Final Report of the Federal Advisor on Wait Times

Chapter 8: What the Future Holds

The effort and enthusiasm that is being applied to the management of wait times in Canada is very encouraging. The partnerships that are being created across the country, as wait times focus the energies of health regions, professions, institutions and facilities, are producing important results. New managerial, business and industrial practices are being investigated and applied, results shared and outcomes compared.

In this respect the future is bright. There are many good reasons why system transformation is necessary and many positive outcomes that will result if federal, provincial and territorial governments opt to continue down this road. As I have indicated throughout my discussions across the country the transformation of health care systems around the issue of wait times can have a more generalized effect on the system as a whole. There is substantial potential in this effort so long as the full breadth of patient-focused strategies are pursued.

I will reiterate them here:

1. On-going research is required to identify areas where the development of new benchmarks will be helpful. Operational research is required to ensure that business practices and system re-engineering hit the right mark. Those responsible for our health care systems need to know what the results of our wait time initiatives are, and so do Canadians.
   
   
2. Re-engineering of our management, industrial and business practices is essential. Many options are enumerated in this report and some of these options have already been implemented in systems across Canada. Our systems are complex and our work in this area will need continuous oversight and encouragement.
   
   
3. Information technology solutions must be implemented to improve communication and to ensure the availability of accurate and timely information throughout the continuum of care. Although IT can and will substantially improve the management of wait times, the need of caregivers to have correct and current information from primary health care to tertiary care is an equally important reason to pursue this objective.
   
   
4. Cultural change amongst health care professionals needs to accompany re-engineering of health care systems. Health care professionals play a critical role in leading change within delivery systems. New roles, relationships and responsibilities will require change on the part of physicians and other health professionals.
   
   
5. Surge capacity should be developed on a regional basis to permit provinces to meet their own health care needs and to assist other provinces in periods of unmet need.
   
   
6. Public Education is essential if Canadians are to understand and support the kinds of changes that are required in health care and the sustained effort that will be required to get there. Articulating the vision is essential, as is the careful education that Canadians should reasonably expect about the elements of change. We require the patience of Canadians, their support and attention. Just as Canadians told us about unacceptably long wait times, they will tell us about system transformation and whether or not our efforts are having the desired effect.

In some jurisdictions we have started to move in these directions. Despite having just begun, new issues and challenges are before us. There is no static time in the health care system. Change is a given and these new challenges are likely to emerge before our progress on wait times is completely secure. It is for this reason that apart from the transformative changes I have recommended, other aspects of health systems reform are essential as well.

I believe that preventative activities within public health programs are not optional to improving health systems - indeed many of us believe that earlier investments in comprehensive public health programs might have spared Canadians some of the health conditions that are pervasive now. Similarly, primary health care renewal is key - to ensure early identification of illness and risk factors and to provide the comprehensive care that patients deserve. Management of the prescription drug supply and new methods of financing drugs will be critical to sustaining our health care system. We must move on these fronts as well.

8.1 Patient Wait Times Guarantees

A new federal government has committed itself to the introduction of Patient Wait Times Guarantees. The timing of this commitment prompts me to make a few comments regarding guarantees, despite the fact that this issue was not explicitly included in the work that I was asked to do.

We can benefit from the experience of other countries. Several European countries have experimented throughout the 1990's with a variety of approaches to wait or care guarantees. These experiences can help Canadians understand more fully when wait time guarantees might be helpful, what their effect might be and what is involved with their administration. It is important to note that in European countries wait time or care guarantees were implemented in conjunction with other system reform initiatives.

Wait time guarantees can be defined or described in different ways, so that certain parameters of existing systems are protected or not protected. For example, in the United Kingdom and Sweden, care guarantees have been limited to the public domain, with choice of treatment being offered in another jurisdiction. Many choices are available to governments, depending on what alternatives they consider effective, timely or beneficial. It appears that wait time guarantees typically have the early effect of reducing wait times. This initially happened in Denmark where critical illness guarantees were later abandoned for a "general waiting time guarantee". Denmark's processes recognize that resources are not limitless, so those with the greatest need are given priority for care outside the local health care system.

