Submission to the Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities: Study on Labour Shortages, Working Conditions and the Care Economy
HealthCareCAN, the national voice of Canada’s research hospitals and healthcare organizations, welcomes the opportunity to submit this brief to the Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities as part of its study on Labour Shortages, Working Conditions and the Care Economy.
The labour shortage and working conditions in the health system are among the biggest challenges to delivering timely high-quality healthcare in Canada. Healthcare workers, who account for nearly 10% of people employed in Canada and more than 66% of all health spending – which equates to approximately 8% of Canada’s GDP – are not only our health systems’ greatest resource, but also a crucial part of our economy.1 We commend the Committee for undertaking this critically important study and for taking a holistic approach to the challenge Canada is facing.
This is not a new problem. Canada’s health sector has faced various workforce shortages for years, a problem that has only been exacerbated by the COVID-19 pandemic. This has led to health systems across the country collectively dealing with labour shortages, at a scale not seen in recent times and possibly ever. In addition to the impacts on patient care, these shortages lead to substantial physical, mental and emotional impacts on healthcare workers at all levels and across the continuum of care.
The pandemic has provided many learnings, including the need to attract, train and retain workers differently, which cannot be lost once the pandemic is over. As noted, the impacts are being felt across Canada, and health system leaders from coast to coast to coast are seized with developing and implementing pan-Canadian solutions to address current concerns and set Canada on a better course moving forward.
Healthcare workers have clearly and repeatedly warned of the increased levels of stress, anxiety, depression and burnout they face.2 Research from around the world, including here in Canada, shows that these issues, which were concerns prior to the pandemic, have only worsened due to the added risk and workload brought on by the pandemic. A crowdsourcing initiative conducted by Statistics Canada in late 2020 showed that 70 percent of the 18,000 healthcare workers surveyed reported that their mental health worsened during the pandemic.3 Healthcare workers reported worse mental health regardless of whether they were in direct or indirect contact with confirmed or suspected COVID-19 cases, with 77 percent of those with direct contact and 62 per cent of those with indirect contact indicating that their mental health was worse than before the pandemic.4 Additionally, 40 per cent of individuals with direct contact and 29 per cent of individuals with indirect contact rated their mental health as fair or poor.5 These findings offer a glimpse into the significant, detrimental impact the pandemic is having on the mental health and wellbeing of healthcare workers – impacts that have no doubt worsened in the almost year and a half since the study was conducted.6
It is important to recognize that even among healthcare workers, mental health impacts are felt differently. For example, certain healthcare workers – like nurses, orderlies, aides and personal support workers – provide the type of patient care that exposes them to circumstances that could lead to heightened psychological distress, such as violence or abuse. Workers in these roles are also disproportionately women, immigrants, newcomers, racialized individuals, and, in certain cases, working low-paying or part-time jobs with little or no benefits. This does not discount the very real mental health impacts experienced by other workers in the health system, including those working in support, administrative and leadership roles.
The fallout from riskier working conditions and poorer mental health brought about by the pandemic is being felt across the country as healthcare workers retire early, move to less demanding healthcare roles, or leave the system altogether. Many more are planning to leave once the pandemic is over.
The toll COVID-19 is taking on healthcare workers is substantial and will endure long after the pandemic is over. It is crucial that governments address the health workforce shortage with both short-term and long-term action. Such concerted action is vital to ensure the country has the health workforce it needs to continue dealing with COVID-19, perform non-COVID medical procedures and treatments, tackle medical procedure backlogs, and provide high-quality care to those who need it.
Throughout the pandemic we have been reminded that when the population is not healthy, our economy will not be healthy. The same is true for our health system. Healthcare workers are the system’s greatest resource, and when they are well taken care of so too are people across Canada.
1. Improve the immigration process to better leverage the skills of immigrants and newcomers to help meet existing health system needs over the short- and medium-term.
Many healthcare organizations are eager to leverage the skills of immigrants and newcomers already in Canada to address immediate health human resources needs. However, barriers exist that make the recruitment of foreign-trained healthcare workers a significant challenge.
