Everyone agrees that Canada needs more GPs, that hospital wait times need to come down, and that people should have access to the right kind of care when they need it. But how do we get there? I got insight from Nadeem Ismail, director of health policy at the Fraser Institute and Dr. Aniello Martin, chair of the Department of Family and Community Medicine at the University of Toronto. Nadeem, Dr. Martin, thank you so much for joining us on the program. Let's start with our health care system in general. We can I can assume that both of you can agree that this system is not perfect. There are things that need to be fixed. But Dr. Martin, let's start with you. What what is working in our health care system?

Well, the first thing that's worth noting is that Canadians are actually quite healthy as a group. We live a long time compared to the average. And when you get really sick in Canada, you actually get terrific care. Canadians have lower rates of dying in hospital from stroke. We have excellent outcomes for cancer and cardiac care. And of course, we're covered, all of us for a core set of services, doctor and hospital services without having to to pay for those services, which means that we have good equity of access when you can get into the system. And so there there's lots to celebrate and lots to be proud of as a pretty healthy bunch.

Nadeem, what positive aspects stick out to you in our health care system?

This is a health care system full of highly trained professionals who are doing their best for patients. Certainly we see it on the outcome side when when you're going in with a very critical condition. The Canadian health care system is actually fairly good at dragging people back from the brink of death. And I think certainly some of the outcomes are quite positive. So in many ways, a positive system, and we do have a very high spending record, which is not necessarily a bad thing. It shows a very high level of commitment to a high quality health care system.

All right. The C.D. Howe report that we referenced earlier says that Canada ranks very poorly, nine out of ten in access to care. When we talk about access to care, that is broken down into a subcategory of affordability and timeliness. Dr. Martin, why is Canada so behind when it comes to access to care?

Well, let's talk about affordability, because that's one that I think for many people is not intuitive. And the reality is actually that while we have very good coverage for physician and hospital services, we have lagged behind other countries in terms of our coverage of everything else. So in my practice, it is common for me to see people who don't have any coverage for their prescription medication, who don't have coverage for mental health services, who don't have coverage for physiotherapy. And so this question of affordability crops up in the lack of of breadth of coverage for a whole lot of services that are critical part of modern medicine.

We have to remember, of course, that Canadians have some of the longest waiting lists for access to health care in the developed world, in spite of the fact that we have some of the highest health spending in the developed world. So we're spending a great deal of money, and yet we have some of the worst waiting times in the developed world, wait times that reach a record length year after year. And that high spending constrains our ability, of course, to do other things. So I think it's easy to point to say government's not doing enough. But the reality is government is doing a lot of things very wrong.

What other countries are we talking about? Who are we comparing ourselves to?

Well, let's look at other developed nations with universal access healthcare systems the Netherlands, Germany, Switzerland where they have very good access to primary care, to emergency care, to specialist care, to an elective surgery, shorter waiting times in each of those areas, much shorter than Canada is. But even other nations that spend a lot less than we do and do better, like Australia, where they have shorter wait times and a lower level of spending. So it's not-- Canada is not unique in having a universal health care system, but we are unique in having this incredibly long wait times experience.

Dr. Martin, let's talk a little bit about other aspects of our health care system. What areas do we look at that are holding us back in terms of competing with some of those other nations?

Well, I think one of the few areas where Nadeem and I might actually agree on this is that even in areas where we've got these highly trained professionals, wait times are often long because we're not doing a very good job of coordinating the resources that we have. So, you know, when I see a patient in my practice who needs a hip or knee replacement, for example, I have very little way of knowing who could who could see that patient most quickly. And we don't have a coordinated system of getting people in with the next available provider in their region. And so we find actually that not only are wait times long in general, but they're highly variable by region. And, you know, even within each province and territory. And so there's a lot that we could be doing to better coordinate those services so that when it's determined that what a person needs, for example, is to see a neurologist, that they're given the next available appointment with the next available neurologist at a convenient location in their region who can deal with their issue. And there are lots of examples in some of the countries that Nadeem names, and even in Canada for some kinds of services. So for example, we we see in Ontario in our cancer care system, you know, I don't refer to doctor so and so radiation oncologist my patient, when they have a new diagnosis of cancer is seen in a regional cancer centre by the next available expert who can deal with that form of cancer. And so those those things are all centralised. The same is true for cardiac care. You know, people aren't waiting to see a specific individual. They're they're put into a single common queue and seen by the next available provider. And actually those are some of the systems where our outcomes are the best and our wait times are the shortest. So there's a lot that we can do even before we start talking about spending more money, whether it's public money or private money, to coordinate better the resources that we've got.

