How to shorten hospital wait times in Canada

Long wait times are the vulnerable soft underbelly of our health system. Canadians treasure our single-payer, publicly funded program of physician and hospital care, virtually as a defining part of our national identity. And yet, increasing legal and political pressure over quick access to elective surgeries threatens to undermine that support.

The Commonwealth Fund 2017 report ranked Canada last among 11 countries in timeliness of care. A case currently before the B.C. Supreme Court aims to topple provincial regulations that limit private payment for medically necessary services, claiming that surgical wait times for elective procedures violate the Charter of Rights and Freedoms.

The truth is few people anywhere in the world love their health system. Why?

Health care is expensive. So expensive — at $5,900 per person per year in Canada, US$9,900 in the U.S. and £2,900 in the U.K. — that it costs more than many people are happy to pay, whether through taxation, insurance premiums or out-ofpocket payments.

Many Americans still lack health insurance and even insured Americans may not be approved for every treatment. Among developed countries, Germany has the highest public support for its health system but even there, 40 per cent believe the system requires fundamental changes or a complete rebuild.

Does not mean that Canadians are doomed to long waits for elective surgery forever? There is actually much that can be done fairly easily without resorting to private payment. We can address the supply of surgical procedures, the demand for surgery and improve co-ordination within the system to gain significant improvements.

Increasing the supply of surgery can be achieved by paying hospitals using “activity-based funding” payments for each procedure they do rather than receiving an annual budget in the hope they will meet the demand. Re-imagining the way we use hospitals, incorporating new anesthesia techniques and virtual care to transform common procedures like joint replacement can reduce costs and free up beds to increase the supply of procedures.

The demand for surgery is also elastic. Removing people who are not in dire need from surgical wait lists improves access for those in greater need. It also prevents the overtreatment of healthy people, which is rampant in many areas of medicine. Thirty-two per cent of patients waiting for cataract surgery in B.C. had near-perfect vision is one example.

Ironically, the current case before the court — the most pressing legal challenge to the constitutionality of Canadian medicare — is in part about access to arthroscopic knee surgery, a procedure that might actually cause more harm than benefit in some patient groups.

Wait times may be long on average but they are not long everywhere. Take the example of knee-replacement surgery in Ontario. At first glance, the waits certainly seem long: in 2017, only 78 per cent of people had their knee replacement within the recommended six months and 10 percent waited longer than nine months. In spite of this, half of all people actually had their surgery within three months.

Why is it that some people have surgery quickly and others wait? Mostly, because there is little co-ordination of surgical practices. Long ago, other industries adopted effective queue-management strategies that prevent situations where some people wait much longer than others. “Single-entry” models — where all people enter one queue and take the next available slot once they get to the front of the line — smooth out the waits and increase efficiency in banks, fast-food restaurants and at Disneyland.

Centralized intake, triage and referral of patients to appropriate heath-care providers — taking advantage of inter-disciplinary teams, including nurses and physiotherapists — would go a long way to reducing variation in wait times and improving access to surgery.

Medicare is not perfect but it still provides excellent care to those who become ill and require hospital care. Decisive action to improve wait times is necessary to maintain the public confidence that is required to preserve our health system for future generations.

The good news is that this can be done by fixing Medicare’s problems with surgical precision, without killing the patient in the process.