, and I think for a lot of our partners and for many in government, it’s that we need to all pull together. In order to overcome these kinds of crises, we need our government officials and elected leaders and health experts and hospital leaders and fantastic front-line clinicians all working together, all communicating, all sharing their thoughts and findings. Sometimes that’s going to be acrimonious. Sometimes it has been acrimonious. We are worried about social cohesion now, right? Everywhere: the economy, health-care system, mental health, you name it.
But every organization working in good faith has a role to play here. And it’s okay to disagree. It’s okay to debate. It’s okay to challenge the government in public if, at the end of the day, we as a society make a better decision. And so that’s a big lesson for me, and I say that with complete deference to the responsibilities of our elected officials and as someone who has had to lead efforts through the last year and a half that I would most certainly rather not have.
But we’re proud of what we’ve done. We’re proud of how we’ve been able to co-operate and at other times challenge the government. But ultimately it’s all toward the same objective, which is ending this pandemic and protecting Ontario. The loss of life is equivalent to a world war for this country. I think people have lost their understanding of the scale of the devastation, primarily because the battlefield was in long-term-care homes and in the intensive-care units of hospitals, not being broadcast on TV or reported in newspapers like a traditional war would be. But we have tens of thousands dead. That’s war-time-level casualties for Canada.
But, look. There’s not just a consensus on the lessons learned from this pandemic now — I’d say there’s unanimity. Ontario hospitals have proven themselves to be remarkably resilient, adaptable organizations. I couldn’t be prouder of what they have done. And I mean it in every sense of the word. Their efforts alongside colleagues in LTCs and at ORNGE and EMS and patient-transfer services, home-care providers — everyone has given it their all, and we should all be very, very proud of that. But we can do better. We can break down the silos. We can use the lessons we’ve learned. We can do better for Ontario’s seniors. And that’s what we will do.
This interview has been condensed and edited for length and clarity.