Public Solutions Could be Undermined by Private Interests

May 24, 2007

Long waits for elective surgery and privatization are the price Canadians must pay for their well-intentioned but fatally flawed public health care system, right?


In fact, the above conclusion cries out for a second opinion. That's because when it comes to surgical waitlists we are currently experiencing a 'Eureka' moment. Although waiting for surgery is the hottest political problem facing Canadian health care today, resorting to more private care in order to ensure timely access to health care isn't necessary.

That's because low-cost public solutions to long wait times are being used to fast-track procedures such as hip and knee replacements. Successful projects currently underway in B.C. and elsewhere in Canada show that the private sector does not have a monopoly on innovation and efficiency.

One of the most impressive projects is the Richmond Hip and Knee Reconstruction Project, a bargain at $1.3 million in start-up costs. It has slashed median wait times for surgery up to 75 per cent. Wait lists shrank by 27 per cent and cases completed increased by 136 per cent.

How did they do it? Staggering operations between two dedicated surgical rooms, making clinical and surgical practices consistent and investing in new equipment were critical. But none of these changes would have happened without the project's core strength - cooperation and collaboration from everyone involved, from cleaners to surgeons to community care workers. 

Project leaders also created a 'toolkit' containing practical information on how to replicate their success.

Richmond's innovations were embraced by a number of facilities, in particular Lion's Gate Hospital's Joint Replacement Access Clinic and UBC Hospital's Centre for Surgical Innovation. Both facilities have also dramatically cut wait times for hip and knee replacements.

Similar projects exist across Canada, but not in nearly enough numbers considering how many Canadians still wait too long for surgery. It's a curious situation given the attention governments pay to the wait list issue. This puzzle is particularly perplexing here in B.C. because instead of replicating these proven strategies on a province-wide scale, the government appears to be moving toward more privatization. 

At the opening conference of the "conversation on health," Brian Day - President-elect of the Canadian Medical Association, owner of a private surgery clinic and outspoken advocate for private delivery - offered his prescription for the waitlist ailment. The Premier, Finance Minister and Health Minister have all expressed a keen interest in his ideas.

Day's proposal is a new form of hospital funding which would create a competitive market in health care based on recent changes in the United Kingdom. In a nutshell, the U.K. reforms involve: guaranteed public funding for private surgery clinics; a shift from global-funding for public hospitals to payment after the fact based on the number of patients they attract for specific services; and a 'patient choice' component whereby family doctors must offer patients a choice of five hospitals, one of which must be a private clinic. 

The result is an environment where everyone - public and private - competes with everyone else for patients. This rivalry promises to reach ridiculous heights - public hospitals are now allowed to use celebrities to advertise their services. (I can see it now - 'David Beckham had smashingly successful knee surgery here!')

Since the first reforms began - about three years ago - a number of professional organizations and academics have sounded alarm bells. Their concerns include patients receiving unnecessary care, greater inefficiency in the system, higher administrative costs and a worry that the 'choice' element benefits only the wealthy and articulate. These doubts were clearly expressed at the British Medical Association's 2005 annual meeting when delegates passed a unanimous resolution that "more emphasis should be placed on collaboration as opposed to competition."

Imported to BC, these reforms would undermine rather than sustain public health care and undo the very real gains made by waitlist projects like the one in Richmond.

The pros and cons of a parallel private/public delivery system have been rigorously researched. The international evidence concludes that a competitive environment created by such an arrangement results in: longer waits for patients in the public system because private clinics draw scarce doctors and nurses out of the public system; greater average severity of illness among patients in the public system because private clinics 'cream-skim' those who are cheaper and easier to treat; and higher health care costs because private clinics tend to charge higher prices. For example, in 2004 the British Medical Journal reported that the public system was charged 11 per cent more on average and up to 40 per cent more for some procedures performed in private clinics than for the same procedures performed in public hospitals.

Broader implementation of efficiencies depends on more collaboration. A health care marketplace - where private clinics and public hospitals go to battle for patients - depends on just the opposite.

Alicia Priest is a journalist and former nurse, and co-author of "Why Wait? Public Solutions to Cure Surgical Waitlists," published earlier this month by the Canadian Centre for Policy Alternatives. Dr. Jacky Davis is a British consultant radiologist and clinical director who has worked in the National Health Service for 35 years. She is a founding member of the Keep Our NHS Public campaign.