Final Report of the Federal Advisor on Wait Times

Executive Summary

Recently there has been increasing attention paid to elements of performance in Canada's health care systems from the perspectives of sustainability, efficiency and timeliness. Wait times for some surgical and medical procedures have increased and emergency rooms are seen to be experiencing heavy patient loads with long wait times. New technologies and new drugs bring with them higher expectations and higher costs.

Federal, provincial and territorial governments are engaged continuously in the challenging task of finding solutions to these problems. First Ministers' Meetings (FMM) have devoted particular attention to health system challenges that are intrinsic in the national objective to provide comprehensive care that is accessible to all Canadians.

The issue of wait times has been increasingly a high priority for Canadians and therefore prominent in media reports. Following the 2004 First Ministers' meeting, a $5.5 billion fund was established to assist provincial and territorial efforts to reduce wait times. In December 2005, ten wait time benchmarks were established in five priority areas: cancer, cardiac, diagnostic imaging, joint replacement and sight restoration.

However important the issue of wait times might be, dealing with wait times in isolation from health care systems will have limited benefit. Wait times are a symptom of a larger problem. In order to create a more efficient and effective health care system, Canadians need to support a transformation that puts patients at the centre of the system. There are several elements that require attention in this transformation, all necessary but not individually sufficient to create change. I am recommending that this transformation be advanced by immediate action in the following areas:

• ongoing research to support benchmarking and operational improvements;
• adoption of modern management practices and innovations in health systems;
• accelerated implementation of information technology (IT) solutions;
• cultural change amongst health professions;
• development of regional surge capacity; and
• public education to support system transformation.

It is my view that by addressing these key areas, patients will be better served, wait times will be reduced and health care systems will become increasingly responsive to the needs of the patient.

Each of these areas is addressed in this final report. I have attempted to provide sufficient background and/or explanation for each of these elements of transformation. It has not been possible to include all of the ideas and arguments for change, nor descriptions of all the innovations that are underway on a large or small scale. In every provincial jurisdiction there are clinicians and managers who are experimenting with innovative ideas and efficiency-seeking practices, whose work is challenging existing practices. We need to harness the initiative and talent that exists in our midst and encourage its further development.

I have identified six areas for recommendations:

Benchmarks, Indicators and Ongoing Research

The 2004 First Ministers' 10-Year Plan to Strengthen Health Care^[1] committed provinces and territories to the process of establishing wait time benchmarks for the five priority areas noted above. Evidence-based benchmarks were announced on December 12, 2005, and the provinces and territories are now in the process of implementing changes to achieve these benchmarks by December 2007. First Ministers also committed to establish comparable indicators of access to health care professionals, diagnostic procedures and medical treatments. Provincial and territorial governments have indicated that, as of March 30, 2006 comparable indicators to measure progress against the benchmarks have been developed and approved. Continued research is essential. Our efforts to date make the best use of available evidence but, as work progresses, we will need more comprehensive knowledge and more conclusive evidence.

I recommend:

1. That the Canadian Institutes of Health Research (CIHR) undertake research to:

• evaluate the effect of the benchmarks established through the FPT process;
• broaden the scope of benchmark research to include costing and appropriateness criteria; and
• identify areas in which additional benchmarking is required or desirable to improve patient outcomes.

2. That multidisciplinary, collaborative panels (including researchers, clinicians and government representatives) be established to review evidence and recommend additional benchmarks to FPT governments.

3. That CIHR develop additional capacity through existing health policy institutions across Canada to enable them to study best business and industrial practices to support wait time reductions.

Management and Innovation

There are many practices that can be adapted from the experiences of business and industry to increase the efficiency and effectiveness of Canada's health care system. In many respects our health care systems have fallen behind other human service sectors in adopting modern management practices and the innovations that guarantee that services are provided at a high level of quality, consistency and timeliness. Our system can adapt high standards of performance from wherever they exist, using leaders to influence change and training programs to bring the workforce up to new performance standards.

I recommend:

4. A national network of wait time champions (one per province) be established to lead the development and promulgation of best practices throughout provincial health are systems;

5. As an extension of the foregoing recommendation, that provincial capacity for wait time coordination/navigation in health regions and major institutions be established;

6. That the Canadian Health Services Research Foundation implement a continuing, multidisciplinary educational program for health care professionals, for the purpose of developing wait list management leadership and skills and for a period of time that equips existing health care professionals to adopt best practices; and

7. That provinces and territories adopt best practices for wait times including:

• the use of single common waiting lists;
• an approach that permits patients to be referred to a speciality service that prioritizes the patient by acuity and offers the first available slot for intervention;
• the use of queuing theories to alter current processes;
• innovative case management;
• team based care;
• appropriateness; and
• pre-habilitation programs to ensure fitness for surgery.

