Final Report of the Federal Advisor on Wait Times

Chapter 6: Additional Issues

Early in the discussion regarding wait times in Canada it became clear that there were several specific issues that required attention and that were not formally a part of my mandate. Each issue has implications for understanding wait times and each issue has significance for health care systems in general. I am addressing these issues as a part of this final report both to recognize the work that others have done on these subjects and also to encourage an FPT discussion such that these elements of analysis can be added to wait times discussions in Canada. These issues are:

• wait times for children
• surge capacity
• health human resources
• gender-based analysis
• Cinderella diseases
• other provincial priorities

A brief discussion of each of these items follows. Where specific work has been undertaken on the subject a report is appended. Various individuals and groups from across the country continue to address these issues. I want to thank them for their contribution to this report.

6.1 Children's wait times

Children's conditions were not identified in the First Ministers' 10-Year Action Plan to Strengthen Health Care. Although it might be argued that the five priority areas identified by First Ministers do not explicitly exclude children and their conditions, it is widely accepted that the five areas address conditions most often associated with adults.

Experience shows that many Canadians will automatically assume that children receive care on a priority basis. While this may reflect our common sense or shared values, the fact is that children's hospitals and children's health care generally do not fare better than adult care with respect to financial resources. Additionally, the advocates for children's care are often parents whose time and attention is spent caring for the child. Addressing wait times for children's clinical and surgical interventions is therefore a moral responsibility - a trust responsibility - that needs to be shared by society at large. This report is an opportunity to ensure that Canadians understand that need.

In the fall of 2005, I discussed with the National Child and Youth Health Coalition (NCYHC) research that they were conducting on access targets for children's surgical procedures. The decision that resulted was that NCYHC would continue to develop access targets for key conditions using evidence available at the time.

Fortunately the work of NCYHC was sufficiently advanced that it was possible to proceed quickly to a broad consultation amongst clinical/surgical directors and managers of children's hospitals and health centres in Canada. Access targets were developed using Ontario's paediatric wait time definitions as a model and as a basis for discussion and consensus. NCYHC's report summary and approximately 350 access targets in nine subspecialties are appended.^[52]

I would like to comment on this subject to increase the possibility that children's wait times will join the mainstream of the wait times discussion in Canada and, because of that, enjoy the same success.

Delays in scheduled care, or long waits for needed care, can present problems for adults and children alike. There is however a significant difference for children in that their growth and development is rapid. For some conditions the opportunity to intervene clinically or surgically is very brief - the window opens and closes quickly. To miss that opportunity is to miss getting the most from the procedure over time. Related to this are of course the social, educational and psychological effects associated with illness, hospitalization and the inability of the child to participate in the real work of growing up. The failure to progress with their cohort can affect a child's life for a long time.

I am hopeful that, having addressed this issue, FPT governments will draw the issue of children's wait times into their ongoing discussions. I commend the work of the NCYHC to your attention and trust that it will provide a good basis for discussion between provincial governments and their children's health centres.

6.2 Surge capacity

The issue of "surge capacity" has arisen frequently throughout the wait time discussions. All provinces plan for basic health care services for their citizens, covering the spectrum from primary health care services to, tertiary services. There are however times during which the local system will experience a surge of need or demand that will outstrip its capacity to manage pressing needs in a timely way. In situations such as these, there is the desire, and arguably a necessity, to establish a mechanism through which additional unused capacity, outside of the local region or outside of the province, can be utilized. Sometimes this surge capacity exists and sometimes it does not.

The need to address surge capacity is not new and it does not result solely from our current concern about wait times. Surge capacity has been an issue in Canada for many years. There have always been times or circumstances in which hospitals, regions or provinces have called on one another for help to address volumes of care or specific types of care.

Our ability to anticipate and quantify planned and unplanned health care needs will have to be developed. My intention here is to help define the terms and to illuminate the potential issues around surge capacity so that further study and/or collaboration with respect to this issue can advance.

The term "surge capacity" did not appear frequently in the health care vocabulary in Canada until the severe acute respiratory syndrome (SARS) event in Toronto, Ontario in 2001. Subsequent to the Report of the National Advisory Committee on SARS and Public Health (2003)^[53] and the formation of the Public Health Agency of Canada (PHAC), the term has become more commonplace, and is largely used to describe the capacity for frontline responses to emergencies, including the assembly of special teams from multiple program areas or jurisdictions. The term has also been used to describe the backup or back filling required for experts and clinicians who work on such activities as laboratory testing, data management and analysis, policy development, and emergency responsiveness and management.

