Secondary and tertiary care
Specialized ambulatory physician care is provided on much the same basis as general practitioner
care. Specialists control access to other specialists and allied providers, and admissions to
hospitals, and prescribe necessary diagnostic testing, treatment and prescription drug therapy.
However, specialists have specialized training in their respective field and must be certified, and
tend to be more acquainted with specialty-specific diagnostic tools and treatment. Many
specialists maintain private practices and are more likely to have a staff appointment in a hospital
or an affiliation with a hospital out-patient clinic.
Canadian hospitals are generally operated as private nonprofit entities guided by community
boards or trustees. As such, hospitals in Canada are highly autonomous entities, with the
provinces’ role limited to broad planning functions, funding and capital budgeting. Hospitals in
Canada may be categorized under several different rubrics. On one level, hospitals may be
classed by ownership (or more correctly, original ownership). Hospitals run by religious orders
were once very common, however, many of these have been taken over by other hospitals as
religious orders abandoned ownership or adopted a lay board in their governance structure. The
municipal hospital is another distinction that is quickly fading. Many hospitals were once owned
and operated by individual municipalities, however, after the introduction of Medicare, many of
these hospitals were eventually closed, became part of other hospital systems or were
reconstituted similarly to other hospitals.
Currently, the only hospitals directly run by provinces
tend to be psychiatric institutions, however, many provinces are in the process of divesting these
institutions. The federal government operates a number of hospitals for the military, provides
some facilities for native health, and until recently ran a number of veterans’ hospitals. For-profit
hospital operations account for less than five percent of the total and are predominantly long-term
care facilities or specialized services such as addiction centres or mental health institutions.
These ownership distinctions have faded over a number of years, as provinces began to fund the
hospital system. Hospitals are now typically organized in broader terms as general or acute care
facilities, community or secondary care, and long-term or chronic care. Depending on affiliation
with a medical school, any of these hospitals may also be classified as a teaching hospital. In
larger centres, hospitals may be more specialized as maternity hospitals, children’s hospitals,
rehabilitation facilities or cancer treatment centres. In the largest cities, some institutions have
become highly specialized, with hospitals focused on arthritis care, orthopaedics and women’s
health. Moreover, as part of the restructuring of the health system, many highly specialized
services are being consolidated in single urban centres which service the entire province or region.
Monitoring of hospitals in Canada is undertaken at many levels. Provinces typically control
facilities by monitoring budgets and expenditures. The Royal College of Physicians and Surgeons
regularly evaluate hospitals for inclusion in residency training programmes, and allied
professions, such as physiotherapists, assess individual hospital programmes and departments as
candidates for internships. The quality of Canadian hospitals is monitored by the Canadian
Council for Health Facility Accreditation. The accreditation process requires hospitals to meet
minimum standards to maintain their status. Failure to meet these standards may lead to a ratings
change, loss of teaching hospital status, or, in some cases, a reduction in funding.
To a large degree, the geographic distribution of hospital facilities has been influenced by two
factors. The first is that the majority of Canada’s population lives within 150 km of the border
with the United States. This concentration of the population has limited the need to build a highly
dispersed system. The second is that funding for hospital development was relatively easy to
secure in the 1950s and 1960s. Thus, a large number of hospitals were built to cover the
population. Provinces with a rural base tended to use the funding to build a large network of
smaller hospitals throughout the province, many of which are now closing or being converted to
community health centres as a result of restructuring. In addition, more recent population shifts
have put pressure on the existing distribution of hospitals, particularly in highly urbanized areas.
26 Health care systems in transition – Canada
Other changes in the health care system have put considerable pressure on the hospital sector.
The widespread shift from inpatient care to outpatient care and from inpatient surgery to day
surgery has reduced the use of some hospital services. What started out as a hospital cost-saving
measure has coincided with a growing demand for community and home care. These pressures
have forced many hospitals to consider restructuring, merging or consolidating services. Most
provinces are now also considering more drastic measures, such as complete hospital closures, as
an alternative to hospital-by-hospital bed reductions.
Technological advances have made possible the provision of many hospital services in private
clinics. The number of private clinics providing services such as eye surgery, abortions and
hernia repair has been increasing over the last few years. While the cost of the physician service
component of the care has traditionally been covered by provincial health insurance plans, several
provinces allowed patient charges or "facility fees" to cover facility administration costs This
posed a problem with the accessibility principle of the Canada Health Act and facility fees were
eventually deemed to be user charges in contravention of the act. Deductions from federal transfer
have been made from several provinces in an effort to discourage them from allowing such
patient charges.
