From the medical frontlines
A recent experience illustrates, at least to me, some of the issues which exist in the delivery of healthcare in Ontario. There is a good and a bad news story to tell. Following earlier postings (cmaule.wordpress.com), I concluded that Ontario, and I assume other Canadian provinces, have well trained and qualified doctors, nurses and support staff. It has modern equipment and operating theatres, some perhaps requiring further expenditures, such as the recent shortage of MRI equipment which seems to have been solved, at least in the Ottawa area where MRI wait times have been reduced. The treatment of emergency and life threatening cases seems to work well, although hospitals can be dangerous places due to a persistent high level of infections which arise after admission. Don’t hang around longer than you have to.
The statistics which are worrying are the wait times to see specialists, and the wait times for patients to be operated on by specialists. The reasons are complex involving different aspects of the healthcare system which include, amongst others, the constitutional dimensions of the system, the authority and responsibility of the different players, actions taken by patients and the methods of funding healthcare. Royal Commissions have studied these issues, so that what follows is a barebones description of what happens, as seen mainly from a patient’s viewpoint.
A typical path for a patient is fairly straightforward. A visit to a GP is followed by referral to a specialist perhaps with some X-rays, ultrasound and blood and other tests. The tests are conducted quickly but delays frequently occur in getting an appointment with a specialist. There appears to be a shortage of specialists, especially in some areas like urology, endocrinology and gerontology. What is a reasonable wait time? Opinions differ, but I would suggest 12 to 24 weeks for many non life-threatening cases. A year seems too long and an indication that the system is malfunctioning. What are some of the problems? Geoffrey Simpson in Chronic Condition and others have pointed to a number of them.
Operating theatres are not fully utilised and therefore have spare capacity, more than may be needed to handle any possible disasters. There are either not enough doctors, nurses and hospital beds to provide treatment and allow more patients to pass through the hospital system, or the administration of the system is faulty.
The single most important factor for lengthy operating wait-times appears to be the lack of hospitals beds and care for post-operative patients. Why the shortage? The main reason is that hospital wards are full of chronic care patients awaiting transfer to other facilities. The congestion is caused because of the lack of these facilities elsewhere in the system.
A diagnosis of the overall problem of wait times is complicated due to the system established by Canada to deliver healthcare. What follows touches on some of the main factors which seem to me to be important. In some ways Canada has a self-inflicted problem due to past decisions by different levels of government, with advice from interested parties and little input from patients except as tax payers. Other countries have better functioning systems, so it should be possible to see how delivery could be improved.
Who is responsible?
Healthcare is a provincial responsibility according to the Canadian constitution. At the same time provinces have agreed to treat patients from other provinces in certain cases. Thus elements of a nation-wide system are grafted onto one of provincial responsibility. In the case of emergencies, Canadians will receive treatment in any province regardless of their province of residence. In other cases, such as a patients deciding they would prefer to be treated in an out of province facility, that facility can refuse service, provide service and collect funding from the other province, or if this funding is less than that charged in the province of delivery ask the patient to pay the difference.
An example of what happens in practice is that Ottawa hospitals receive patients living across the provincial border in Quebec. Assuming non-emergency situations, the Ottawa hospital can accept patients and receive one or other form of payment or reject the patients, if it is just a case of preferring to be treated in the Ottawa facility. Both things can happen. But if the Quebec patient is treated in Ottawa and patients are treated in the order they arrive, then subsequent Ontario patients will have longer wait times. Service may be delayed to Ontario residents as a result of Quebec not providing certain services within a part of the province.
It could work the other way and at different provincial border locations throughout Canada. For example, a Cornwall, Ontario resident may find desirable healthcare providers in Montreal
This provincial healthcare scheme with certain universal or federal add-ons can have the following results. One province may decide that rather than expanding its own facilities it will depend on those of another province even though it has to pay that province. It may decide that it is cheaper to encourage its patients to travel across a provincial border than to invest in its own facilities. If so, the patients from the province providing the treatment will experience longer wait times. At one time, it was more lucrative for certain hospitals to treat out-of-province patients than Ontario patients. Apparently this is no longer the case but is illustrative of how a province based system with out-of-province features can affect delivery times.
