Pediatric care in Ontario is in crisis. How did we get here?

We’ve seen sick children in need of intensive care shipped hundreds of kilometres across southern Ontario so they could get it.

Adult ICUs opened their doors to teenagers to free up space for younger children at overflowing pediatric hospitals.

Surgeries for kids have been cancelled, except in the most serious and time-sensitive cases.

And then there are the ERs.

Thousands of children and families have faced record long waits — including a four-year-old girl with Down syndrome suffering from respiratory syncytial virus (RSV) who spent 40 hours in a Toronto-area emergency department.

In a matter of weeks, we have witnessed these strains and much more tearing at our pediatric hospital system.

“This is our 100-year flood,” says Bruce Squires, president of Hamilton’s McMaster Children’s Hospital.

“We were already at — or near the top — of the levee every single year and our system flooded frequently. And now with this 100-year flood, we’re just overwhelmed.”

Ontario’s pediatric health system has for years been underfunded and undersized to meet the demands of the province’s growing population. But it has taken the COVID-19 pandemic and an unprecedented wave of critically ill children with respiratory viruses to break open the cracks that have been forming over decades.

Compounding the crisis is an ongoing staffing shortage, made worse by gruelling pandemic work conditions and illness. Providing care for children is incredibly specialized; the provincial pool of staff, already shallow, is now even more depleted.

The situation, taken as a whole, is forcing us to confront an uncomfortable question: Have we broken a fundamental social contract? Are we failing to meet children’s health and medical needs?

“We are approaching a time where the standard of care in the province of Ontario, or the country of Canada, is just not guaranteed for children anymore,” says Dr. Ronald Cohn, president and CEO of the Hospital for Sick Children, an institution founded in 1875 with the mission statement of treating all sick children in Ontario.

“I don’t think we are quite there yet. But we are approaching it. That’s why we need to act quickly.”

How is it that Ontario — one of the richest jurisdictions in the world — has seen it come to this?

The extent of the crisis

The current crisis extends beyond overflowing ERs and ICUs. At almost every entry point, the system is struggling.

Currently, more than 50 per cent of children on surgical wait lists in Ontario are waiting longer than what is considered clinically safe by medical experts. Wait times for diagnostic tests and medical imaging have ballooned. Kids are waiting years to see a developmental pediatrician.

Children’s hospitals across the country are confronting similar pressures. Yet perhaps more than any other province, the situation is dire in Ontario. In 2019, the province ranked second-last out of all provinces in public-sector health expenditures per capita.

This past spring, the Children’s Health Coalition, a provincial group that includes pediatric hospitals and children’s health organizations, called for a long-term plan to address kids’ health.

The group asked for an investment of $1 billion over four years and for the province to commit to its Make Kids Count Action Plan that addresses, among other things, waits for diagnostic imaging, mental health and scheduled surgeries.

Among the plan’s startling figures:

While doctors, nurses and specialized pediatric staff are working flat out to try to meet the demand, many say they face moral distress because the undersized system prevents them from giving kids the care they need.

SickKids’ Cohn says the plan remains with the provincial government and that leaders are now “in active conversations around how we can work toward a solution.”

A crisis decades in the making

To answer the question of how Ontario got to this point, you have to travel back in time.

Beginning in the 1980s, successive provincial governments shrank the number of hospital beds.

“The idea was that we had overbuilt hospital beds and people should be allowed to age in place and we should start moving more care to the community,” says Natalie Mehra, executive director of the Ontario Health Coalition, a public advocacy group working to protect health care. “It was a well-intended idea.

“But by the latter half of the 1990s, every part of hospital care that was cut was privatized. The vision of a system of care in the community was replaced with a relentless drive to expand privatization and reduce costs by offloading ever more complex patients regardless of their actual care needs.”

In 1996, the Progressive Conservative government of Mike Harris enacted the Savings and Restructuring Act, an omnibus bill more than 200 pages long known as the “Bully Bill,” which modified more than three dozen laws, including the Health Insurance Act, Health Care Accessibility Act, Ministry of Health Act and Public Hospitals Act.

The bill gave sweeping powers to the province to close or amalgamate hospitals, regulate where doctors could practise and open the door to private, for-profit medical facilities.

The Health Services Restructuring Commission, created under the bill, ordered the closure of 39 hospitals in the 1990s.

The cuts also resulted in about 6,000 nurses being laid off. The human resources crisis then forced a Harris government about-face in 1999, and more than 3,000 nurses were hired in the ensuing year.

In total, 64 hospitals were either merged or closed from 1989 to 1998, according to data collected by the Coalition, resulting in a 24 per cent decrease in the number of hospitals. The number of acute-care beds dropped by 33 per cent, while chronic-care beds decreased by 28 per cent during those 10 years, according to the Coalition.

This, despite the fact that Ontario’s population grew by more than a million people over that time.

For some, the plight of 18-year-old Joshua Fluelling became emblematic of everything wrong with the Harris cuts.