Information Technology (IT)

The rapid acceleration of efforts to develop information management and technology will play an important role in supporting innovation. Its most important aspect of this role will be to ensure that the right information is in the right hands at the right time. Information technology (IT) initiatives are costly to implement, but the resulting efficiencies and rebuilding of public confidence will mitigate the expense. Many features of IT require development, including:

• a system-wide electronic health record for all Canadians that will ensure that each physician, specialist, nurse or other appropriate health care professional has current and accurate information on which to base a diagnosis or treatment decision;
• electronic patient registries that will allow a fluent flow of patients through the system;
• digitalization of diagnostic images that provides the opportunity for faster access to images and elimination of duplicated diagnostic testing, resulting in faster diagnosis; and
• tele-health to provide increased access to patients who may be in remote areas or have mobility challenges, as well as providing new opportunities for professionals to provide team-based care.

Each of these technological advances increase the accuracy of and access to information for patients and professionals alike. Patients can expect to receive better care in a more timely manner as a result.

I recommend:

8. That the federal, provincial and territorial governments accelerate the pace of pan-Canadian health information technology through Canada Health Infoway;

9. That Canada Health Infoway:

• Develop wait time tools as proposed;
• Continue the development of the Electronic Health Record with a plan and timeline supported by FPT governments; and

10. That the development of IT health information systems in Canada be accompanied by public education to assure Canadians that privacy of information is secured.

Professional Roles and Responsibilities

The issue of wait times is a systemic problem that requires a systemic solution. Specific measures will be required to advance solutions. Physicians have played a large and important role in defining needs and solutions for wait list management in our systems. The continuous role of physicians is essential for any changes in how we manage wait list issues. In ensuring their involvement, a cultural shift is needed from individual contributions to system involvement and problem solving.

Physicians represent only one group of professionals involved in patient care. Other groups play important roles in the continuum of modern health care. These professionals organize and deliver care across facilities, in and out of acute care, in the home, in private offices and in community settings. The roles that physicians play as "gatekeepers" of the system, as leaders and independent professionals mean that they are key to system change. We need their support and involvement but also their commitment to full participation. Their ability to adopt the measures of change and the culture of change will serve as an important guide for other health care professions.

I recommend:

11. That FPT governments develop a broad base for receiving advice from medical communities with respect to change in the health system and long term planning. The Canadian Medical Forum can be asked to assume this role nationally, with provinces and territories developing similar capacities locally to achieve balanced influence when medical input is deemed important;

12. That provincial Colleges of Physicians and Surgeons establish professional and ethical standards and the means to monitor professional practice with respect to physician management of wait times in provincial health care systems. The Federation of Regulatory Authorities of Canada should coordinate this effort;

13. That faculties of medicine of Canadian universities develop curricula that support changing health care systems and changing expectations regarding the competencies that physicians will require to participate in these systems led by The Association of Medical Faculties of Canada; and

14. That FPT work on health human resources initiatives focus on re-defining professional clinical roles to enable health care professionals to work at their full potential and to offer innovations in health care, which are economical and sustainable.

Additional Issues

Several issues emerged early in my consultations that were not included in my mandate as Federal Advisor on Wait times but were sufficiently important that I want to comment on each. These issues are: wait time benchmarks for children, surge capacity, health human resources, "Cinderella" diseases and gender-based analysis.

Benchmarks specifically directed to interventions for children were not included in the decisions of the First Ministers in 2004. Yet the timing of interventions may be particularly critical for children for two reasons. First, there may exist in the normal development of a child a limited window of opportunity in which an intervention can have the most beneficial effect. Second, the delay of an intervention can cause normal growth and development to be impeded. We need to ensure that wait times for children are given due consideration.

Surge capacity is additional care capacity that is available when and if required. We are most familiar with the idea of surge capacity in the context of public health, such as in the circumstance of epidemics or pandemics. Severe Acute Respiratory Syndrome (SARS) gave health care systems reason to consider the need for planned capacity to be used in times of system stress. Surge capacity is discussed in this report to encourage collaboration on the need for specific regional and national capacities to address wait times and to enable systems to accommodate stress or overload within Canada's borders.

The issue of health human resources (HHR) has been high profile both before and during the discussion of wait times. Shortages of family physicians, anaesthesiologists, nurses or other specialists and health care professionals have added to the stresses and pressures on the health care system. Shortages can add to the problem of wait times and prevent the implementation of solutions. All levels of government are working together on a pan-Canadian strategy to recruit and retain additional health care professionals. At the same time there is an effort underway to work toward innovative use of health human resources by maximizing the use of skills that various health professionals have acquired and by promoting team-based care.

There has been substantial progress over the last few years in understanding the effect of gender in the analysis of health conditions and solutions. Gender-based analysis (GBA) provides a different set of questions about decision making and policies in the practice of health care. GBA could study how men and women are differentially affected by waiting for care and could also be applied to additional questions that are associated with the choice of conditions, the effect of benchmarking and the outcomes of benchmarked care compared to care that is delayed further. GBA recognizes that there are significant differences in access and use of health services that are affected by gender and takes this into consideration when providing advice to policy-makers.

