A health care worker is seen at Toronto’s Hospital for Sick Children in 2022. A recent first-hand experience at Shouldice Hernia Hospital has left Bernard Simon with a much clearer understanding of public and private health care.Chris Young
Bernard Simon is a former Canada correspondent for the Financial Times.
I have grappled for years with the thorny question of private-sector involvement in health care delivery in Canada. On one hand, I’ve been impressed by the argument that profit-motivated businesses spur innovation in hospitals, clinics and diagnostic labs while easing the strain on overstretched and underfunded public services. But I’ve also sympathized with the view that a focus on the bottom line threatens to undermine the principle of universal access, supposedly the bedrock of our health care system.
A recent first-hand experience has left me with a much clearer understanding of these issues, and how we may go about finding the right balance. Judging by the three days I spent at Shouldice Hernia Hospital, a privately run facility on the north-eastern outskirts of Toronto, I can safely say that each side of the argument has much in its favour, but both also have serious shortcomings.
Shouldice, located on a park-like estate once owned by George McCullagh, a former publisher of The Globe and Mail, is recognized as a leader in hernia repairs. Doctors come from around the world to learn about Shouldice’s “natural tissue” technique, which avoids using the mesh employed by most other hospitals for this procedure. Its surgeons stitch up 25 to 30 patients every day of the week, except Sundays. The waiting time is typically two to three months, a fraction of the delay at most public hospitals.
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While a hospital stay is never a pleasure, the three days I spent at Shouldice were as comfortable as anyone could wish for. The place is a well-oiled machine marked by efficiency and punctuality, from the introductory information session offered to new patients each afternoon to the exercise program that runs at 11 a.m. each morning. The hospital’s tranquil, landscaped gardens are a calming environment for a walk. And, as comments on Shouldice’s Facebook page attest, the food would not be out of place in a respectable restaurant in the city. Dinner one evening in the communal dining room started with a tasty green salad (including pomegranates) followed by a hefty pork chop with butternut squash and kale, and angel cake for dessert.
As a layman, I cannot fault the medical care. At my initial consultation, I was thoroughly interviewed by a general practitioner as well as the surgeon assigned to my case. I was scheduled to stay four nights but, like many others, was cleared to go home after three. My recovery has unfolded exactly in line with the hospital’s copious instructions.
I have no doubt that the vast majority of patients leave Shouldice equally satisfied. But I also suspect that most give little further thought to the broader implications of their treatment. In some important respects the Shouldice model risks undermining the key tenet of Canada’s health care policy: that every Canadian – no matter how rich or poor, how healthy or disabled – should have equal access to treatment.
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Let’s start with money. The medical treatment at Shouldice is entirely covered by Ontario’s health insurance plan. (An American patient told me he paid about $10,000 plus travel expenses for his hernia repair at the hospital.) However, all Shouldice’s rooms are semi-private and thus not covered by the provincial health plan. Cost: $305 a night, or $1,220 for a four-night stay. Anyone who cannot afford that kind of money or is not covered by private insurance has little choice but to fall back on a public hospital. Too bad about the longer wait and the less appetizing meals.
Financial privilege is only one barrier. Sitting at dinner in Shouldice one evening, one of my table companions observed that every one of the 30 to 40 fellow patients dining at the time was slim and trim. There’s a reason for that. Shouldice will not accept anyone who is overweight or has health issues that might complicate a hernia repair. I met one man who had been told to come back only when he had lost 30 pounds; I was initially turned away owing to a low hemoglobin count.
One explanation for this policy is that Shouldice is not a full-service hospital. For example, there is no intensive care unit to deal with crisis situations. This means that higher-risk patients must wait their turn in the public system. It also means that institutions like Shouldice are not burdened by many of the costs of public hospitals and can boast a much higher success rate for their procedures – giving them a potent argument to counter critics of the for-profit model. Obviously this does not align with the Canadian principle of universal health care.
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My Shouldice experience has certainly persuaded me that for-profit institutions have a vital role to play in the future of our health care system – but only if they are willing to take on more of the risks and costs of catering to a wider cross-section of the population.
Government should insist, for example, that private hospitals like Shouldice open some four- or six-bed “public” wards whose cost is covered by the provincial health plan. Likewise, they should surely be required to accept a wider cross-section of patients, as public hospitals must, even if that means installing the facilities needed to handle more complex cases. Heaven forbid they might even consider cutting costs by serving simpler meals.
One way or another, the playing field for public and private providers needs to be levelled if every Canadian is to have the same timely access as I did to a world-class hernia repair.