Types of surgery
A more general issue is that there are certain types of surgeries which are routine and repetitive, especially with an ageing population. Hip, knee and other joint replacement, hernia operations, and certain types of eye surgery are fairly standard procedures and could be treated in facilities which cater to the specialties. This happens in the case of the Shouldice Clinic for hernia operations in Ontario. It is a private clinic but is paid for under the Ontario healthcare scheme. Other specialized clinics could be established in order to make better use of resources. At present, too wide a range of different medical procedures are conducted in the operating rooms of general hospitals. If these regular surgical procedures were confined to specialized locations, public or privately owned, then wait-times would be reduced.
Privately operated specialized clinics are seen as creating a two-tier healthcare system. If such clinics are operated efficiently and relieve the pressure on general hospital facilities, then delays of surgeries due to the lack of beds for post-operative care would be reduced.
A related issue is that emergency facilities are used by patients who don’t have emergencies and should be treated in clinics. In part this is because patients are not registered with a GP, although this seems to be changing with the opening of walk-in clinics. Doctors however find that patients who do not get a prescription from one doctor will visit other clinics until they feel satisfied. In 1984, I was part of a commission in Ontario that examined the dispensing fee allowed for prescribed drugs. At that time the government had a record of all drugs prescribed and paid for in Ontario, but would not use the information to reduce the costs of overprescribing within the province. I think this situation prevails today.
An administrative wrinkle which complicates delivery in Ontario is the Ontario Hospital Act which gives certain responsibilities to the CEO of the hospital, but this does not include the services of doctors who are independent contractors reporting to the Chief of Staff not the CEO. In the case of fees charged, surgeon practices or malpractices, these are dealt with by the College of Physicians and Surgeons, a body of doctors regulating other doctors. This is not the case of the fox guarding the hen house, but the fox guarding the other foxes (or hens the hens). Obvious conflicts of interest may arise affecting both patient costs (either private or via taxation) and services provided.
Some forms of healthcare are either not funded by the government or are only funded in part and may be covered by privately purchased insurance, such as dental work, eye care, hearing aids and some prescription drugs. In Canada, it is estimated that about 70% of healthcare costs are covered by the government and 30% by a combination of private insurance and user pay. What the rationale is for public funding of some healthcare procedures and not others, such as eyes, ears and teeth, is a mystery to me. The original rationale for a public system was to address catastrophic illnesses. Over time it has been extended so that general public care is seen as an entitlement for almost all conditions. Once granted, politically it is close to impossible to withdraw.
A visit to a dentist, optometrist and hearing specialist is possible without a long wait. Their facilities are often spacious and well staffed in contrast to many general practitioners. This suggests that these skilled resources are organized, administered and paid for in a manner which allows for timely delivery of the services. In other segments of the system, as suggested, this is not currently the case. Thus my one year wait to see a specialist for a non-life threatening situation. But when age itself is a life threatening condition, then the wait is not appreciated.
Overall my view is that there are administrative shortcomings to the Ontario healthcare system which could be addressed to improve its performance and reduce costs or the rate of cost increase. Some might actually save money. The most important factor may be increasing the number of beds available for post-surgery patients which would require the assignment of other patients to facilities which specialize in their requirements.
I am grateful to David Rothwell who provided detailed remarks on an earlier draft of these comments. I alone am responsible for the above draft. I recognize that the administration of healthcare services is a highly complicated process. Many countries and jurisdictions do it, so that it should be possible to learn from best practices undertaken elsewhere, which may be adopted by Canadian provinces and the federal government. When healthcare and education account for 70% of provincial revenues in Ontario, and probably in other provinces, then we need all the help we can get to achieve cost efficiency, whatever that might mean. If my experience offers any lesson, it is that there must be room for improvement.
Patient Care in Ontario