I recommend:

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.

Public Education

The growing perception that long wait times are pervasive and that little can or is being done to improve them is eroding Canadians' confidence in the system's future. As we move forward with efforts to address wait times and implement system transformation initiatives, the Canadian public must not only understand why change is necessary but be fully informed of changes as they occur.

I recommend:

18. That the public be continually informed and updated of changes taking place in the Canadian health care system;

19. That a three-year public education campaign on wait times be initiated as a collaborative effort between federal, provincial and territorial governments; and

20. That a comprehensive, multi-dimensional public education effort with the capacity to leverage support from other partnering organizations be undertaken.

There are, of course, always financial implications associated with recommendations. Throughout the course of this work, various individuals and organizations were asked to estimate the costs of undertaking the research and initiatives that are the subject of these recommendations. These estimates are included in chart form in Appendix C. They represent notional estimates and have not been subjected to thorough analysis or examination. These estimates should not be regarded as final. The ultimate cost of programs and services is normally affected by negotiation, pre-existing agreements and the capacity of partners to produce intended results.

Additional considerations

It may appear to some that there are obvious omissions in this report. I want to address two of them here so that you can be assured that, while these issues were not formally included in my mandate, they were nonetheless within the scope of my concern.

First is the issue of prevention. Promotion of good health and prevention of disease and disability are crucial to the health of Canadians. Despite having a national infrastructure for public health for many years and despite the efforts of many in this field, it is only in the last decade or so that public health has taken its rightful place as a priority for governments and in the minds of Canadian citizens. Promotion of good health and prevention of disease and disability has an obvious relationship to wait times. Demands on health care systems that could have been prevented make poor use of resources available in the acute care sector. Efforts to limit these demands are important; the responsibility to exercise what control we have over preventable conditions falls both to public health programs and to individuals, institutions and families within our communities. I urge governments to be mindful of this and to ensure that public health and prevention efforts are resourced to do the job that we require of them.

The wait times for First Nations citizens, and for aboriginal people generally, are not addressed in this report. Acute care services are the responsibility of provincial governments. First Nations and all aboriginal people receive acute care services under provincial and territorial jurisdiction. These patients are therefore moved through wait lists, schedules, diagnostic services or hospitalization in the same queues with all other Canadians. That is not to say that there are not particular issues of distance or timing that affect care, only that there is no separate acute care track that is particular to aboriginal patients. It is my understanding that the issue of waits is being explored by Health Canada's First Nations and Inuit Health Branch. I do, however, want to lend my support to the future investigation of wait times for First Nation and aboriginal patients. It has been my experience that issues of access to care for aboriginals are especially complex. It would serve us well if this could be addressed fully.

I want to bring to your attention at the onset, an issue of terminology that you will undoubtedly note within my report. I refer frequently to "health care systems" when I am describing the health care delivery organizations within provinces and territories. I call these "systems" because they are managed independently by provincial and territorial governments, consistent with their jurisdictional right and responsibility. There are some aspects of these systems that are sufficiently similar or interconnected that we can, on occasion, think of our health care system as national in its character and function. Examples of these might be the administrative agreement for reciprocal billing between provinces or the reliance that one province or territory can have on another when assistance is required. Generally the language of the report indicates that while our health care systems are interconnected in some respects and share professional standards and program models, our work to build national consistency and equity, and to collaborate such that we make best use of limited resources, is not yet done.

Conclusion

Although Canada does not have one integrated health care system, provincial and territorial systems have evolved with remarkable affinity. Sooner or later each province and territory faces the same set of challenges and works to find solutions that are more alike, one to the other, than they are different. In the next stage of developing our health care systems, we will require leadership in clinical care, innovation amongst managers and professionals, and the kind of culture that embraces change, improvement and efficiency. Without these characteristics embedded in our health care systems patients will continue to experience long waits for necessary care and health care professionals will find themselves frustrated by bottlenecks and inefficiencies. Without thorough engagement of the public we will struggle forward without their confidence and encouragement.

Our new federal government is looking to a Patient Wait Times Guarantee to raise the accountability bar for our health care systems. This is a commitment that will surely require careful analysis of implementation options and a thorough dialogue between federal, provincial and territorial governments. I believe that my recommendations are very relevant to this dialogue. In order to achieve the level of performance that a Patient Wait Times Guarantee implies, we will need to take all steps necessary to maximize the system's efficiency and effectiveness.

As a result of my consultations, it has become clear to me that the decision-making that is undertaken between levels of governments is sometimes overburdened. The complexities are such that agendas are full, and officials challenged to do their own work and the work of collaborating as well. It appears that the role of advisor, in this case for wait times, has been a useful role. Arm's length, the role has had sufficient autonomy and sufficient time to encourage discussion and develop ideas. As similar issues arise it may be that a similar model will be useful again.