This article was originally published in Maclean's Magazine on October 17, 2005
Ottawa Fudging Hospital Wait-time guidelines
TO HEAR federal Health Minister Ujjal Dosanjh tell it in the House last week, the task of setting firm guidelines for how long Canadians should wait for surgeries and diagnostic scans sounded right on track. Last fall, the Prime Minister and the premiers signed a deal promising to set those targets in five areas - cardiac and cancer surgery, eye operations and joint replacements, along with scans like MRIs - by Dec. 31, 2005. "That deadline is to establish benchmarks," Dosanjh said when pressed in Question Period on the wait-times issue. "No government has the option not to do it." But what exactly did he mean by it? Anyone who assumes he meant final national standards for the important procedures on that so-called Big Five list might be in for a disappointment. The top federal official on the file suggests the benchmarking work is only beginning, not nearing a conclusion. "I think what's really coming at the end of December," Dr. Brian Postl, Paul Martin's wait-times czar, told Maclean's, "is a starting point for benchmarks."
Postl was appointed by Martin only in July to spearhead Ottawa's talks with the provinces on wait times. The problem, he said, is that the scientific evidence needed to back up benchmarks often doesn't exist. According to last fall's deal, they must be "evidence-based" - not just goals politicians deem acceptable or targets that grow out of a loose consensus among doctors. Postl notes that some firm benchmarks are possible, likely including goals for how quickly to perform heart surgery, an area that has been studied in detail. But for many other treatments, medical opinion remains mixed. How quickly does a baby boomer with a chronic bum knee need to get an MRI? At what point in the gradual deterioration of eyesight must a cataract be lasered away?
Those are valid points of debate among experts and interested patients. But in the political arena, such fine details might be lost. Martin and the premiers boasted they had accomplished something historic when they signed the September 2004 accord. The 10-year, $41-billion plan to fulfill Martin's grand pledge to fix health care for a generation was touted as different from previous big cash deals because this time the provinces had agreed to carved-in-stone dates for action. And the year-end deadline for setting "evidence-based benchmarks for medically acceptable wait times" is the first. Failure to make good could be a political disaster. Dosanjh stops short of admitting that might happen, but in an interview he dialed down expectations. "There may be a pan-Canadian consensus and the ability to have at least some benchmarks in all of the five priority areas," he said. "This deadline is about making sure we make our best efforts."
So more than a year after the first ministers signed their pact, bracing talk of deadlines and details is giving way to more muted musings about best efforts and starting points. Critics say Ottawa made a fundamental mistake by not holding back new money from the provinces until they accomplished what was promised. Instead, $5.1 billion in new federal funding earmarked to help cut waiting lists will flow no matter what the provinces do. Dosanjh defends Martin's decision not to make cash contingent on action. "This is not like an ordinary contract with penalties and processes to determine who gets what at what time," he said. "The first ministers entered into an extraordinary contract which is based on trust and a common belief that we all want to travel in the same direction."
The country's top lobbyist for physicians isn't buying it. Dr. Ruth Collins-Nakai, president of the CANADIAN MEDICAL ASSOCIATION, says the premiers are grabbing the cash and shifting their attention to other priorities, notably their recent emphasis on schools and skills. "There's no question that the provinces feel they've depleted the bank account at the federal ATM of health, and they are now at the ATM of education," she said.
Remarkably, many federal and provincial officials say their wait-times strategy was not changed much by last June's landmark Supreme Court of Canada decision, which seemed to open the door to more private care. The court found that as long as waits for publicly insured services are unacceptably long, Quebec was violating its provincial charter of rights by denying patients the option of buying private health insurance. It gave the provincial government 12 months to make reforms in line with the ruling. In a recent speech, Quebec Health Minister Philippe Couillard said he's open to a European-style system with parallel public and private systems. "Are the French, British and Scandinavians backward?" Couillard asked. "If it's between the European and the U.S. model, I'd rather go toward the western European model."
But policy-makers outside Quebec aren't talking like that. Postl said the court's decision reflected "the view of Canadians that wait times are too long," and the solution is to boost spending and better manage the public system, not to allow a private one that he argues wouldn't cut waits anyway. And there are signs of progress in public care. Dr. Alan Hudson, the neurosurgeon heading Ontario's wait times strategy, was handed $240 million by the province to cut waits. His no-nonsense approach: offer hospitals cash for boosting the number of priority procedures they performed, for instance, $750 for each cataract removal over what they were already doing. He says the cash has bought the province 17 per cent more cardiac procedures, 28 per cent more hip and knee surgeries,16 per cent more cataract operations, and 42 per cent more CT and MRI scans. "It's amazing what you can do with a bag of money," Hudson says.
And huge sums are being poured into health care across the country. The discouraging thing is that sometimes even a lot doesn't seem nearly enough. "Particularly on the orthopaedic side, we're facing a demand curve that is huge," said B.C. Health Minister George Abbott. "We're only holding the wait times stable on hips and knees - we're not improving them, even though the number of procedures is going up dramatically." The solutions might come through long-term change in the way doctors work. In Winnipeg, Dr. Eric Bohm, an orthopaedic surgeon, is doing six joint replacements a day, about double what's normal, by shuttling between two state-of-the-art operating rooms instead of working in one. An assistant gets his patients ready, time-consuming work surgeons are usually involved in. "When I'm finished in the first room," Bohm says, "I can walk into the second room, everything's ready to roll, and I pick up the knife."
But such innovative new ways of working will take many years to change the system. In the meantime, with pressure from an aging population and increasing demand for care, no wonder politicians are reluctant to get locked into benchmarks they might well have a hard time meeting. But benchmarks are what they promised. From now until Dec. 31, the scramble is on to see what they can deliver.
See also HEALTH POLICY.
Maclean's October 17, 2005