HealthCareCAN members identified the following specific, major challenges to Canada’s current immigration process as it relates to the health sector:
In the current context where there are people in Canada with the requisite skills to fill a position but who do not want to work in the sector, the requirement to complete a Labour Market Impact Assessment (LMIA) presents a challenge to hiring temporary foreign workers to fill vacancies.
For publicly funded healthcare organizations that have identified vacancies, paying Employment and Social Development Canada to complete an LMIA is an additional, costly step that public institutions, as employer, must undertake. There is an opportunity for reducing red tape between these publicly funded institutions that operate at the provincial/territorial level and the federal government which manages the immigration process.
The employer must bear the cost of the LMIA, which is $1,000 per candidate. These costs are viewed as prohibitive for many employers.
At the time of writing, the processing time for work permits from inside Canada is approximately 134 days.7 This includes for cases of applicants seeking a change to the conditions of an existing work permit. These timelines are challenging for candidates looking to change employers or relocate to a different community or jurisdiction.
Many candidates are opting to relocate to Canada only after they have received permanent residency. Though relocating on a work permit would enable the candidates to relocate more quickly, candidates have reported too many risks and complications with being on a work permit while awaiting permanent residency confirmation. For example, in British Columbia, under a work permit, any dependent student must pay a fee of $75 per month for the province’s Medical Service Plan (MSP) coverage; spouses of the work permit holder are not exempt from the foreign home buyer tax; and spouses have difficulty with things like acquiring drivers licenses. In British Columbia, the current processing times for those seeking permanent residency through the Provincial Nominee Program is approximately, eight to 10 months for Express Entry and 18 to 24 months for Skills Immigration. While the examples used here are specific to British Columbia, similar challenges are reported by members in jurisdictions across the country.
In some cases different English Proficiency Tests are required by Immigration, Refugees and Citizenship Canada (IRCC) and the regulatory colleges, and these tests are non-transferable. For example, while the College of Physicians and Surgeons of British Columbia (CPSBC) will accept the IELTS Academic, this test is not accepted by IRCC. IRCC will accept the IELTS General, but this test is not accepted by the CPSBC. CELPIP is accepted by both IRCC and CPSBC. These differences often lead to confusion, and, in many cases, candidates being required to write more than one English language examination. While the examples used here are specific to British Columbia, similar challenges are reported by members in jurisdictions across the country.
Healthcare organizations do not know when individuals have arrived in Canada with the necessary skills to fill healthcare roles. If healthcare organizations knew about individuals with the requisite background seeking work, they would hire and support them in getting their licensing to enable them to practice.
Social supports are needed to assist newcomers as they immigrate and to enable them to take on healthcare roles, such as loans for housing, childcare, and other supports for similar needs.
There have been several announcements by the federal government in recent months outlining changes to improve the immigration process and investments to facilitate the recruitment and licensing of newcomers in the health sector. These are welcome developments and will help address some of the concerns listed above. However, to truly make an impact in tackling health workforce shortages, especially in the short- and medium-term, the immigration process would benefit from further streamlining and scaling of solutions to address the concerns listed above and leverage the skills of qualified immigrants and newcomers. For example, it would be very helpful to have a mechanism within the federal immigration process that would connect healthcare employers and immigrants and newcomers to help healthcare organization fill vacancies. Many healthcare organizations have the resources to support these individuals in navigating the settling and credentialing process, but they need to be aware that these individuals are in the country and qualified for available roles first.
2. Support interprovincial/territorial coordination of education and licensing.
As Canada faces a health workforce shortage and as virtual care gains popularity, the implications of jurisdictional barriers that exist in healthcare education and licensing – both within Canada and internationally – are heightened. During the pandemic measures were implemented to facilitate the movement of healthcare workers across provinces and territories to help the hardest hit areas. Similarly, necessary processes were implemented to support providers who had to switch to providing virtual care at the onset of the pandemic.
These approaches worked well, and Canada cannot afford to return to the pre-pandemic status quo once the pandemic is behind us. We must make permanent what, at the time, were viewed as temporary solutions to shore up a struggling system, including measures to support health workforce mobility and the virtual delivery of health services across provincial and territorial borders.
