The Canadian healthcare system holds a fundamental position in our national identity, significantly influencing our communities’ well-being and quality of life. However, healthcare and emergency workers are facing many challenges across BC and these challenges are translating into challenges that all communities now face in securing a stable and robust supply of healthcare services.

Traditionally, the healthcare system has been seen as the sole responsibility of the provincial and federal governments, and there has been little to no role identified for local governments and communities. In that context, local communities have often felt disempowered regarding how to address local healthcare supply challenges.

This project empowers local communities to take an active role in retaining and attracting healthcare workers to their community.

The range of initiatives outlined in this playbook includes ways that local governments, businesses and organizations can take effective action to counteract the challenges healthcare workers face including:

• Cost of education and student loans
• Long hours, overtime and burnout
• A lack of a sense of community support
• Clinic space –availability and high lease costs
• Costs of fitting out a clinic
• Cost of staff and administration loads
• Technology limits
• Many others

Acknowledgements

Introductory Letters

The Challenge

This section explores the significant challenges that we are facing in the healthcare system with respect to stresses on our healthcare workers, and the connection they have to local governments and organizations

A summary of many of the core challenges that healthcare and emergency personnel face today include:

• Long hours, significant overtime and burnout
• Challenging workplace morale Frustration with system inertia and the lack of change
• A lack of time off including maternity leave, and a general work/life balance
• A lack of a sense of community support
• Clinic space –availability and high lease costs
• Costs of fitting out a clinic
• Cost of staff and administration loads
• Technology limits

These challenges are interconnected with local governments and organizations and are discussed further below.

Housing
High housing costs make it difficult for healthcare workers, especially those with lower incomes, to find affordable accommodation near their workplaces. In addition, if a large portion of their income goes towards housing, healthcare professionals may struggle to meet their other basic needs. While physicians, surgeons and others are paid well in the healthcare system, they cannot perform their roles without the support of dozens of other workers in the system – most of whom are paid average salaries.

The average Canadian house price in 2022 stood at approximately $704,000, and it is higher, up to twice that, in many of Canada’s larger urban areas.

The payment on a mortgage is approximately $500-600/month per $100,000 borrowed, depending on the interest rates. As such, for a $500,000 townhouse or condominium, with a $100,000 downpayment, the family would be paying $2,000-$2,400 a month in mortgage costs, plus utilities, taxes, insurance and maintenance costs – pushing that cost closer to $3,000/month – in after tax income. This means that a condominium or townhouse home will require between $40-$50,000 a year in gross income. This translates into a $25-30/hr salary rate – just to pay for housing.

The average house price in British Columbia in 2022 stood at about $997,000 Canadian dollars.

The cost of buying a home has become so expensive that many people rent for increasingly long periods of time. While renting is a legitimate and respectable form of tenure, we are at a transition point where most cities do not have enough rental housing stock to supply both new renters (young adults, immigrants, others) and to keep a growing percentage of existing renters in rental housing stock.

Historically, many purchased a home in their 30s and freed up the rental stock for the next generation. With the high cost of purchasing a home, many are staying in the existing rental stock for much longer. This has created significant demand for rental units, which has driven up rents rapidly, triggering government rent control legislation in some cases. Incentives and financing are being offered for new-built rental housing, the challenge is that new housing is very expensive. The growing cost of rents then reduces the ability of renters to save a downpayment to purchase a home, further prolonging their rental tenure, and increasing the demand for rental housing.

The reality of paying current rents for homes now requires a significant salary to cover rent, utilities and insurance. With an average rent for a 2 bedroom unit in BC frequently over $2,400 and with utilities and insurance added, it again requires a salary of over $30,000 after taxes to pay for housing.

Rental statistics – May 2023

The majority of large hospitals and major healthcare facilities are in more urbanized areas, where the housing is the most expensive. As such, the cost of housing has become a major stress factor in the lives of healthcare and emergency workers.

Beyond just the cost of a mortgage or rent, additional costs such as insurance, taxes, utilities, repairs and others continue to climb, faster than incomes. As such, the combined costs of all factors in housing continues to remain a major challenge to our healthcare and emergency workers.

