Final Report of the Federal Advisor on Wait Times

Chapter 1: Introduction

1.1 Background

In recent years there has been an increasing attention to the state of Canada's health care system. Family doctors are in short supply, wait times for surgical procedures are increasing and emergency rooms are experiencing heavy patient loads resulting in lengthy wait times. We all know someone who has felt the effects of these conditions in some way. Federal, provincial and territorial governments continue to collaborate to find remedies to these problems and by doing so to relieve mounting pressures on health care systems. First Ministers' meetings deal with many issues, but an ongoing concern has been how to sustain the public health care system and implement efficiencies while at the same time providing comprehensive care to all Canadians in a timely manner.

The 2003 First Ministers' (FMM) Accord on Health Care Renewal^[2] and the 2004 FMM 10-Year Action Plan to Strengthen Health Care^[3] reflected Canadians' concern that the health care system needs to respond more quickly to the public's needs. It also reflected the desire of First Ministers and Ministers of Health to increase accountability to Canadians. First Ministers intuitively understood that Canadians needed improved access to quality care.

In a separate but related event, the Supreme Court of Canada, in June 2005, made its decision on the Chaoulli-Zeliotis case, which resulted in the ruling that the Government of Quebec could not prevent the sale of private insurance for health care procedures covered under the provincial public health insurance plan. A majority of judges agreed that some health care wait times are unreasonably long and violate the rights of individual Canadians. Public interest in the wait time issue and the need for government progress for a solution relating to issues of access has increased as a result of this decision. It brought timeliness into the definition of access in a way that was new to the Canadian health care scene.

In 2004, $41.3 billion in additional federal funding was committed for multiple initiatives to improve the Canadian health care system. Of this, $5.5 billion was set aside for wait time-related initiatives. The fund has allowed the provinces and territories increased flexibility to respond to their own wait time priorities and has assisted them in building capacity to measure, monitor and manage wait times across the country. A year and a half later substantial progress has been made on these commitments by federal, provincial and territorial governments.

Health Ministers were also charged with the dual objectives of better management and measurable reductions of wait times in five priority areas (cancer, cardiac, diagnostic imaging, joint replacements and sight restoration). In order to achieve these goals, governments agreed to establish comparable indicators and evidence-based benchmarks for wait times by December 31, 2005 and multi-year targets to permit patients to receive care consistent with established benchmarks by December 31, 2007.

Federal, provincial and territorial Health Ministers announced evidence-based benchmarks on December 12, 2005 for "five types of non-emergency surgery, radiation therapy and cancer screening." These benchmarks were developed from evidence identified in part by the Canadian Institutes of Health Research (CIHR), commissioned by provinces and territories for this purpose. These benchmarks represent a major step forward to achieve the progress that First Ministers intended. The achievement was not however perfect. In general there is scant evidence on which to base benchmarks. In the area of diagnostic imaging, for example, it was not possible to declare benchmarks for CT scans or MRI's definitively. These will require more research before benchmarks can be identified.

Public Awareness about Wait Times

For the majority of the Canadian public the health care system and health care issues represent the number one priority for federal, provincial and territorial governments. Polls have indicated that 49% of Canadians believe current hospital (and clinical) wait times for surgical procedures are unacceptable and that Canadians wait an unreasonably long time for access to health care services.^[4]

In recent years Canadians have expressed concern about the health care system in general. This concern has grown out of a waning confidence in governments' ability to support and sustain the system as well as Canadians having direct experience with wait times for diagnostic tests and surgical procedures that they consider too long. Cancer patients waiting for radiation treatments and individuals suffering from pain or increasing disability due to hip and knee conditions grow understandably frustrated with lengthy waits to receive care. "Consistently, Canadians identify long wait times as the number one barrier in accessing health services."^[5] This barrier has become the focus for the federal, provincial and territorial governments who are working diligently to address these concerns.

The Health Council of Canada in June 2005 shared its view of the perspective of Canadians and the resonance that they felt with the FMM decisions of November 2004:

The Canadian public understands that wait times and wait-list management are complex issues that will require time and national coordination if they are to be addressed. Despite this complexity, the objectives of a national approach to improving wait times are basic and speak to Canadians' core needs and values. Citizens want to feel confident that when they need it, they will get access to health care within a time frame that does not significantly compromise their health or well-being - and they want a system that is fair, providing the sickest people with the fastest access to care without compromising access for those whose needs are less urgent but no less real. These principles of the importance of individual access to care and equity at the system level should guide all decision-making around wait-list management and must trump the interests of providers, administrators and governments.^[6]

Canadian Wait Times Project (CWTP)

Following the commitment of First Ministers to develop evidence-based benchmarks, the federal government made a decision to appoint an independent advisor to aid with the complexities of the ongoing FPT process. I was appointed as the Federal Advisor on Wait Times in July 2005 with a mandate (Appendix A) to undertake activities to ensure "meaningful reductions in wait times" and to "identify and continue to develop consensus on establishing comparable indicators and evidence-based benchmarks". In addition, I was mandated to examine the health care system, address existing knowledge gaps, and encourage the adoption of tools and methods to better manage wait times. These goals were to be achieved through dialogue with provinces, territories and stakeholders, such as health care providers and health system researchers.

An intergovernmental advisor, a communications advisor and an executive assistant, all seconded on a part-time basis from the Winnipeg Regional Health Authority (WRHA), supported the Office of the Federal Wait Times Advisor. In addition, my office was served by a group that came to be known as the Canadian Wait Times Project (CWTP), which consisted of a full time director, two policy analysts and an administrative assistant located at the WRHA and an additional analyst on a part time basis towards the end of the project. Funding for staff, travel and accommodations were provided by Health Canada. The project office operated at arm's-length from Health Canada.

