The number of acute care hospital beds per capita is an imperfect measure of a health care system's ability to respond to the COVID-19 pandemic. After all, beds are easy to acquire, as are hotels or similar buildings to put beds in. It is ventilators, IV drips, heart monitors, masks, gloves, and, above all, skilled health professionals that are the crucial resource constraints in this crisis. However if most hospitals operate with more or less the same ratio of nurses/beds, IV drips/beds, ventilators/beds and so on, looking at the number of beds per capita is a pretty good way to compare different countries', or regions', health care capacity.
In my last post and this piece for IRPP I discussed Canada's low number of beds relative to other OECD countries, and interprovincial disparities in bed numbers. In this post, I drill down to the health region level, show just how much hospital bed numbers differ across regions within the same province. This gives a useful indicator of Canada's regional disparities in health care funding and access to health care - and thus raises questions about the overall structure of health care financing in this country, and the allocation of health care resources.
The most dramatic regional differences in beds per thousand people can be found in Ontario:
The Ontario bar at the bottom of the chart gives the provincial average; a map of Local Health Integration Networks can be found here. The chart is based on population numbers calculated by Kayle Hatt from Statistics Canada's health region-to-2016 census dissemination blocks files. A spreadsheet containing Kayle's numbers can be downloaded here. Hospital bed numbers are calculated from Canadian Institute for Health Information data. My spreadsheet can be downloaded here.
The Local Health Integrations Networks (LHINs) with extremely low bed numbers per capita are mostly in the 905 area surrounding Toronto. The Central West LHIN, for example, includes Brampton; the Central LHIN encompasses North York, Vaughan, Richmond Hill and Newmarket. These areas have experienced very rapid population growth, and bed numbers have not kept up. To some extent the high number of beds per capita in Toronto Central relieves pressure from the surrounding areas. However a number of central Toronto hospitals are specialized, such as the Hospital for Sick Children and the Princess Margaret Cancer centre. My own interpretation of the numbers is that, in communities across Ontario, health care resourcing is not keeping up with population growth.
Here is a comparable chart for Alberta
The variations across health regions in Alberta are not so dramatic, but a similar pattern, with Calgary having fewer beds per capita than other zones, appears in that province as well.
Here are the numbers for BC:
Fraser Health and Coastal Health are the two health regions that serve the Lower Mainland. Again we see this pattern of relatively low number of beds per capita in rapidly growing urban areas. Even if some of the 235 beds under the Provincial Health Service Authority were to be attributed to Fraser or Coastal health, the overall pattern would not change.
Quebec numbers are not available; numbers for other provinces can be found in the spreadsheets linked above.
I have some confidence in the numbers in the charts above, and in the linked spreadsheets, because the provincial level acute bed counts per capita are a pretty close match to those given in this Ontario Hospital Association (OHA) report - screenshot here:
The OHA numbers above are for 2015-18, whereas my numbers are for 2017/18, so the two do not match exactly.
Kevin Andrew of University of Victoria also worked up some regional bed count numbers. He used a slightly different method to match population counts to health areas. His results, using Canada-wide data, finds the same inverse population/beds correlation.
Kevin Andrew's chart shows absolute population levels, rather than rates of population growth, and so highlights another aspect of modern medicine. There have been revolutions in information technology, innovations in medical practice, and long-term shifts in the nature of the disease burden. Together, these have allowed hospitals to smooth bed consumption. In a metropolis of 4 or 5 million people, the number of people requiring treatment for cancer, heart disease, and so on, at any given time, is fairly predictable, so the number of beds per capita can be kept relatively low, and the system can operate at or near capacity at all times. It's an efficient and, in ordinary times, a safe strategy.
But these are not ordinary times, and hospitals around the world - ones with more beds per capita than Canada does - are being overwhelmed. One likely consequence of these extraordinary times is that we will take a long and hard look at our health system.