Transportation
Housing is typically less expensive farther from a metro core business area, and as such, many choose to live farther outside the city, and therefore farther away from major healthcare centres. This distance triggers the familiar challenge of long commutes, which leads to many negative factors in terms of stress, fatigue, transportation costs, less time with the family and for healthy living, and many others.

Many cities are increasing the cost of parking to deter automobile use, however this approach requires efficient alternatives to mobility that would connect housing to where healthcare facilities work. The reality is that few cities offer transit systems that will meet the needs of a family whose members work at various healthcare institutions. As such, the cost of transportation is rising significantly.

Daycare
Working parents need daycare – for children and/or pets. The cost of daycare has become increasingly high, and the supply increasingly scarce.

Childcare
The average expenses for daycare in British Columbia are covered by parents, as stated in the Child Care Provider Profile Survey of the region. The BC Government notes that the average cost of daycare in the province is approximately $1,000/mo.

The Province is expanding its $10/day daycare program to help address this issue, but the challenges remain in accessing daycare. Low wages, burnout and other factors are challenging many daycare providers and the supply of daycare spaces is a real challenge for many.

This situation is especially challenging for healthcare and emergency workers as they are often on less predictable shift work, many after business hours. Hiring a babysitter or nanny in 2023 costs around $20/hr typically, an amount which seriously erodes the income of a healthcare worker on a night shift.

Petcare
Many individuals or couples may not have children, but many will have pets. While some pets are more self-sufficient, dogs require supervision over the course of the work-day.

The cost of doggy-daycare varies significantly. Pet-Keen’s price guide in 2023 notes it costs typically $35-51/day for daycare (and similar or slightly more for overnight care) or $700-$1,000/month for business days. This price is close to the cost of child daycare.

General cost of living
The general cost of living continues to rise, especially in a condition of higher inflation rates – increasing the costs of everything related to daily living. The costs of food have risen significantly in recent years in Canada, as well as consumer goods, such as clothing, home and recreational goods, and many others.

Education
Healthcare and emergency workers require significant training to be able to do their job, from one- or two-year certificates, to nearly a decade of post-secondary education to become a doctor, and more to become a specialist. The availability of seats on schools is largely set by provincial funding. The cost of tuition is set by a combination of the educational institution, and Ministry of Education policy.

The funding for educational institutions has not increased at the same rate as demand and as such, students face higher tuition fees every year. In addition, the cost of rent and living for most students has also increased significantly as noted above. This situation both deters individuals from pursing this education, or more commonly, results in significant student loan debt. Many sources suggest that the average student loan debt for a doctor is in the range of $100,000.

The provincial and federal governments offer various programs for student loan debt assistance, but many healthcare workers face significant challenges at the beginning of their career as their debts are high but they only receive entry level salaries.

Working conditions
A key issue that is receiving more attention today is the working conditions that our healthcare and emergency workers face every day. Some of the challenges have been exacerbated by the COVID 19 pandemic, but there were many problems before the pandemic that have resulted in record levels of burnout and healthcare workers leaving the profession.

The workplace experience for healthcare workers was significantly impacted by the pandemic, with ongoing implications. Over 85% of healthcare workers felt more stressed during and since the pandemic due to increased workloads. Nearly two-thirds of healthcare workers considering leaving their jobs noted that stress was a primary reason. https://www150.statcan.gc.ca/n1/daily-quotidien/220603/dq220603a-eng.htm

A recent study in Canada suggested that up to 40 percent of of healthcare workers in 2021-2022 are facing symptoms of burnout, and fifty percent intend to leave the healthcare system altogether. https://mentalhealthcommission.ca/news-releases/49456-situation-critical-distressed-health-care-workers-in-need-of-psychological-support/

In later 2021, there were 126,000 vacancies in the healthcare and social assistance sector – nearly double the vacancies two years earlier. https://www150.statcan.gc.ca/n1/daily-quotidien/220603/dq220603a-eng.htm

From 2020 to 2021, there was a notable decline in the provision of healthcare services by physicians in Canada, with a 7.9% decrease overall. Family medicine experienced a 7.1% decrease, while specialists saw an 8.9% decline. This decline marked the first time in 20 years that total physician payments experienced a decrease, specifically a 2% decline. The reduction in services can be attributed to the impact of COVID-19-related public health measures. These measures led to a shift in priorities towards addressing COVID-19 needs and a reduction in non-critical care and elective surgeries. https://www.cihi.ca/en/health-workforce-in-canada-in-focus-including-nurses-and-physicians/overview-impacts-of-covid-19-on

