The Conversation: How to solve Canada’s wait time problem
May 16, 2018
A new analysis from the Canadian Institute for Health Information (CIHI) shows wait times for hip and knee replacements and also cataract surgeries have increased across Canada since 2015.
But we love our health care system. In particular, we take pride in the principle that care should be provided on the basis of need, rather than ability to pay.
Our system and its virtues have become part of our collective identity. We even named Tommy Douglas, the architect of medicare, “The Greatest Canadian of all time.”
Are long wait times simply the price we must pay in order to uphold our Canadian values of equity and fairness?
As a doctor of medicine and professor who has spent a career in health policy and advocacy, I disagree. Our health system — designed in the 1960s — is in dire need of an overhaul. Canadians and their health needs have changed, but the system hasn’t changed with them. Wait times are not the core problem. They are a symptom of the problem.
And, like every doctor, I would rather cure the problem than just treat the symptoms.
A nation of perpetual pilot projects
It can be difficult to challenge the status quo, particularly when the health system has become so iconic.
Critics argue, however, that our “system” is not really a system at all — our public investment is largely confined to doctors and hospitals while home and community care, drugs, rehabilitation, long term care, dentistry and many other important health services are paid for from a mixed bag of public, private and out-of-pocket sources.
Our federated model has created provincial and territorial silos, and our attempts at integration and reform have largely fallen flat. Monique Bégin famously said that we are a country of perpetual pilot projects, lamenting our inability to scale-up and spread new ways of doing things.
The highly respected Commonwealth Fund has consistently ranked our system either ninth or 10th out of 11 peer countries for many years now.
On one issue in particular — wait times — we rank dead last.
The ‘wait time problem’
Nearly every Canadian family has a wait-time story. We wait in emergency departments. We wait to see family physicians. We wait for tests, procedures and surgeries. We wait to see specialists. We even wait to get out of hospital — an increasing number of Canadian seniors find themselves in acute care hospital beds not because they are sick, but because they cannot live independently and have nowhere else to go.
Successive provincial, territorial and federal governments have all acknowledged and addressed the wait-time problem. In 2004, Prime Minister Paul Martin announced a 10-year health accord with the provinces, touting it as the fix for a generation.
The Wait Time Alliance (WTA), a national federation of medical specialty societies and the Canadian Medical Association, developed a list of evidence-based wait-time benchmarks for nearly 1,000 health services so that progress could be measured.
A total of $41.3 billion was spent by the federal government over 10 years, including $5.5 billion to specifically address wait times in five key areas: Cancer, cardiac, sight restoration, medical imaging (CT and MRIs) and joint replacement.
Some provinces, notably Ontario, saw improvement. Annual report cards from the WTA and Canadian Institutes for Health Information (CIHI) showed modest improvements across the country.
A landscape of chronic disease
But now were are seeing slippage. Performance on wait times is holding steady at best. It’s increasingly clear that all this money bought us time, but did not fix the problem.
And no wonder. Because the problem is not a lack of investment. Canada has the fifth most expensive health-care system in the world. In 2017, we spent around 11.5 per cent of our GDP on health care.
Spending more is not the solution. Spending smarter is.
The underlying problem is the system itself (or, rather, the lack of a system). The hodgepodge of bureaucracies, budgets, facilities and providers that collectively carry out the business of health care in this country are more disconnected than ever before.
At the same time, patients’ health-care experiences are changing. No longer is the health-care landscape dominated by acute illness — where you get sick, you get treated and then you get better.
Increasingly, the landscape is dominated by chronic disease. In fact, most patients with chronic disease actually have multiple chronic diseases.
How to fix the system
Our system is not designed to provide optimal care for these patients and, as a result, everything slows down. Patients with complex needs who are not really acutely ill wind up in emergency departments and hospitals.
Emergency departments and hospitals, in turn, experience overcrowding and can’t do what they are designed to do. Surgeries and procedures get cancelled, wait times increase and everyone gets delayed care.
Fixing the system is the only way we will ever get wait times to come down. History has shown that spending more money doing the same things over and over does not work.
A great place to start would be to develop and implement a national seniors’ strategy. Such a strategy would acknowledge that the new health-care landscape is one of multiple chronic diseases driven by our aging population. It would work to develop a properly integrated, transdisciplinary model of care in the community.
Doing so would free up hospitals to do what they are supposed to be doing — looking after acutely ill people and performing procedures and surgeries. Budgets that align with patient trajectories, wherever they are in the system, rather than with institutions or programs, will allow smarter, more efficient spending.
And building in incentives for better patient outcomes, shorter waits and enhanced satisfaction will help realign our primary accountability — to the patients we serve rather than to the institutions where we work.
Dr. Chris Simpson is a professor in the School of Medicine's Division of Cardiology is a past president (2014-15) of the Canadian Medical Association (CMA).
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