An independent, external Advisory Group was established early in the project to provide direct advice and support throughout the project. The Advisory Group held one face-to-face meeting and three teleconference meetings at various stages. The members of the Advisory Group, individuals and organizations that contributed to this report at various levels throughout the consultation process are listed in Appendix F. I owe a debt of gratitude to each one of these individuals for their expertise and their contribution to my understanding of the wait time issue and the larger issues of transforming the Canadian health care system.

Activities of the Federal Wait Times Advisor

It was apparent at the onset of this task that FPT governments were engaged in work to meet the commitments of the 10-Year Plan. Many advances had been made at all levels of the health care system to reduce wait times, some more visible than others. Political leaders and governments had committed human and financial resources and by doing so had raised public confidence that wait times could and would be reduced. Provinces and territories have since funded Regional Health Authorities (RHAs) to invest in improved capital and technological capacity as well as additional health human resources. Health care professionals are making changes deep within clinical settings and systems to make care more efficient and more timely.

1.2 Overview of Phase I

The commitment of First Ministers to establish evidence-based benchmarks by December 31, 2005 meant that the project naturally evolved into two phases. Activities in Phase I focused primarily on provincial and territorial engagement in order to achieve the benchmarks. Phase I also served as a period to receive initial feedback and support for the concepts of system transformation that in my view are required not only to sustain the effort that began with the first set of benchmarks, but to substantially reduce or eliminate wait times in the longer term.

Our regular meetings were initiated with the Ministers and Deputy Ministers of Health across Canada. Personal visits took place in provincial capitals throughout the fall of 2005 with provincial Deputies and with territorial Deputy Ministers as a group. The goal of these discussions was to ensure that my work was supportive of individual jurisdictions, each with their own challenges associated with wait times, but also so that my mandate could encourage further collaboration.

In addition to the process of consultation with provinces and territories, I was provided many opportunities to present at conferences and meetings to promote a broader understanding of my mandate as Federal Advisor and, more importantly, to receive feedback on key issues facing the health care system and relating to wait times.

Finally many national health agencies and provincial, territorial and federal groups have had strong commitments to improving the health system of Canada. I had the privilege of exploring issues of wait time management with these groups over many opportunities for discussion. A complete list of presentations can be found in Appendices E and F.

Some may note that this discussion about wait times does not address First Nation or aboriginal issues. For the purpose of this report, wait times are a part of acute care services. Acute care (largely the provision of physician and hospital services) falls exclusively within the jurisdiction of provincial governments. Consideration of issues associated with acute care wait times therefore encompasses all acute care patients in provincial delivery systems, including all aboriginal patients.

The primary objective of the Phase I of the Canadian Wait Times Project (July to December 2005) was to assist in finalizing the work begun by the provincial and territorial governments to establish wait time benchmarks in the five priority areas of cancer, cardiac care, diagnostic imaging, joint replacement and sight restoration.

A secondary objective during Phase I was to develop and promote the understanding of common definitions for key wait time terminology such as benchmark, indicator, access target and wait time. To facilitate the use of common, accurate definitions a technical briefing was held prior to the formal announcement of the benchmarks.

The Canadian Institutes of Health Research (CIHR) assisted the provinces and territories by developing evidence to support the declaration of benchmarks. Benchmarks (Table1.1) with the exception of diagnostic imaging, were announced by FPT governments immediately following a technical briefing on December 12, 2005. The announcement not only provided the formal details of the benchmarks declared by the provinces and territories but also established authoritative voices related to wait times management.

Table 1.1: Benchmarks Announced December 12, 2005

Priority Area	Service	Wait Time Benchmark
Cancer	Curative Radiotherapy	within 4 weeks of being ready to treat
Cardiac	Coronary Artery Bypass Graft	Level 1: within 2 weeks Level 2: within 6 weeks Level 3: within 26 weeks
Sight Restoration	Cataract	within 16 weeks for patients who are at high risk
Hips & Knees	Fixation of Hip Fractures	within 48 hrs
	Hip Replacement	within 26 weeks
	Knee Replacement	within 26 weeks
Diagnostic Services	Mammograms	women aged 50-69 every two years
	Cervical Screening	women starting at 18 yrs old, every three years to age 69 after two normal pap smears

1.3 Overview of Phase II

With the declaration of benchmarks, the focus in Phase II of the project turned to the promotion of a more fully developed strategy for transforming the health care systems that would build upon and sustain the efforts that began with benchmarks. This work involved further consultation with provinces and territories, many presentations and discussions. The second round of meetings with the provincial and territorial Deputy Ministers of Health included more specific discussions on the various elements of system transformation and frequently included other provincial and territorial health system officials who were able to bring additional expertise to the table.

Consultants were obtained under contract to undertake qualitative research to inform the content of this report in the areas of management and innovation, professional roles and responsibilities, surge capacity and public education.

In addition, three invitational workshops were held. The first, held in Winnipeg on December 9, 2005, and the second, on March 17, 2006 in Toronto, were useful in fully understanding the complex issues that would be the subject of research on benchmarking and system change discussed in Chapter 2. The third meeting held on March 2, 2006 in Winnipeg addressed issues associated with professional roles and responsibilities. This discussion informed Chapter 5 of this report.

1.4 Conclusion

Canada-wide consultations with provincial and territorial governments, many health care professionals, academics and managers have aided in the completion of this report. I believe that my recommendations reflect the varied perspectives and some of the hard thinking that are necessary to bring about change.

Chapters 2 through 8 will detail the thinking behind the recommendations of this report. It may appear that there is an endless inventory of choices for innovations and change. But in fact, while the choices are indeed many, they are not entirely optional. I believe the six strategies that are presented are interdependent - they go hand in hand to ensure the change that we have begun will continue, wait times will be reduced and Canada's health care systems will perform better and produce better patient outcomes.