Governments, regulators, educational institutions, professional associations, employers, and unions must work together to reduce jurisdictional barriers to adapt to changing health system and patients needs, including better coordination of healthcare education and licensing. The federal government must play a leadership role to convene stakeholders and facilitate the implementation of solutions in this area.
3. Support the health, wellness, safety, and resilience of the healthcare workforce by expanding mental health and wellness research, programs, and resources specific to healthcare workers.
The mental health and wellness challenges experienced by healthcare workers were well-known prior to the pandemic and have only worsened over the past two years. The need for more action to support mental health and wellness due to pandemic challenges extends to healthcare workers. These dedicated individuals have been at the front lines of the fight, and greater investments by governments at all levels is needed to support the mental health and wellness of healthcare workers.
The federal government must help improve mental health and wellness for healthcare workers by providing dedicated funding for research into the mental health and wellness of healthcare workers. The effects of the pandemic on the health workforce are only starting to be understood and it is likely that there will be long-term implications after the pandemic ends. Better understanding how the health workforce has been impacted and what can be done do to best support healthcare workers’ mental health and wellbeing is vital as Canada faces continuing health workforce shortages and increasing demand on the system over the coming years.
The federal government must also further invest in programs and resources to help improve the mental health and wellness of healthcare workers. The creation of the Wellness Together portal and additional investments in mental health research are good first steps. The federal government must sustain these efforts while increasing programs geared specifically to help healthcare workers. Psychotherapy, needs assessments, peer support, and workplace mental health training and intervention services are only some of the resources that would help healthcare workers maintain their mental health and wellbeing.
4. Implement a pan-Canadian health workforce planning strategy with the goal of gathering and analyzing workforce data and developing solutions to tackle the shortage of healthcare workers and address the factors hindering recruitment and retention.
Canada does a poor job of health workforce planning, and a lack of a pan-Canadian strategy makes it difficult to ensure that the right number and type of workers are in the right place at the right time. This impacts patient care, leads to poor working conditions for healthcare workers, has economic ramifications for Canada, and perpetuates current inequities in the health system, especially given the sector has a high percentage of workers who are women, immigrants, newcomers, and racialized individuals.
Not fully understanding the makeup of the health workforce across Canada has led to competition for talent between provinces and territories. The competition is so high that employers are required to increase remuneration to attract and retain healthcare professionals, which increases health system costs. Similarly, newer healthcare workers are seeking a better work-life balance and are consequently choosing to work part-time hours. This shift increases the number of healthcare workers that are needed, and because this change was not planned for, training additional professionals to respond to this demand did not occur. It is reasonable to assume that healthcare workers of all ages may look to strike a better balance once the pandemic is over, further contributing to ongoing shortages. These are only some examples of the implications of a lack of health workforce planning on workers, patients, health systems and the economy.
Canada lags its OECD peers in health workforce data collection, infrastructure, and analytics.8 Many countries undertake health workforce planning at the national level and have established dedicated bodies to collect and analyze data on the health workforce, conduct research, forecast health system needs, and contribute to policy development to strengthen the health workforce and health system.
For example, Australia has been conducting national-level health workforce planning since at least 2008, creating a centralized agency to carry out health workforce planning and reform to address the challenges of providing a skilled, innovative, and flexible health workforce in the country.9 The agency’s initial study looked at health workforce needs between 2012 and 2025, first developing projections for the size and type of health workforce required to meet future needs, and then modeling the training pipeline necessary to meet the health workforce size and type needs.10 The country’s health workforce planning strategy is continuously updated, with the current national health workforce strategy extending to 2031.
In the United States, the National Centre for Health Workforce Analysis (NCHWA) develops reports on the US health workforce, including projecting supply and demand for healthcare professionals by discipline.11 The NCHWA is part of the Health Resources and Services Administration, an agency of the US Department of Health, responsible for improving health outcomes and health equity.12
There are also examples of workforce planning in other sectors right here in Canada that could be used as a basis for developing a health workforce planning approach. For more than 20 years, BuildForce Canada, a national industry-led organization, has helped the construction industry manage workforce requirements by providing labour market information, tools and resources, including data-intensive scenario-based forecasting to assess future labour market needs across 34 trades.13
A pan-Canadian health workforce planning strategy will increase understanding of workforce shortages, the factors contributing to them, and help inform the development of solutions to tackle issues. It will also provide insight into future needs and help support development of strategies to ensure Canada has the health workforce it needs to meet future demand. Such a strategy must be aligned with a robust pan-Canadian vision for healthcare.