Nadeem, I'll get you to to respond to that. And also, what else is what else do you think is holding us back?

I think Dr. Martin makes a great point. And certainly when we look at the experience of Saskatchewan, where they reduced their waiting list from the longest in the country to the shortest in the country, we see that coordination of care in that central intake was actually a key piece of the process. But we also have to remember, not only are we spending more than everybody else, and not only are we waiting more than everybody else, we have some of the fewest physicians, medical technologies, and hospital beds in the developed world. This is a Canadian. This is a health care system that's fraught with lack of access, with a capacity issue that needs to be solved. And it's not a money problem. The question is, I think, how do we get more money, more value, rather, for the health care dollars we're already spending, how do we get better access to services? And I think if we look at those other developed nations that are doing a better job, we just see a different set of policies in place. We see a larger role for private entrepreneurs and the private sector to bolster capacity. We see different financial constructs to lead to a much better overall health care experience that in total is more affordable for patients and far more equitable. I note Dr. Martin talked about equity in the Canadian health care system. We're mid-pack to below average when it comes to measures of equity in health care.

Nadeem, let's stick with you. You mentioned some policies there. What? Give us some examples of some nations and some policies right now that you're looking at their health care system being like wish we had that right now.

Well let's come back to that C.D. Howe report, which was largely built on the Commonwealth Fund study looking at developed nations with universal health care systems. The very best systems when it comes to access, have private competition in the delivery of universally accessible services. They have private competitive insurance. The private sector is not an enemy of the health care system in these nations. It's a valuable partner in delivering better universal access health care experiences. That's true in Australia, Germany, the Netherlands, Switzerland, the top performing nations are all doing this. Canada is behind in involving the private sector in our health care system.

Dr. Martin, when Nadeem says private, I see a smile on your face. For some people when they hear that word with health care, there is a reaction. I want to get your response on what Nadeem had to say there.

Well, I mean, I think, you know, from my perspective, it's it's a smile because, you know, those of us in medical education are working overtime right now to train more doctors than we've ever trained before in Canada, because I think it's true that our physician to population ratio in Canada needs to be higher. And there's work underway to, you know, to train more nurses across the country, etc. But part of the dilemma that we face that I think it's important for people to understand is that given that we do have shortages of health care professionals, and those shortages, by the way, are global, the World Health Organisation and other global multilateral organisations have declared shortages all over the world in all kinds of areas. If if we open up for private entrepreneurship, what we often find is that we're we're pulling those scarce resources out of the public system and into these other, these other models. So I think we have to be careful about unintended consequences here. You know, it may be that a job in a private surgical clinic is attractive to a nurse. And and that that nurse then leaves the public hospital to go and work there. And what happens then is that the understaffing and the wait times in the public hospitals and the public system actually get longer. And so we have to we have to look at the whole thing as an ecosystem. We can't just pull one aspect of another country's health care system out and say, well, you know, they have a bigger role for the private sector, therefore, putting the private sector into the Canadian context would make things better. There's lots of reason to be concerned that actually, it would make things much worse.

Nadeem, I'll get you in for a quick response and then we'll shift over to Ontario here.

Certainly we have an overall manpower shortage. We don't necessarily, relative to international averages, have a nurse shortage. But we also have to remember we have unemployed surgeons in Canada who can't find surgical placements. We have surgeons willing to do more surgical time who can't get access to the public operating room. We have nurses leaving the public system because they're unwilling to accept the working conditions, and simply leaving the profession or working in the United States, in spite of the fact that we have very few professionals, medical professionals, particularly relative to other countries, we have spare resources in this country that we can tap and make much better use of than we are now.

All right. Closer to home, the Ministry of Health in Ontario says it's hit a major milestone by reducing the Health Care Connect waitlist for primary care by 50%. Dr. Martin, that seems pretty significant.