Approximately three quarters of Canadian physicians noted that their workload has increased since the pandemic and that the quality of care has decreased. https://www.cihi.ca/en/survey-results-reveal-the-challenges-experienced-by-family-doctors

Healthcare workers often work extended hours, face significant overtime demands, and are susceptible to burnout due to the demanding nature of their jobs. In 2021, healthcare workers experienced the highest average overtime hours in over a decade. Approximately 21% of employees in health occupations, totalling more than 236,000 individuals, worked overtime. On average, they worked 8.2 hours per week of paid overtime and 5.8 hours per week of unpaid overtime. Among different occupations, paramedics (45%), salaried general practitioners/family physicians (34%), and respiratory therapists (31%) had the highest proportions of workers engaged in overtime hours. These levels of overtime have many long term impacts on the health of workers, and the quality of the time they have for their families and other needs. https://www.cihi.ca/en/health-workforce-in-canada-in-focus-including-nurses-and-physicians/overview-impacts-of-covid-19-on

Healthcare and emergency workers face many challenges in their workplace in a context of overwork and insufficient resources, that can undermine workplace morale, which creates further stresses. And when the healthcare system’s functionality becomes in any way compromised, negative reactions from the community in response to perceived lower service levels, can further compound the challenges. Nearly half of helathcare workers considering leaving their jobs noted that job satisfaction and mental health and wellbeing was the reason. https://www150.statcan.gc.ca/n1/daily-quotidien/220603/dq220603a-eng.htm

Clinic management
The Canadian healthcare system structures most primary care around a business model where physicians are expected to operate their clinics as small businesses, providing services and then invoicing the healthcare system for their time. As such, physicians must take on the costs of office real estate, staff, extensive record keeping and reporting, and other business costs. Most physicians become doctors to provide medical service, not to become medical clinic administrators. Over half of physicians in Canada are not satisfied with the amount of time they have to spend on paperwork. One study suggested that Canadian physicians are spending nearly 50 million hours per year on administrative tasks. https://www.cihi.ca/en/survey-results-reveal-the-challenges-experienced-by-family-doctors

Medical offices compete with all other types of businesses for commercial space in communities, and with increasing real estate costs, this can be a significant challenge. The health and safety requirements as well as required technology can bring significant additional costs to the design and construction of a clinic.

Physicians are not trained as business managers, so the many issues that arise in real estate, human resources, financing, insurance, and many other factors of running a business, become a challenge for a physician to manage – all of which take time away from providing services, or increase business management costs if others are hired to manage the clinic.

Conclusion
This section has outlined some of the challenges faced by healthcare workers, and the growth of these stressors and the impact they are having over time.

For many sectors, such as tourism, we have comprehensive public/private sector strategies. However, for one of the most important in our lives today, healthcare, there is no coordinated strategy for healthcare worker retention and attraction that empowers everyone to take action.

Senior governments have been responding with new resources, new policies and agreements, but the scale of the challenge is significant. Furthermore, many of the stressors in the lives of our healthcare workers are outside the conventional scope of the healthcare system, and as such, we need to explore the issues and opportunities associated with the dimensions of the local community and government that can assist healthcare and emergency workers.

More importantly, each community will need to chart its own path in addressing the challenges and unique social capital it has to respond to the challenges and opportunities.

The range of actions proposed range from small programs to help a single healthcare worker to much more structural initiatives, such as municipal-managed healthcare delivery. Ultimately, each community can create its own custom strategy and evolve it over time as resources allow.

A key factor in the creation and successful implementation of any multi-party community program is “coordination” – the connecting of groups to opportunities or needs, and the continued coordination of stakeholders and initiatives. Any individual or group in a community can assist in playing a coordinating role, and many are needed.

Together, with the opportunities outlined in this Playbook, BC communities can empower themselves to support, retain and attract healthcare and emergency workers in their communities.

Local governments

Opportunities for local governments to support healthcare workers