A well-staffed health system, with healthcare workers who feel mentally and physically well, is vital for a functioning health system and the delivery of high-quality patient care.
a. Work with provincial and territorial governments to establish a body to enable strategic pan-Canadian health workforce data gathering, research, planning and forecasting.
As a crucial piece of a pan-Canadian health workforce planning strategy, a body must be established that is responsible for collaborating with the provinces and territories to gather health workforce data and conduct research into health human resources to better assess and plan for Canada’s health workforce needs.
Collaboration between all levels of government is needed as much of the existing data gathering, and regulatory and funding decisions for health human resources occurs at the provincial and territorial level.
First and foremost, this body must address existing data gaps. While many institutions and provincial and territorial governments collect some data on the health workforce, the data collected is not necessarily comprehensive enough to provide a complete understanding of the current health workforce and its characteristics, nor does it include all the information that would be needed to forecast and plan for the health workforce of the future. Having an overall sense of the health workforce across the country is imperative given the increasing mobility of healthcare workers and graduates across Canada and internationally.
Once there is a base understanding of the health workforce across the country, this body would turn to researching, analyzing, and developing policy to respond to existing workforce gaps and strategies to address longer-term needs. This could involve a variety of tools and resources, such as studies, forecasting and trends on the health labour market, and guides and best practices for recruitment and retention.
This pan-Canadian body must also examine opportunities to address health workforce shortages through education, credentialing, and scopes of practice. It must also work to create a more equitable and representative workforce that reflects Canada’s population, and one that is inclusive for all people seeking care.
Given the level of collaboration needed between all levels of government, health system organizations and stakeholders, employers, unions, regulators, educational institutions, and others, we recommend that such a body be at arms-length from any government, including the federal government. This will foster buy-in from all parties needed for this approach to succeed and help ensure that the work and objectives of this body are met, and not subject to political agendas.
5. Collaborate with provincial and territorial governments, regulators, and educational institutions to train more Canadian healthcare workers – particularly from Indigenous communities – in the professions and fields necessary to meet the long-term needs of the healthcare system.
Over the long-term, Canada must train more healthcare professionals. This involves increasing the number of seats available in university and college programs for all healthcare professions, expanding access to marginalized, Indigenous, and other racialized groups, and enhancing support to maximize postgraduate training and internship opportunities.
Developing programs such as campaigns to familiarize young people from across Canada – with a particular focus on Indigenous youth – with health sector jobs and providing financial and other incentives to those considering a career in healthcare can help attract people to healthcare professions. Providing additional support to students throughout the education and training process, which can be achieved through financial incentives, grants, and tuition relief programs, are further measures that can encourage individuals to pursue healthcare as a career. Such awareness and support programs could help fulfill recommendation 23 (i) from the Truth and Reconciliation Commission of Canada Calls to Action to: “Increase the number of Aboriginal professionals working in the health-care field.”
The labour shortage and working conditions in the healthcare system are among the biggest challenges facing Canada. While the crisis has been decades in the making, the COVID-19 pandemic greatly exacerbated the situation. The federal government must play a leadership role in addressing the crisis by convening, facilitating and supporting all levels of government and key stakeholders, including healthcare organizations, in a collaborative approach that will identify, develop and implement solutions, with a focus on those outlined in this submission.
Bourgeault, I.L. December 17, 2021. A path to improved health workforce planning, policy and management in Canada: The critical co-ordinating and convening roles for the federal government to play in addressing eight per cent of its GDP. The School of Public Policy Publications. Volume 14:1. Retrieved from: https://journalhosting.ucalgary.ca/index.php/sppp/article/view/74064.
Crettenden, I. F., McCarty, M. V., Fenech, B. J., Heywood, T., Taitz, M. C., & Tudman, S. 2014. How evidence-based workforce planning in Australia is informing policy development in the retention and distribution of the health workforce. Human resources for health, 12, 7. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3922608/.