Consider the hypothetical circumstance of a surge and an extraordinary volume of case types requiring access to the health care system. This could include a natural or manmade disaster, such as a storm or refinery explosion, respectively. Less dramatic circumstances might include an extra large number of cases moving through the system as a consequence of an unplanned event, e.g. flu season or multiple traumas during a prolonged period of inclement weather conditions. Surges can also occur when human resources are not adequately available. One of three surgeons retiring in a practice setting could well cause an increase in wait times until a replacement is recruited.

Contrary to unplanned events, surges in activity and demand may be a consequence of planned events, such as the need to increase the supply of services (such as cataract surgery to clear up backlogs of scheduled patients waiting for long periods). The urgency of a planned disturbance in activity level, or the perception of it, may be influenced by a wide variety of factors: clinical, economic and political, to name but a few.

An additional circumstance potentially exists in insufficient volumes of cases in a particular healthcare jurisdiction, prompting the concentration of care for such cases geographically and in juxtaposition to a region with greater capacity and expertise. This volume/quality relationship is well researched, particularly in high-tech and high-intensity services. In short, the more you do, the better you get at it. This stretches the definition and notion of surge capacity. Concentrating volumes of services of any type requires management and processes for the specialized centres, in order for the specialized capacity to be met.

There may be other imaginable surges which could include a "rush" for services brought on by the public, as a consequence of fear or hysteria, such as a surge of people seeking vaccination, or indeed any scenario when individuals in a planned or unplanned fashion place an unusual demand on the system for access. In every case, there are two central challenges:

• dealing with the surge in activity; and
• dealing with its short and long-term impact on the balance of the health care system.

This of course has a direct and measurable impact on provision of scheduled services and hence, waiting times.

Table 1 attempts to categorize surge into two broad categories of unplanned and planned service components.

Table 6.1: Surge Capacity

	Scope	Nature	Scaled Accountability
Unplanned Case Volumes	1.1 Disaster	Natural	Local; Provincial; environmental services; PHAC
		Man-Made	Local; Provincial; environmental services; PHAC; military services
	1.2 Non-Disaster (Converts to 1.1 depends on magnitude/intensity	Infectious	Local and provincial health labs ± Public Health Laboratory (Winnipeg)
		Traumatic	Local; Provincial; multi-provincial
		Toxic	Local; Provincial; multi-provincial; environmental
		Public hysteria	Local, provincial ± PHAC
Planned Case Volumes	Provincial	Case backlogs	Local & Intra-provincial ± multi-provincial
	Multi-provincial (might assume by agreement)	Specialized interprovincial referral centres	Provincial/Multi-Provincial

For the purposes of this report, the following operational definition is offered: Surge capacity is the responsiveness of the health care system to absorb both planned and unplanned requirements of access. Whatever the cause of the surge, the issues and challenges of coping with additional requirements for access have implications for both patients and caregivers, as well as those affected as a consequence of the collateral impact of the surge.

Canadians have experience with organizing health services to address a need where volume is insufficient to warrant a specialized program of care. Western Canada's Child Cardiac Care Consortium was established to gain the advantages of higher volumes and collaborative practice between four western provinces and has been highly successful in terms of both clinical management and clinical outcomes.

Concentrating expertise and capacity such as this requires special and defined service agreements. Capacity to deal with planned activities and high-tech services stresses the system in different ways than does providing capacity for unplanned services, such as trauma. For a specialized referral centre to cope with volume, capacity must be built into the system in advance.

Examples of existing concentrated services in the provinces are contained in the following tables: Intraprovincial (Table 6.2) and interprovincial services (Table 6.3).

Table 6.2: Concentrated Intra-provincial Services*

• Kidney Transplantation
• Trauma Services
• Neuro-vascular and Cardiovascular Interventional Services
• Selected Cancer Services (e.g. Radiotherapy)

*representative, not comprehensive

Table 6.3: Concentrated Inter-provincial Services*

• Heart and Heart/Lung Transplantation
• Paediatric Cardiovascular Surgery
• Bone Marrow Transplantation
• Extracorporeal Membrane Oxygenation for Low Birth Weight Infants
• Hyperbaric oxygenation for anaerobolic sepsis, carbon monoxide poisoning, and diving injuries

*representative, not comprehensive

The criteria that is best applied to the development of concentrated out-of-province services includes a combination of 1) a supply for high-tech or high-intensity services, with 2) some combination of demand for extremely expensive infrastructure and/or 3) highly qualified personnel. The benefit associated with concentration of provincial services is that there can be concentration of infra-structural costs, as well as qualified expertise in personnel, providing the additional benefits of an environment for better training and research. The downside of concentrating services is the impact on patients having to be moved, families separated from them or being required to travel.

Being responsible for service delivery requires provinces, through their health care regions and facilities, to provide access for both scheduled and emergency services. Inter-provincial/territorial agreements are essential when services are shared or concentrated.