The Canadian health care system constrains costs by constraining the supply of health services. A supply-constrained system is one that has few spare resources to cope with a pandemic. One important take-away from that observation is that other actors - actors that are in the business of stockpiling equipment in case the unthinkable happens, like the military - need to get involved in pandemic planning.
Another key take-away is that the current means of constraining the supply of health care may be inefficient. The simplest way of constraining supply is not to increase it - to stick to the status quo in terms of, say, bed numbers, or funding for particular procedures or health envelopes. However a policy of sticking to status quo resourcing when needs are increasing (or decreasing) more rapidly in some areas than others can lead to an inefficient and inequitable allocation of health care resources.
The question is - how can Canada do better?
Excellent post Frances. I noticed the Northwest LHIN does quite well though still low by international standards. Good to know.
Posted by: Livio Di Matteo | March 24, 2020 at 02:21 PM
Livio, Thanks! On the Northwest LHIN - yes, I would imagine that's probably something to do with smaller hospitals needing to have a bit more spare capacity because they can't take advantage of the law of large numbers like big city hospitals can? Or do you have another take on it?
Posted by: Frances Woolley | March 24, 2020 at 02:45 PM
It's several things. Partly they have to have a certain number of smaller hospitals outside of Thunder Bay given the region is about the size of France. Second, there is the spare capacity argument given the relative remoteness. If a small hospital in a place like Marathon serves a large geographic area for many things with more specialized cases requiring transport to Thunder Bay.
Posted by: Livio Di Matteo | March 24, 2020 at 04:01 PM
Livio, thanks, that's what I'd have figured. What's the population growth rate been like there - are the numbers consistent with the funding inertia argument (there's always been a hospital in Marathon so we keep funding a hospital in Marathon)?
Posted by: Frances Woolley | March 24, 2020 at 04:15 PM
Population growth has actually been positive particularly in the First Nation communities.
Posted by: Livio Di Matteo | March 24, 2020 at 04:44 PM
How can Canada do better? Maybe by taking a cue from Shakespeare? « First let’s kill all the lawyers! » In this cas MBA’s and everybody at the Treasury Board who advise us to get rid of idle capital?
Posted by: Jacques René Giguère | March 27, 2020 at 01:17 AM
Jacques René - "How can Canada do better?" is a difficult question. Rational, evidence-based decision-making in health care would be a good first step. I'm not sure that throwing money at hospitals is, in fact, the answer - there are other acute needs in the system e.g. long-term beds in nursing homes, public health. What irks me is what looks like arbitrariness in bed allocations, rather than the overall level of beds. It's also becoming increasingly clear me that pandemic response and day-to-day health care needs are quite different things, and need to be funded differently. There's also that classic Canadian tension: the federal government has all of the revenue raising capabilities, the provinces have all of the spending responsibilities. When provinces decide that they're going cut taxes in order to be open for business...well...that's what's behind the numbers in the post.
Jason Kirby, the person who does the chart round up for Macleans, is getting a bunch of people to comment on COVID19. I've written up a short paragraph which gives some of my long term thinking on this.
Posted by: Frances Woolley | March 27, 2020 at 10:28 AM
My first job long ago ( and I mean a longer ago than the long ago of last week) was in public health. Having trained in Industrial Organization I knew nothing about the subject but my boss told me « I once had an economist and I liked his work, so I asked HR for one ».
Let say you buy one billion N-95 masks at $0.75 a pop over 5 years. It’s a rounding error that will save you a 25% drop in GDP. We’ll leave the cost-benefits analysis as an exercise to the first-year student. I wanted to leave the calculus about the dead to my colleagues at the Treasury Board but they told me they don’t care.
Posted by: Jacques René Giguère | March 27, 2020 at 08:38 PM
A problem is you run out of nurses even with ventilator stockpiles. I've got an outline of the social distancing tradeoff; the at risk vs (near term) Q-of-Life sacrificed SD-ing:
A class of SD acts, such as all our breakfasts at a coffee chain, should be measured by the number of communicable contacts incurred. For some positions, one key immune individual makes it a low spread event. The corporate chain-of-command can work with design engineers for pop up tents kiosks. There is also low capacity in present off-peak mall hours and parks.