Essentially wait time guarantees take advantage of capacity that exists elsewhere. In the Canadian system, which is geographically very large, we would ideally take full advantage of our local, provincial, territorial and national capacity before considering out-of-country options for care. The structure(s) of our health care system, its management and culture, all affect system performance and therefore outcomes. The consideration that these structural elements are now receiving, in this report and in policy or public fora, bodes well for the system's future.

I would like to suggest that the decisions taken in Quebec, that permit the province to pay publicly for services provided in the private sector,^[58]are worthy of close attention. The Quebec plan allows for a period of trial, of a guaranteed wait time on a limited basis, with attention paid to the effects that such decisions have on the integrity of the system as a whole.

Although experience with wait time or care guarantees has been varied, wait time guarantees conceptually follow naturally from wait time benchmarks. I believe, however, that the process of identifying wait time guarantees, defining their scope and term, predicting their effect, must be done with care. We need to understand associated risks, benefits and costs of wait time guarantees before taking on more in the short term that we can reasonably support in the long term.

At the same time alternatives for system restructuring and re-design bring with them new or different principles and arrangements that are welcomed by some and alarming to others. The choices that we make in the next few years are important ones.

There are three principles necessary to a discussion of wait time guarantees. All of these principles require the support of provincial and territorial governments.

1. Evidence-based benchmarks are critical to the development of wait time guarantees;
   
   
2. System transformations as described in this report are necessary to underpin guarantees of any kind;
   
   
3. Maximum use of existing capacity and strategic development of new capacity is essential:

• The development of regional networks of excellence can allow for more timely access in and between provinces and territories. The concept of a network of excellence accepts that volumes of work and quality outcomes are closely related. This is especially the case in complex surgeries, when the demographics may offer a low volume of cases. (The capacity to build regional networks of excellence might be examined to some advantage in Canada where regions are created naturally - Atlantic Canada, Quebec, Ontario and Western Canada.) Creating additional regional capacity could result in direct wait list reductions. By redirecting care of low volume/highly complex procedures additional space for further wait list care could be identified. Federal, provincial and territorial governments might wish to test the potential of this alternative by developing a series of regional pilot projects. If we make careful choices, regional networks of excellence would have the additional advantage of building new capacity to serve all Canadians, as and when required.
• Other alternatives for capacity development should be explored through discussion with provinces and territories. In this context the alternative of contracting to private providers might also be considered. This should occur, however, 1) only when the purchase of private services results in greater advantage to the publicly-funded service than what would be achieved by investing the same public funds in the public system and 2) where contractual conditions clearly specify volumes of care, anticipated outcomes and unit cost..
• Use of out-of-province/territory access points, either in other provinces or in the U.S., represents an additional alternative. All provinces and territories have used this mechanism from time to time to accommodate needs that have exceeded capacity. Most of these interventions have been of a short duration permitting more capacity to be developed locally. Out-of-province/territory and out-of-country options are the most expensive way of providing health care services.

The choice of one policy option or another, or the combination of several, will affect the outcomes of our system and its cost. A thorough federal, provincial and territorial discussion will be required.

8.2 Conclusion

The recommendations contained in this report will support effective use of our existing resources and will maximize the possibility that wait time guarantees might be met. If the transformation of health care systems were to be achieved through collaboration and synergy fostered amongst Canada's provincial and territorial health care systems, we could reasonably expect the vast majority of our wait list issues to be managed effectively.

I am hopeful that Federal, Provincial and Territorial Ministers will want to discuss the observations and recommendations of this report, many of which emanate from the experience, experimentation and wisdom of leaders, managers and professionals within their own health care systems. I believe that the implementation of these recommendations will bring about a new era of health care delivery in Canada and that patient experiences and outcomes would benefit significantly. I am also aware that the recommendations imply change that may be unsettling in some quarters or a challenge to manage. The ability of governments to take charge of these changes and bring them to fruition will increase if the efforts of our governments are synchronized and collaborative.