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Global healthcare systems struggling under increasing pressures

South Africa is not alone in buckling under a myriad challenges in its healthcare system as similar pressures place strain on public health systems in other parts of the world, too, writes MedicalBrief.

In Britain, the NHS is experiencing critical staff shortages and a lack of beds at a time when strike season is in full swing, while in France, the healthcare system is in crisis despite there being more doctors and many more nurses there. And further afield, in Canada, waves of respiratory diseases, staff attrition and an older population are taxing the country’s overburdened hospital system. In the US, New York has just seen a return to work of thousands of striking nurses, where staff shortages and patient overloads countrywide are taking their toll.

French President Emmanuel Macron has promised to change how the country’s hospitals are funded and to free doctors from time-consuming administration to break what he called a “sense of endless crisis” in its health service.

But various measures over the past few years – like bonuses of €50 000 for GPs in under-served areas, and ending a cap on the number of medical students in France – have failed to plug healthcare gaps.

The pressure on both hospitals and GPs has continued to mount with a triple-whammy of winter illnesses.

After years of Covid, and inflation biting, many say chronic staff shortages and increasing demands are making their work impossible and threatening the health system. Some hospitals report up to 90% of their staff on “sick leave protest” at the conditions, reports the BBC.

And the country’s second-largest health union has called an “unlimited walkout” this week, after a fortnight of strikes by French GPs.

The causes of the healthcare crisis are complex, but the long-term pressure of an ageing population alongside a shortage of medical staff was brought starkly into focus by the pandemic.

France has more doctors per head of population than the UK, and many more nurses.

But the World Health Organisation reports that almost half of French doctors are over 55 and approaching retirement. In the UK, that figure is around 15%.

Many younger medics are put off by the growing professional and financial pressures, which are punishing a workforce exhausted by Covid.

The National Order of Nurses estimates that 40% of working nurses want to resign, despite the government allocating an extra €12bn a year for hospital workers’ salaries.

Macron’s promise to change how hospitals are funded is designed to ease some of the pressure.

As in the UK, French hospitals are partly funded according to the procedures they carry out – an incentive to undertake as many high-paying procedures as possible.

Macron wants to shift to a funding model based on jointly agreed health objectives, though it’s not clear yet exactly how that would work. And it doesn't solve the problems faced by GPs, some of whom work must 60 hours a week to survive.

Most GPs operate as individual private practices, with 70% of each consultation reimbursed to patients by the state.

GPs want a doubling of the consultation fee from €25 to €50. The government is willing to look at an increase, but not one this big.

Some GPs are leaving, or looking for rarer, salaried positions in clinics or hospitals, free from endless paperwork and able to work limited hours.

Macron has promised to recruit more medical assistants, and delegate some tasks to pharmacists and nurses, to free up more consultation time for GPs.

But this won’t directly tackle one of the biggest problems: large swathes of rural and suburban France known as “medical deserts”, without access to a doctor at all.

The government has resorted to offering €50 000 signing-up bonuses for GPs who commit to the most under-served areas for five years.

And the National Assembly has just passed a new law, requiring all fourth-year medical students to complete a year’s internship in a so-called medical desert, some of which haven’t had a GP for four years or more – similar to SA’s community doctor service.

GPs working on a per-consultation basis, as the majority do, say rising inflation and growing paperwork forces them to work very long hours. In a medical desert, those pressures exist alongside acute demand, little medical support, and limited public services.

Macron has promised that 600 000 chronically-ill patients living in France without a doctor will have access to one – or to a treatment team – by the end of 2023.

The situation almost parallels that in Britain, where record levels of NHS staff are resigning, “resulting in a workforce post-Covid that cannot do or sacrifice anymore”, a nurse from London told The Independent.

In the second quarter of last year, 42 400 staff voluntarily quit their NHS jobs – higher than any quarter over the past decade.

The crisis is escalating across all areas of the health service, according to Dr Simon Walsh, from doctors’ union the British Medical Association (BMA), who said the health service was “in unprecedented territory, where harm is actually occurring week after week”.

Analysis showed 7 200 staff gave “work-life balance” as the reason for resigning.
This is the highest ever recorded for this reason, and is now the second most common reason for staff to leave the NHS.

A row over pay with the government has prompted unprecedented strikes from NHS nurses, paramedics and other staff, with further planned later this month. The NHS also faces a potential three-day strike from junior doctors later this year.

According to the latest figures, 2 161 staff left their jobs due to a “better reward package” – this was also the highest recorded to date.

Last year The Independent revealed internal NHS estimates showing the government was set to miss its target to have 50 000 more nurses working in the NHS by 2023-24, due to the number expected to leave their jobs in the next year.

Pat Cullen, the general secretary and chief executive of the Royal College of Nursing, said: “Nurses are leaving after realising they can get similar or better pay in supermarkets and retail without the stress of the job.”

Internal NHS figures last week showed 50 000 patients a week over December and early January waited more than 12 hours in Accident & Emergency (A&E) for admission. This was a new record.

Patients have complained of waits on trolleys in A&E lasting for days, and the most vulnerable being left to wait hours in cars and ambulances.

After a meeting with UK Health Secretary Steve Barclay last week, the council chair for the BMA, Professor Philip Banfield, said: “If we don’t restore junior doctors’ pay we’re going to see even more of them leaving. The NHS is in crisis, the number of absent doctors from shifts and the locum bills, for example … and the harm that is coming to patients because of staff shortages.”

