Chapter 4: Immediate and long-term capacity pressures

Capacity pressures are also contributing to the problem of hallway health care in Ontario. There are several causes to the capacity challenge:

  1. Ontario may not have the appropriate number of hospital, or long-term care beds to meet the health needs of the population,
  2. there is insufficient capacity in community care systems – like home care and mental health and addictions care – to prevent people from needing to go to hospital and to enable them to return home from hospital quickly, and
  3. the province is not using the beds across the system as effectively as possible. In practice, this means that there are people across the province who are spending time in hospital beds because they can’t access other options for health care.

There are many patients in Ontario who are waiting in the wrong place in the system, and who require an alternate level of care (ALC). For example, in October 2018, almost 16% of days in hospital were spent by patients that were waiting for care in another setting.footnote 23 This rate is high, and it is also increasing despite investments in more beds across the system. As of November 2018, there were approximately 4,665 patients designated as requiring an ALC.footnote 24 This represents a 4% increase in absolute volumes compared to the year before.footnote 25

In addition to being high, the ALC rate is different depending on where you are in the province, and can change depending on the time of year. As of October 2018, the range of ALC rates across Ontario was between 5% and 34% - with some challenges more pronounced in the northern part of the province and in the Greater Toronto Area.footnote 26

There are many examples of people waiting for health care in the wrong spot across the system that could benefit from a different kind of support. For example, over 9% of people designated as requiring an ALC who have been waiting more than 30 days are people who have specialized mental health needsfootnote 27 who could be served – with appropriate supports – in supportive housing rather than hospital beds.

Another area where we can see the direct impact of capacity pressures is in how difficult it can be to find space in long-term care homes. The largest proportion of cumulative ALC days (province-wide), are currently attributed to patients waiting to be discharged to long-term care (59%).footnote 28 This means that people are waiting too long in hospitals before moving to an open bed in a long-term care home. This is in part due to the fact that long-term care homes are currently at 98% capacity, with roughly 78,910 residents in 627 long-term care homes across the province, and also because community supports are not expanding fast enough.footnote 29 For example, a 2017 Canadian Institute for Health Information report found that in Canada more than 20% of seniors admitted to residential care could remain at home with appropriate supports; furthermore, seniors assessed in hospital are substantially more likely to be admitted to residential care than those assessed in the community.footnote 30 The mis-match of capacity, demand, and use of services is one of the main pressure points facing the health care system, contributing to hallway health care.

Waiting for care in the wrong spot: Understanding alternate level of care (ALC)

A common approach for measuring the appropriate use of space for patients is by tracking the number of patients who require an ‘Alternate Level of Care.’ When a patient is occupying a bed in a hospital and does not require the intensity of resources or services provided, the patient is designated as requiring an alternate level of care.

ALC rates and volumes are just one way to measure how effectively the health care system is flowing patients through to different care settings. It is a designation that refers to patients who remain in hospital although they no longer require hospital-level care. 

A high-performing health care system would have a low ALC rate, which would mean that patients are receiving appropriate care for their needs in the right setting.

Population aging & health care services

According to population projections, Ontario’s senior population (individuals 65+) is expected to almost double from 2.4 million, or almost 17% of the population in 2017 to 4.6 million, or almost 25% by 2041.footnote 31 As an example, of what this means for health care services, consider that 76% of seniors (aged 75+) who require care are currently receiving care at home. To maintain that ratio, the system would need to provide home care services to 97,194 more clients.footnote 32

Population growth by age group, 2017 to 2041


12M (<65) 13.5 (65 to 74) 14.5M (75+)


12.25M (<65) 14M (65 to 74) 15M (75+)


12.50M (<65) 14.5M (65 to 74) 15.25M (75+)


13M (<65) 14.75M (65 to 74) 16.25M (75+)


13.75M (<65) 15.25M (65 to 74) 16.75M (75+)


14.25M (<65) 15.50M (65 to 74) 17.50M (75+)

(Source: Ministry of Health and Long-Term Care, 2019)

One of the challenges associated with an aging population is an associated rise in the number of patients with dementia. Close to 228,000 Ontarians are currently living with dementia, and this number will grow to over 430,000 by 2038.footnote 33 Dementia is one of the leading causes of dependency and disability among seniors, and caregiving responsibilities for an individual with dementia can have a significant impact on family and friends.

Between 2008 and 2038, dementia will cost Ontario close to $325 billion.footnote 34 This includes health care and other costs, including lost wages, or out-of-pocket expenses by people with dementia or their care partners.

Approximately 64% of residents in long-term care homes have dementia.footnote 35 Some long-term care homes cannot care for additional residents with dementia since the numbers are already so high – which can delay admission and cause additional strain on families looking for support.

And while we focus on the rising number of seniors requiring different health care services, it is also important to note that in the next twenty years there will be more than 560,000 more children (0-18 years of age) in Ontario.footnote 36 Proactive and early health care interventions will help these children have better lives, and will help reduce health care costs over their lifetime.

Social determinants of health

The social determinants of health are the economic and social factors that impact our health. They play a critical long-term role in health care, particularly for those suffering from chronic conditions. Having a job, eating healthy food and having a safe place to sleep are foundations to good health.

Population growth & health care services

In addition to the anticipated growth among the aging population, Ontario’s general population is also growing larger. Demographic projections suggest that the province will see an increase in its population by roughly 30% by 2041.footnote 37

This population growth will not occur evenly across the province, which will have an impact on how the health care system plans to handle this future growth, and where it allocates its limited resources to address the anticipated increase in demand for services.

In particular, projections suggest that the Greater Toronto Area (GTA) will be the fastest growing region of the province. By the year 2041, the GTA’s population is expected to grow by 41% or by approximately 2.8 million people compared to the year 2017. Similarly, population growth will be slower in certain parts of the province, which will impact the system in different ways.footnote 38

If no action is taken, these demographic changes will significantly impact the availability of health care in the province. With no additional capacity created – or no other efficiencies in the system found – the hospital bed rate in Ontario will decline from approximately 222 beds per 100,000 people in 2018 to approximately 173 beds per 100,000 people in 2041.footnote 39

The projections are more concerning for the long-term care bed rate, which is projected to decline from 72 beds per 1,000 people aged 75 or older to 29 beds per 1,000 people aged 75 or older by 2041. This is a total decline in the long-term care bed rate of about 60%, or the equivalent of 48,000 bed closures by 2041 if nothing is done.footnote 40

Simply adding more beds to the system will not solve the problem of hallway health care. For example, community mental health and addictions services, as well as community rehabilitation services are two areas where additional access to services could help relieve some of the pressures causing hallway health care.

Given the current pressures on capacity and the implications of future demographic shifts, the Council will be looking for innovative solutions to remove unnecessary barriers preventing Ontarians from receiving culturally appropriate, timely, and fair access to health care.