This column by Armine Yalnizyan was originally published by the Toronto Star on Wednesday February 8, 2023. Armine is a Contributing Columnist to Toronto Star Business featured bi-weekly.
We do it all the time. At the deli, at the airport check-in counter, on the phone: we queue for the first available person to serve us. Why not in health care? In most places, access to health care is rationed like it’s still a cottage industry, one patient waiting for one doctor at a time.
This ‘cottage industry’ accounts for seven per cent of GDP and 13 per cent of all jobs in Canada.
After 60 years of providing care for a population that has doubled in size, waits are getting longer. Nowhere is waiting more punitive than for elective surgeries and treatments that address pain, immobility, impaired vision or cancer. There’s no excuse now for not doing better.
On Tuesday, the federal government announced it will send $196 billion to provinces and territories over the next 10 years to help Canada’s buckling health care systems. Of this, $46 billion is new funding. Roughly $19.3 billion of the new money tops up the Canada Health Transfer, an unconditional flow of funds from federal coffers to provinces and territories. About $25 billion is on the table with mutually agreed to conditions, designed to buy and monitor change over the coming decade.
That $25 billion will trigger a flurry of bilateral agreements with each province, addressing local needs and priorities within a national framework of goals. This builds on an approach to fiscal federalism that echoes the early learning and child care bilateral agreements of 2021-22: new federal funds don’t require shared costs, but they require an action plan and commitment to improve target areas that everyone agrees needs work: primary care, mental health services, supporting health workers, reducing backlogs and modernizing information flows.
A straightforward, relatively inexpensive fix that ticks all these boxes and should be a priority for every premier: centralized wait-lists. This should have been done yesterday. There’s no excuse for not starting tomorrow.
We’ve been talking about how to streamline access to care using queuing theory for more than 20 years. You’ll find a detailed section on centralized wait-lists on pages 138-150 of Roy Romanow’s 2002 report Building On Values: The Future of Healthcare in Canada.
In a clear-eyed review of what happened next, Jonathan Harris, then a health researcher for the Canada’s Drug and Health Technology Agency, reviewed outcomes from Winnipeg, British Columbia, Nova Scotia and Saskatchewan. His findings showed that centralized wait-lists deliver huge results — for example, reducing the number of patients on a surgical wait-list in Saskatchewan by 89% from 2010 to 2015.
More surgeries and shorter waits were possible by using existing facilities more intensively (more evenings and weekends). Staffing drew on more team-based care, encouraging people work to the full scope of their competencies. Surgical and post-surgical results were more clinically consistent, with fewer return visits to emergency.
Despite indisputable improvements, these initiatives never became a system priority. Why? Lack of focus. Reallocation of resources. New administrations with new political missions.
A centralized wait-list pools referrals through a single entry point, triaged for urgency, and links to a booking system. It’s one stop-shopping that requires interoperability between booking systems and systems that track surgeries, on a daily basis.
We’ve got the technology, but few places handle this well across systems and regions within a province, let alone across the country. So far, Quebec is most advanced. Alberta is getting close, but challenges remain managing resources across regions.
According to the Government of Ontario, 206,000 people are waiting for a surgical procedure like a hip replacement or a cataract removal, roughly the same level as before the pandemic. You can check out how long the latest reported wait is for your type of elective surgery on a provincial website, but the data isn’t always up to date, and it won’t tell you where the wait is shortest in Ontario. The province does not offer that kind of choice.
Instead, the Government of Ontario has offered you the option of paying more for faster, private service.
Last year Ontario invested $300 million to deal with surgical wait-lists. Recently, Dr. Bob Bell — a former CEO of the University Health Network — noted the Government of Ontario is now paying 30 per cent more for a cataract surgery in a private for-profit facility than in a hospital, just to convince more private for-profit facilities to step up to the plate.
Now that Ontario expects an infusion of $77 billion new federal dollars over the next 10 years, isn’t it time for our government to focus on identifying and staffing underutilized facilities in hospitals, an extraordinary feature of the past few years, rather than funding for-profit providers? Will it do more to retain doctors and nurses in the public system, instead of paying 30, 40, 50 per cent more for exactly the same staff through for-profit clinics and agencies?
There’s no country, anywhere, where more for-profit care improves public care. Only if the public system is fully funded and functioning optimally can a privately funded system embellish the public cake, like icing, without destroying what it’s supposed to be adorning.
We’ve got the tools to fix these problems, what we’re missing is the political will. Daily updates and pooled wait-lists across regions — perhaps even across provinces — can save money, time, and even lives. Those savings are increasingly difficult to ignore.
Of course wait-list management isn’t all we need. At its best, it simply taps the potential of underutilized capacity in hospitals. We also need to stanch the hemorrhage of doctors and nurses out of publicly-funded care, and need a better spectrum of care to get people into and out of hospital more quickly. And we need more focus on keeping people out of hospital in the first place.
That means more dedicated “factories” of routine day-surgeries, diagnostic services and cancer treatments. It means better rehabilitation and continuing care options for post-ops, settings that don’t rely as heavily on doctors and nurses. It means better primary care through more interdisciplinary teams.
And it means more upstream public investments to keep people healthy, combating housing and food insecurity, and providing more access to mental health resources.
Starting now, we can improve our use of the most expensive element of our single-payer, publicly-insured approach to health care: hospitals. Ironically, done right, it would make us less reliant on hospitals for the full spectrum of our health care needs.
Many will see the dollar signs flashed by the federal government on Tuesday and believe the wait for health care reform is over.