And in Canada, the situation is not much better.

The death of Allison Holthoff, who went into cardiac arrest after waiting for treatment in an emergency froom for more than seven hours at the end of December, has prompted calls by politicians for an investigation into the Canadian province’s emergency room backlog. But Holthoff’s death is also the latest fatality to expose a mounting crisis in hospitals countrywide, which have been worn down by waves of respiratory viruses and exacerbated by a chronic staffing shortage.

Last summer, many emergency rooms in rural communities shut down. In larger cities, people waited dozens of hours for emergency care. At Canada’s largest children’s hospital, SickKids, a four-year-old child was separated from his family and flown more than 350km for treatment of a near-fatal sepsis infection amid overcrowding.

“Emergency rooms are the barometer for our healthcare system,” said David Carr, a physician and professor of emergency medicine at the University of Toronto. “We’re facing the ‘perfect storm’ – we’ve been thrown a virus that is crippled our healthcare system and while we’ve managed to get hold of it in many ways, what we have not come to grips with is the sheer attrition of nurses and healthcare team members.”

While the winter months are typically the worst for emergency rooms as respiratory viruses take hold, Canada’s shortage of health professionals – and the rising rate of burnout – is worsening an already bad problem, reports The Guardian.

Further compounding the staffing shortage, healthcare systems are experiencing a “geriatric tsunami” of ageing patients whose care requires a growing share of healthcare budgets and efforts.

These crises have brought healthcare systems to a breaking point. As medicine falls under provincial jurisdiction – but is funded by the federal government – political leaders have feuded over fixes to a languishing system.

Amid a shortage of family doctors, more cases that should be addressed earlier are ending up in the country’s emergency rooms.

Exacerbating this, Canadian medical students who study abroad are often unable to practice medicine when they return home due to arduous licensing requirements.

Provincial premiers recently floated a proposal that would make it easier for foreign-trained nurses and doctors to earn Canadian credentials. But experts warn the move cannot be made quickly and requires more resources than simply rubber-stamping paperwork.

Meanwhile, as 7 000 nurses return to work at two of New York’s busiest hospitals after a three-day strike, colleagues countrywide say it’s just a matter of time before frontline workers at other hospitals begin walking the picket line.

Problems are mounting nationwide with staffing shortages, overworked nurses beaten down by the pandemic and a broken pipeline of new nurses, reports PBS NewsHour.

Nurses are juggling dangerously high caseloads, said Michelle Collins, dean at the college of nursing and health at Loyola University New Orleans.

Union leaders say the tentative agreement ending the strike by nurses at the privately owned, non-profit Mount Sinai Hospital and Montefiore Medical Center, which hold more than 1 000 beds in New York City, will relieve chronic short staffing and boost pay by 19% over three years.

The walkout, which ended last Thursday, was just the latest dispute between nurses and their employers. Last year, six unions representing 32 000 nurses launched strikes countrywide.

Describing hospital environments where nurses are unable to take breaks because they have too many patients, president of the American Nurses Association Dr Jennifer Mensik Kennedy said nurse believe their only option is to strike.

“They feel as if their voices haven’t been heard before with this exact topic,” she said. “This could continue.”

In California, nurse unions at two hospitals are likely to strike this year when their contract expires, said former ICU nurse Peter Sidhu, who now works for the state union. Sidhu, who fields objections from nurses statewide saying their caseloads are unsafe, has received 7 000 such complaints in Los Angeles hospitals since December. Objections have at least doubled since before the pandemic began.

Nurse shortages were plaguing some hospitals years before Covid-19 hit, and signs of a crisis loomed, with a large swath of the workforce nearing retirement age.

The Department of Health and Human Services last year found that more than half of all nurses were over 50, a much higher percentage compared with the overall US labour workforce, with only a quarter of people 55 or older.

Aspiring nurses are lining up to replace those retirees but even that has hit a snag, with widespread faculty shortages at nursing colleges. In 2021, nearly 92 000 qualified nursing school applicants were denied entry into a programme – because of a shortage of educators, says the American Association of Colleges of Nursing.

The government agency has pumped more money into its National Health Service Corps programme, which covers student tuition for health workers in high-need communities. Since 2019, it has nearly doubled the number of nurses and nurse faculty it sponsors.

Sidhu said there’s a shift in the profession, with fewer nurses wanting to work 12-hour shifts, multiple days a week. Many are taking jobs at clinics, where weekend or overnight shifts aren’t required. Some are simply burnt out from working in a hospital.


The Guardian article – Emergency room death highlights Canadian healthcare crisis (Open access)


BBC article – France's health system under pressure of increasing demands (Open access)


The Independent article – Record levels of NHS staff resign as nurses say they are ‘broken’ (Open access)


PBS NewsHour article – How the NYC nurses strike points to a nationwide problem with staffing (Open access)


See more from MedicalBrief archives:


NHS nurse walkout could delay chemo, dialysis and urgent procedures


36% of UK doctors suffer from workplace burnout


GPs worldwide harshly impacted psychologically by pandemic – Meta-analysis


French medics protest against health budget cuts


SA nursing under threat as UK, Canada lure staff to address crippling shortages





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