In order to concentrate tertiary and quarternary referrals, there needs to be a sound database from which to determine the demand for services. With information derived from such a knowledge base, concentrated services would need to be organized in a fashion so as to achieve balance between the service rate and the arrival rate, or otherwise line-ups form, either at the specialized or the referral sites, or both. Simulation modelling is useful to accomplish the supply and demand match. The fuel for simulation modeling is data available through regional health authorities and the CIHI.

Census and demographic information required for long-term planning comes from Statistics Canada. Linkage of regional data and a variety of health-related survey data and instruments from Statistics Canada offers very active opportunities for new insights on population health and interventions.

Different kinds of surge capacity required across Canada require different approaches:

• For informed thinking and strategies in unplanned surge, we can learn from existing emergency and disaster demand approaches, for better coordination and integration of these services.
• For backlogs, attention must be given to adding interim and additional supply, while paying attention to creating and not altering supply and demand match necessary for steady-state conditions.
• In the case of specialized referral services, planned volume must be rationalized and form the basis of service agreements, with the receiving centres adding sufficient capacity so as not to compromise its regular activities and service volumes.
• For unplanned surges, standby capacity is a theoretical but costly and often impractical consideration. Multipurpose training offers some ability to cope. But, for both these surges and planned increases in activity much more use must be made of plans that incorporate industrial management techniques.

I urge federal, provincial and territorial governments to consider the potential of arrangements planned to address issues of surge capacity. There will be times and circumstances for which need and demand cannot be safely accommodated in a timely way and close to home at the same time. Our provincial and territorial health care services have developed different bodies of experience and expertise to address the needs of different populations with different health issues. This diverse capacity can be captured for the benefit of all Canadians.

Canadians would be well served by further investigation of this potential as a means to address planned or unplanned volumes of needs. All regions of Canada continue to experience shifts in need and capacity that are not yet managed. The ability for provinces and territories to look across the landscape of unmet need and to collaborate proactively will create a network of health systems that is more fail-safe. The "natural" regions of Canada (West, Atlantic, Quebec and Ontario) would be wise to collaborate to study their needs for clinical and/or surgical capacity and develop innovations to address as yet unmet need. The federal government could support this effort by investing in provincial efforts to define needs and the surge capacity that is required to address them. This initiative would lend itself easily to four regional pilot projects. There is of course a need for collaboration amongst the provinces and territories in one region but it would benefit Canadians as well if these four regions could take collaboration to the next level and plan for inter-regional synergy. While Canada's Constitution provides for provinces to manage health care delivery systems within their own boundaries, it does not prevent them from together creating complementary capacities.

6.3 Health human resources

It is often said that people are the greatest asset of the Canadian health care system. The "people" in this case is an enormous volume of professionals, paraprofessionals, managers and policy makers who work in diverse environments and in complex systems. However regular reports show that the public and professionals are concerned about the sustainability of the health care workforce in Canada. Shortages of anaesthesiologists, family doctors, psychiatrists, nurses and other health care professionals cause concern for the public alongside sometimes significant delays in treatment.

Like other issues addressed in this chapter of my final report, health human resources (HHR) is not one of the issues that I was specifically mandated to address. The issues of HHR are significant. They relate to wait times and more. The scope of HHR management includes changes in the way health professions are perceived, the ability to recruit, new educational challenges, distribution, distribution according to need, safety at the worksite and of course volume - the numbers of health care providers on the ground and their availability to work when we need them. The list is long.

It is important that health departments, health regions and the public are aware of the initiatives that are being undertaken across the country to address some of the issues of health human resources. Officials in Health Canada who are assigned to this task and who work with provinces to accomplish their mandate have prepared a report to describe current national collaborative initiatives. The report on the Pan-Canadian Health Human Resource Strategy can be found appended to this report.^[54]

6.4 Gender-based analysis

In health care, as in many other fields of social importance, our efforts to progress and do good work sometimes foreshorten the planning period. We find out in due course that the plans that we made and the solutions that we contrived have overlooked important considerations, the understanding of which would have made for a better plan, a better program or service.

This argument applies well to the policy tool of gender-based analysis (GBA). For a very long time we planned programs and developed care plans with no consideration of the difference between men and women, boys and girls. It is only really over the last couple of decades that consideration has been give to these issues and that our planning, evaluation and care processes have been urged to look at and understand these differences and their implications for health care systems and patient care.

The relevance of gender-based analysis is as important to the issues of wait times as it is to other issues of health care. Failure to understand differential outcomes on population groups is a failure to do the work well.