In January 2000, Fluelling was being taken to hospital after suffering a severe asthma attack. His ambulance was redirected from Scarborough Grace Hospital, which was nearest, to Markham-Stouffville Hospital, much farther away. In the ambulance, Fluelling experienced respiratory failure and suffered severe brain damage. He died in hospital.

Pat Armstrong, professor emeritus of sociology at York University, has researched Ontario health care for decades.

“There was a big move, and it wasn’t just Harris, to say hospital expenditures are out of control,” she says, noting that the push from the restructuring commission meant hospital surge capacity was effectively eliminated.

Medical advances, including better prenatal care and surgical innovations allowing kids to have shorter recovery times, reduced the need for hospital beds. So, too, did safety laws, such as those for infant car seats and bicycle helmets, which lessened childhood injuries. And budgets for pediatric hospital beds and services subsequently shrank.

But as time went on, and other childhood medical needs arose — a steady increase in mental health conditions, babies born preterm surviving into adulthood due to new technologies — Ontario’s pediatric health system didn’t grow with them.

Tightening budgets

In 2003, Dalton McGuinty’s Liberals were elected. Citing massive shortfalls in successive provincial budgets in the ensuing years, they funded hospitals’ global budgets at a rate below inflation before freezing them and preventing them from running deficits.

The Liberals did reduce surgical wait lists for many procedures and increased the number of MRIs and CT scans.

By 2008, more than a third of hospitals weren’t able to balance their books, even though by law they were compelled to.

In 2015, CHEO — the Children’s Hospital of Eastern Ontario in Ottawa — facing a budget shortfall, cut 50 nursing positions and lost some 90,000 nursing hours a year.

The following year, CHEO sent a proposal to the Ministry of Health seeking additional funding to increase its pediatric surgical capacity. At the time, 35 per cent of kids in Eastern Ontario were waiting longer than clinically safe for their scheduled surgeries, Alex Munter, the hospital’s president and CEO, told the Star this fall.

That proposal was not approved.

Recently, facing an unprecedented wave of critically ill children with respiratory viruses, CHEO, a pediatric health care and research centre in Ottawa, was forced to open a second pediatric ICU.

This past week, the hospital announced it was partnering with the Canadian Red Cross to provide workers to staff clinical-care overnight shifts.

“These are long-standing problems,” says Munter, who has repeatedly referred to this fall’s pediatric crisis as “an overnight problem decades in the making.”

He points out CHEO’s emergency department, rebuilt in 2011 to accommodate 150 patients a day, has surpassed that number every day this year.

In the background of all this, the number of graduates from nursing and medical programs in Ontario hasn’t kept up with population growth. That has resulted in, among other consequences, a very small pool of health-care workers specializing in pediatric care.

“That’s nurses, social workers, psychologists, psychiatrists, physicians, you name it,” says Emily Gruenwoldt, president and CEO and Children’s Healthcare Canada, a national association that represents children’s health care delivery organizations. “So we really need to start thinking about building that pipeline.”

In mid-November, her organization called on Canada’s federal, territorial and provincial governments to come together to scale up infrastructure to meet the needs of a growing population of children and youth and develop a strategy to grow the workforce with people with the skills needed.

A first-hand look

On Monday, Health Minister Sylvia Jones toured McMaster Children’s Hospital, which opened in 1988 as part of a general hospital and became a fully pediatric site in 2011.

Squires, the hospital’s president, says Jones saw the packed emergency department where 12 kids had been admitted but were still waiting for beds and that in treatment areas she walked past children lying in beds in hallways. In the neonatal ICU she heard about the crowded conditions.

Hospital leaders made it clear to Jones that resources haven’t kept up with rising needs in the region, Squires says.

These worries extend beyond the congested hospital, where kids wait — sometimes years — to receive care, the delays affecting long-term health. Squires says 500 kids a year are being added to the wait list to the hospital’s developmental pediatric service. That’s on top of a wait list already double the service’s current capacity.

“Children are waiting two years after being identified, and the net result is the developmental windows to intervene for their condition just can’t be met,” he says. “I’m at a loss for words to express how tragic that is.”

A spokesperson for Jones said the government is making permanent investments to double critical care beds for seriously ill patients at CHEO and increase such beds at McMaster Children’s Hospital.

“We know emergency department volumes have been increasing year over year and we are not OK with the status quo. That is why the Ministry of Health has taken a ‘team Ontario’ approach and increased hospital capacity across the board by adding over 3,500 new critical care, acute and post-acute hospital beds,” said spokesperson Hannah Jensen.

Despite these investments, it is undeniable that the health-care system is barely equipped to deal with the current surge in pediatric patients.

Cohn of SickKids sums it up.

“Our system was never designed in a way to deal with the current acute pressures and patient volumes we are seeing.”

Kenyon Wallace is a Toronto-based investigative reporter for the Star. Follow him on Twitter: @KenyonWallace or reach him via email: kwallace@thestar.ca

Megan Ogilvie is a Toronto-based health reporter for the Star. Follow her on Twitter: @megan_ogilvie