Waits for care are the biggest political issue facing Canadian health care—a priority reflected in the accord reached by the federal and provincial health ministers a few days ago. They agreed to set limits on wait times for major surgeries and treatments, but conceded that these limits would be targets rather than guarantees. This is welcome news for Canadians already on long wait lists. But, despite years of debate on the issue there is still little discussion of making more efficient use of existing resources and facilities.
Meanwhile, the operators of private clinics and their supporters have seized upon the Supreme Court’s Chaoulli decision which struck down a Quebec ban on private insurance for Medicare-covered services. They are aggressively developing for-profit clinics to sell services to the public sector and any individual who has the cash to jump the public waiting lists.
Before going down this road, however, Canadians would do well to consider public sector solutions to the wait-times problem. Two such reforms are readily available:
Establish more specialized short-stay surgical clinics within the public sector to provide the efficiencies that private clinics have capitalized on—but without siphoning millions of public dollars to private owners
Adopt lessons learned from queue-management practices in other sectors. We have only to look at how line-ups have been streamlined at banks, for example, to see how a better coordination and flow can dramatically reduce wait times.
First, the public system should shift as many minor procedures and low-risk elective surgeries as possible (e.g., hip and knee replacements) to short-stay, public, specialized clinics. It has been widely—and wrongly--assumed that the only such clinics are for-profit businesses. In fact, Toronto’s Queensway Surgicentre, a division of the Trillium Health Centre (a public hospital), is the largest not-for-admission surgical centre in North America. And in Manitoba, in 2001, the government bought the Pan-Am Clinic from its private sector owners. It now operates as a unit of the Winnipeg Regional Health Authority.
Evidence from both Queensway and Pan-Am suggests that public sector delivery is superior. These clinics achieve the benefits of specialization and innovation normally ascribed exclusively to the private sector, while reducing overall administrative costs and providing broader societal benefits.
The second new public sector approach to health-care waits is the use of applications of queuing theory to manage waits and delays. Queuing theory applications are used to maximize flow in such diverse areas as air traffic control and manufacturing. Rather than thinking of every wait list as a capacity or resource problem, we need to look at delays through the “lens of flow.”
While Canadians tend to assume that, if there is a wait for health care, there isn't enough of it, most waiting is not due to lack of resources. For example, many breast patients have to wait for a mammogram, then wait for an ultrasound, and then wait again for a biopsy. The Sault Ste. Marie breast health centre reduced the wait-time from mammogram to breast-cancer diagnosis by 75% by consolidating the previously separate investigations. If a woman has a positive mammogram, she often has the ultrasound, and sometimes the biopsy as well, on the same day.
We could also eliminate waits for doctors' appointments. Family doctors often have delays of four weeks for appointments. The wait is typically shorter just before vacation and longer thereafter, but overall it is fairly stable. A doctor's capacity may be close to meeting demand, but he or she is servicing last month's demand today while postponing today's work until next month. If doctors could clear their backlogs, then theoretically they could go to same day service.
The Saskatoon Community Clinic serves over 20,000 patients. In 2004, patients faced a four-to-six-week wait for appointments. The centre temporarily increased resources to clear its backlog, re-designed some of their care pathways, and now provides same-day service.
We could also dramatically reduce delays for specialist care. The Hamilton HSO Mental Health Program integrated 90 family physicians with 23 counsellors and two psychiatrists. The result – the number of mental health patients treated went up by 900% while the family doctors made 70% fewer referrals to the psychiatry specialty clinic.
The enemies of Medicare have used the legitimate public concern about delays in the system to peddle ill-advised policies such as for-profit delivery and private finance. They may claim that private clinics will deliver faster care at a better price, but the peer-reviewed literature demonstrates that for-profit care tends to cost more while, if anything, providing inferior quality services. Even Alberta Premier Ralph Klein admitted in a candid moment that sending patients to private clinics in his province will cost more than if the services were provided in the public sector. For-profit clinics siphon off public resources to their owners.
The public solutions proposed – specialty clinics in the public sector and application of queueing theory to health care wait lists – are but two of many alternatives to private finance and for-profit delivery. Others include increasing surgical capacity in public hospitals and putting greater emphasis on prevention. There is no shortage of such public system solutions if the political will is present.
Let’s not add private problems to our health care system. We already have the public solutions at hand.
(Michael Rachlis, MD, MSc, FRCPC is a health policy analyst and the author of three national best-selling books about Canada’s health care system. This article was adapted from his recent paper—Public Solutions to Health Care Wait Lists—for the Canadian Centre for Policy Alternatives, the full text of which may be found on the CCPA website: www.policyalternatives.ca)