Gender-based analysis is more than counting the number of women and men, boys or girls that have received service to make sure that the number is about the same. It is about getting under the numbers, before and after programs are planned and implemented, to understand the effect, both of sex and social conditions that make unanalysed programs and unanalysed care sometimes miss the mark. GBA is an area of work that helps us to ensure that appropriate care of high quality is available to all men and women, boys and girls.

The processes to develop benchmarks, access targets and indicators related to wait times have been concerned primarily with the issues of how to increase the efficiency and effectiveness of the health care system to meet these goals. What has not been addressed in these discussions and research activities is the differential effect that disease, or indeed waiting for care, has on men and women.

In order to include this discussion in the final report, a partnership was struck with the Women and Health Care Reform Group who have agreed to allow their full report on the different impacts of wait times experienced by each gender to be appended. I hope that in this way Canadians can have a better understanding of gender-based analysis in a broad sense and how it can change the way in which issues in the health care system are examined. You will find the report of the Women and Health Care Reform Group in the appended reports.^[55]

6.5 Cinderella diseases

The term "Cinderella disease" has emerged in Canada around the issue of wait times. The term is an intuitive one and applies to the diseases that were not recognized, or "priorized" in the five selected areas of concern for which benchmarks were to be developed. "Cinderella diseases" are the ones that did not get invited to the ball. Unlike the "big five" -(joint replacement, cardiac, cancer, sight restoration and diagnostic imaging) these conditions and diseases, though important, have not made it into the first "cut". The fear is, and the danger is, that the five conditions that figured prominently in FMM agreements will starve out all others for attention, resources and technology, leaving Cinderella diseases behind, in the shadows, at least temporarily if not permanently. This concern has been raised both by the public and by health care professionals in an Ipsos Reid poll undertaken in fall of 2005 and which states that "2 in 3 (Canadians) are concerned that meeting the wait time benchmarks in the five priority areas will come at the expense of other health care services."^[56]

I need to caution that in the daily business of health care a possibility always exists that either a real need is present or there is the perception of a need. Often there are claims, some correct, that insufficient attention is being paid to one condition or another, or that a particular condition could be treated more effectively if only another service, drug or facility were available. This is the reality that has caused health care systems in provinces to look to evidence to identify what the priorities are or should be, what interventions are actually effective and which are not, and what organized programs for a small population or for a large population can achieve the most benefit to individuals and society. We look to evidence to help clinicians and managers to make defendable decisions.

However the concern regarding "Cinderella diseases" is well taken. It is not appropriate for our health care systems to be so focused on limited areas that we neglect others. While it is important to dedicate resources to shorten wait times for procedures and interventions that are currently experiencing worrisome waits, it is also important to ensure that other diseases and conditions do not become the next areas to see wait times increase. Care must be taken to transform the system so that the efficiencies are experienced across our health care systems and not just within the five areas in which benchmarks have been set. Success for one area should not come at the expense of another.

The ongoing operational research (discussed in Chapter 2) that is being undertaken by CIHR would study the effect that benchmarks in specific areas have on other areas of the system. This research information can be used to influence and inform benchmarking and research processes.

6.6 Other provincial and territorial priorities

Canadians also need to be aware that the issue of wait times is important to different provinces and territories in different ways. Provinces, territories, regional health authorities and facilities are learning from one another about better business practices, improved use of technology and information systems. That learning will set new standards for efficiencies, appropriate wait times and satisfactory outcomes.

But apart from the forward-thinking work that provinces and territories are doing with respect to wait times, each province and territory has a unique set of program priorities that may not be affected by the wait time work at all. Many of these priorities will be identified annually in the provincial/territorial Speech from the Throne and then funded in provincial and territorial budgets. They range from intervention programs (crystal meth intervention might be a good example) to programs designed to address chronic conditions at various stages of their progress (diabetes would be a good example of a long term initiative). Provinces and territories in their own health care systems need to strike the right balance between the issues that draw public attention nationally and the issues that occupy the hearts and minds of citizens within the cities and towns of the provinces. The work performed by health care decision-makers presents unique challenges.

6.7 Conclusion

Although not expressly identified in my mandate, I am hopeful that these comments regarding additional issues will bring clarity or understanding to several issues that will remain with us as we forge ahead to address wait times in Canada.

Chapter 6: Additional Issues Recommendations

15. That provincial and territorial governments give consideration to the access targets developed by the National Youth and Child Health Coalition and consult as required with clinical leaders in children's health care, in order to consider their implementation. Further, that the conditions affecting children be included alongside adult-related conditions at the outset of future benchmarking processes to ensure that children receive equitable attention to their time-sensitive needs;

16. That FPT governments mandate an expert group to investigate the need and potential for surge capacity through the development of regional centres of excellence; and

17. That ongoing research related to wait times adopts a broad approach to gender-based analysis in order to ensure that the issues of gender are considered thoroughly.