A focus on access to health care in Canada

Readers of CMAJ are likely familiar with the journal’s 4 areas of focus: health services, mental health, vulnerable populations and sepsis. In 2017, the journal’s interim editor-in-chief, Diane Kelsall, led the medical editors and CMAJ’s editorial advisory board to choose these foci, asking the questions, “Which trends in health care should concern us?” and, “What emerging issues do we worry about?”1 Over the past 5 years, CMAJ has advanced knowledge in these 4 topic areas. However, with new journal leadership and a new editorial advisory board, it is time to reconsider the journal’s foci.

What are the pressing concerns in Canadian health care today? The problem that people in Canada are struggling with most has been present for a long, long time: getting the health care they need, when they need it. Essentially, the most pressing concern is access.

People’s inability to register with a family physician, long waits in emergency departments, barriers to seeing a specialist, delays to “nonurgent” surgeries for conditions that limit quality of life, and lack of resources available to those with pressing mental health concerns have long been features of Canadian health care. So much so that some policy-makers and even patients are starting to see them as merely nuisances rather than failures, and are grateful for any minor change that makes Canada’s health care systems a little less awful.

As a newcomer to Canada in 2013, I, Kirsten, was shocked at how my personal efforts to find a family physician went nowhere and perplexed at the health system’s lack of cohesiveness. After a while, I became one of the shruggers. I did not like waiting 6 hours in the emergency department — bleeding, cold and without analgesia — to be seen for a separated shoulder after a rain-day bicycle accident, but I shrugged about it because I had come to accept that that was the way things were. I live with low-level anxiety about the possibility that I or one of my kids will be injured or become sick.

I, Andreas, moved to Wellington county in southern Ontario 2 years ago and needed a local family physician. The family practices I called told me that they were accepting patients only through Health Care Connect, a program run by the regional health authority. That sounded promising to me — a central registry seemed an equitable way of managing a scarce resource. Little did I know how scarce! A recent letter informed me that, “The list of registered patients in the Waterloo–Wellington region has hovered around 7000 over the last few years …” and “… most offices don’t accept through [Health Care Connect] on a regular basis or in high volume, so you are expected to also look on your own.” On calling family practices again last week, I got 1 of 2 responses: either they accepted patients only through Health Care Connect, or I could go on their waiting list, which was about 5 years long.

These are our experiences as people with great privilege and connection; undoubtedly, those of others are much worse.

The COVID-19 pandemic seriously shocked and disrupted our health systems in Canada and beyond. But the truth is that Canada’s health systems were not robust before the pandemic, and the holes are now only more plain to see. Problems that existed before the pandemic are now compounded by serious staffing shortages, unhelpful government policies that impede appropriate retention of health care workers, workforce burnout and postpandemic fatigue, and by social factors that exist outside the control of the health systems but drive both the need for care and restrict access to it.2

It is not enough to tinker around the edges anymore. Although efforts that support decreasing rates of unnecessary testing may be something to applaud, they are never going to be the solution to our health systems’ serious access problems.3 Big and radical changes are needed. What could real, impactful health system change look like — change that would equitably and affordably support all people’s health and well-being, while protecting those who work in health care?

CMAJ editors have ideas, but we do not have all the answers; those must come from you. The journal’s role in Canada’s health systems is primarily to act as a conduit for high-quality, evidence-based information and scholarly opinion that can influence health care for the better — a forum for the presentation of solutions. We acknowledge how difficult it is to effect radical changes in large and complex systems and how important it is to avoid unintended consequences while changing course. We understand that health care is political, which can also impede major change, but advancing workable solutions to Canada’s health care access crisis is an urgent need in 2023, and CMAJ is the place for that conversation. This is why CMAJ’s editors, with guidance from the current editorial advisory board and other stakeholder groups, have chosen access to care as the journal’s focus for the next 2 years.

In 2023, editors will be commissioning articles and prioritizing submissions to CMAJ that offer bold solutions to the pressing problems of access to health care in Canada. We will remain interested in submissions of articles on other topics, and we will continue to use an equity lens when considering what we publish; however, we hold a firm intention to create the space to advance knowledge on health system interventions that can improve access to care.