Marginal profitability is being lost and firms are closing whereas you may get 30% immune staffing soon in Wuhan and NYC. It is an open reflexive economic issue how to cross the gap. Utilitarian means and ends should be permitted more such un-SDing credits, likewise for expected contributors (not bloggers) towards pandemics and maybe disasters. With better sensors you may want to time in not too dense locales, a square-wave pandemic workforce (it is risky) and have some infected right away to immediately start-up a post-pandemic workforce, and then apply extra brakes to plateau the cases and health care limits.
There is a golden opportunity to do longevity research here as a long-term economic stimulus but it makes bioevents happen without decent neuro-imaging. We can remove freedoms and add some back based on these metrics, for many replicating risks.
Posted by: Phillip Huggan | March 28, 2020 at 08:44 PM
Jacques René - yes, as a society we make some decisions about risks and how to prepare for them that end up looking really dumb in hindsight. It's not just a recent thing either - e.g. all of those magnificent forts (the citadelle in Quebec, Fort Henry in Kingston, the big fort in Halifax) that were built after the war of 1812 and then almost immediately became obsolete.
Phillip - your observation raises the vital importance of data and testing in dealing with COVID19. Trace and contain seems to make a lot of sense to me, but we're past the point where that can happen any time soon in most Western countries. Knowing who had antibodies would also be incredibly useful.
Posted by: Frances Woolley | March 29, 2020 at 01:23 PM
They are testing using cultures, say across a room, to see if a slightly desiccated airborne virus is viable. These types of tests for treatable or accessible pathogens, should be mass-produced. The vaccine model works but eventually we will transition to exporting decontamination and getting patient zero. Decontamination is also needed for partially restarting economy parts. I think our busy building standards should be upgraded to hospital standards using new technology. There should be cross flow of air circulation among rooms/tenants. This suggests better motors, filters, a new duct material, and ultimately new fireproof and optionally porous building materials. We can probably safely find a way to stop cytokine storm before it alters the steric and/or chemical environment of the lungs, but to really bear down and use gene therapy is risky while we don't have good employee screening.
Sometimes the rust belt can easily retool for a new product and sometimes the production machine needs to be bought. We can list products we will need for all sorts of disasters, and now, manufacture the production machine or at least the tool and dies required. For every future disaster we can do this and economically measure our resilience net worth even if it is a GDP carrying cost to store stuff. Many people will have a disaster job to attend to and be on reserve for such.
NYC plateauing for 13 weeks is a July 4th economic restart, ignoring health care. These "disaster parts" supply chains will fall if a GD happens. Tangential products made by the suppliers who make disaster parts and required machinery, can keep them afloat. Restarting NYC early might hurt neighbors. We clearly need smaller ships and smaller nursing homes but there is a robot with a hammer/lighter to defend from later.
Posted by: Phillip Huggan | April 08, 2020 at 03:27 PM
...if restarting early, rust belt supply chains can be maintained that are capable of making many things to keep the surface area of the economy small (big brother picks the products). The shuttered discretionary income sectors can be socially distanced; a game or theatre at 1/12th capacity with a worker paying extra and either he or the venue is subsidized (tailing off as an immune population is built). Right now the trickle down is hurt, but paying extra for SD-ed discretionary services restores it if even 30% of the sector remains for the newly pseudo-rich to enjoy. For some factories and services positions where SD-ing isn't possible, very aggressive symptom assessing is needed. Probably the employee should be isolated while away from work and receive future spending power. Aerodynamics, microbiologists, et al., are needed to redesign workplaces, and recreation parks/malls to achieve SD-ing before part of an economy is restarted. Design engineers should learn to make surfaces decontaminatable. Paint might be all that is often needed. Immunotherapy R+D is a logical sector to buttress.
Posted by: Phillip Huggan | April 11, 2020 at 06:29 PM