Hallelujah. I mean, I couldn't be happier to see the waitlist for primary care in Ontario beginning to come down. And I'll say that this is what happens when we declare a priority. And one of the reasons why the government of Ontario declared a priority is because our politicians were hearing it at the doors, you know, people saying to them, how is it possible that I can't get a family doctor? Why am I having to run around and beg and plead and ask my aunt if her family doctor will take me? Et cetera, et cetera. When we all feel that access to primary care should be a right, and it should be easy to to access a primary care team in my neighborhood, just like my kid can go to the public school. And so we are beginning to see movement on that list, in part because government has invested. New teams are being built, you know, new doctors are being trained. We've streamlined access for internationally trained professionals to come into primary care. But the other thing that they did with Health Care Connect Connect was they cleaned up the list because, as you know, when the list is uncoordinated and people have been sitting on it for a long time, it turns out people have moved, people have left, people have found a family doctor in the interim. You know, there's all kinds of things that that that people are on multiple lists, which we see actually all over the Canadian health care system, people on waiting lists for three different MRI machines, and then they fail to show up for the other two because they already got one someplace else. So this lack of coordination is a major factor in the length of our wait list. And it is something that we you can reduce the wait times just by cleaning up your data. But in the case of primary care, we have also begun to reduce the wait times because we are investing effort and energy and money in trying to turn the system around. And nothing could make me happier.

Now just to catch our viewers up. The province committed to connecting 235,000 people that were on the Health Care Connect waitlist as of January 1st, 2025, to either a family doctor or primary care team by spring 2026. So Nadeem with that, my math, I think I'm all right here. 118,000 Ontarians connected with a primary care team. It's not insignificant, is it?

No, and certainly very positive for 118,000 Ontarians, certainly positive for those connected to them. This is a positive step, but it's a very political statement. It's half of the people who are on the list at January 1st, which is all of 250 odd thousand Ontarians, where the college is saying there's over 2 million without a doctor. We know in 2024, 300,000 Ontarians left emergency rooms when they needed care because they couldn't get access to the health care services. 10,000 died on a waiting list in 2023, 2024. So it's a very small gain in a system that's doing quite poorly, but it is certainly a positive gain for 118,000 Ontarians, without question, a positive shift for them.

Well, and I would say actually that I'm I mean, just because people die while on a waiting list doesn't mean that they die because they're on a waiting list. People die all the time for all kinds of reasons, at the same time that they're on all kinds of, you know, they're also doing lots of other things at the same time that they die. But I will say that, you know, this question of access to primary care is not just an issue in Ontario. It's an issue across the country. And we all know that when you don't have a family doctor or a primary care team, nothing else works in the health care system. People should not be having to go to the emergency department with a stroke because their hypertension, their high blood pressure was not well-managed because they didn't have a family doctor. People should not be getting admitted to the hospital with an avoidable exacerbation of chronic lung disease because nobody was keeping track and giving them their their flu immunization and renewing their papers, etc.. And so. This needs to be a core priority for every single provincial, territorial and the federal government across the country. People need to be able to expect to access primary care close to home, and that's not something that we're going to be able to fix anywhere overnight. But when a government declares a priority and the medical profession gets behind it, and the people of Canada say this is a priority for us, then we can start to move. And I think that is we are seeing the beginnings of that in British Columbia. We're seeing the beginning of beginnings of it in Ontario, in Prince Edward Island. There are lots of great examples of models happening across the country. It's not just going to be doctors, it will be interprofessional teams, because that's the model of the future is doctors working in teams with nurses, nurse practitioners, pharmacists, other healthcare workers in order to be able to serve a larger number of people with the resources that we've got.

Dr. Martin, you had mentioned fixes. So I want in our last little minute that we have make sure that we touch on some solutions. Nadeem, what kind of best practices can we adopt when we look at those peer countries, whether it's Netherlands, Germany, the UK or Australia? What? Give me two solutions.

I think the answer comes back to getting better value for money. And again, if we look at 100% of the top performing nations, whether it's those nations with the best wait times, experiences or the best outcomes from the healthcare process, performing better than Canada is, we see private competition, entrepreneurship and innovation involved in the healthcare system. The private sector is not an enemy of universal healthcare. The private sector is in fact a partner in getting a high performing universal access healthcare system, a system we're already paying for. And we certainly don't need to spend more money on healthcare. We're already a top spender. We just need to get the actual value for the dollars we're already spending.

Dr. Martin, get the last word.

Well, we're we're in agreement that we need better value for money. And what I would say is, as a person working in the healthcare system, I don't want to see more competition. I want to see more collaboration. I want to see hospitals working together to make sure that when my patient needs something, they get the next available appointment in my region. And I want to see teams not just of physicians, but of other healthcare workers working together to take responsibility for the neighborhoods and the populations that we serve. It's that kind of collaboration, actually, that defines the delivery models in many of the other countries that are outperforming us. And I think that's what we need to see more of in Canada.

We are going to leave it there. Dr. Martin, Nadeem, thank you so much for joining us on the program. Thank you so much. Thank you.