Timely access to care for all Canadians: The role of the federal government
Providing timely access to care remains a pan-Canadian challenge
Providing patients with timely access to health care remains a pan-Canadian challenge. Regardless of where they live and which level of government is responsible for delivering services to them, patients from across Canada have been facing this challenge for the past two decades. While some progress has been made to reduce lengthy wait times over the past decade, the challenge will only intensify as Canada’s population ages.
The Wait Time Alliance’s (WTA) 2014 annual report card identified some progress on reducing wait times in several provinces, a change in direction from the previous two annual reports. While this is encouraging news, the report card notes that there still remain some key gaps in timely access for Canadians:
- Wait times in Canada still remain significantly higher than in most leading industrialized countries. As the Health Council of Canada recently summarized, Canadians wait longer for primary, specialist, and emergency department care compared to citizens in most of the 11 countries surveyed in 2013. Furthermore, when all of the wait periods in a typical patient’s health care journey are considered together, an even more striking picture of delayed care emerges.
- Canadians’ timely access to necessary medical care depends on where they live. For example, 90% of patients in Newfoundland and Labrador received their hip replacement within six months compared to only 37% of patients in Nova Scotia.
- Wait times can vary significantly among regions within a province and among institutions within large communities. No province is immune from this variation.
The health and economic cost of wait times on Canadian patients and their families
Serious health consequences to long waits include: increased mental anguish; physical pain; greater deterioration in patients’ health; longer recovery time following treatment; and poorer outcomes. Children are particularly harmed by unnecessarily long waits given the impact that waits can have on their proper development. Long waits also contribute to poor health system performance (e.g., people use emergency departments to access care to overcome long waits to see family physician or other specialists). Long waits are also economically costly to patients, families and the country as a whole through lost productivity, lost earned income and lost tax revenues for governments.
There are numerous contributing factors to wait times. They include:
- Inability to keep up with increased demand for services;
- Shortages in health human resources;
- Inadequate operating room time and resources (e.g., nursing support);
- Suboptimum use of available operating room capacity within institutions and little coordination of surgical resources among institutions within a community or region;
- System bottlenecks (e.g., waits for residential placement);
- Inappropriate care (e.g., inappropriate requests for diagnostic tests);
- Lack of access to primary care; and
- Lack of system coordination across the continuum of care.
he lack of system coordination and the lack of appropriate residential and community-based options for seniors can dramatically lengthen wait times for patients such as alternate level-of-care (ALC) patients. ALC patients are those who continue to occupy an acute care hospital bed after the acute phase of their inpatient stay is complete and who are waiting for more suitable placement such as in the home with supports or at a more appropriate residential facility.The majority of ALC patients have dementia and other chronic health conditions. Not only are these patients waiting for a more appropriate placement but their use of acute care beds can block beds for elective care and emergency departments leading to surgical cancelations and delays in the emergency department. Strategies to address wait-time issues across the full continuum of care are of the utmost importance if we are to eliminate the negative system experiences faced too often by ALC patients across the country.
The case for continued federal involvement
Strong national political leadership and high levels of physician engagement are key characteristics of countries with high performing health systems. Over the past decade, the federal government has been instrumental in helping provinces address wait times in a number of different ways including providing funding for wait-time reductions via the 2004 Health Accord, appointing a Federal Advisor on Wait Times, and supporting provinces to initiate a patient wait-time guarantee in each province and territory. As the Senate Committee on Social Affairs, Science and Technology recently noted in its review of the 2004 Health Accord, the collective work on reducing wait times was one area of the Accord in which some substantive progress has been achieved.
At the same time, the Senate report recognized the need for more involvement by the federal government to reduce wait times including supporting a review of existing wait-time benchmarks, expanding new wait-time benchmarks for all areas of specialty care, and working with provincial and territorial governments to develop a pan-Canadian vision statement that will foster a culture of patient-centred care in Canada.
Health care consists of many inter-connected parts and the Senate Committee also made recommendations for federal government involvement in other areas that can affect wait times. For instance, the Committee recommended the federal government take the lead in working with provinces and territories to support a pan-Canadian approach to health human resources research and planning. Equally important, the Committee recommended the federal government work with provinces and territories to develop a pan-Canadian Homecare Strategy, increase access to palliative care and develop and implement a strategy for continuing care in Canada. The WTA recognizes that the fulfillment of these recommendations would contribute greatly to reducing wait times for a wide range of elective and emergency care in Canada. For instance, a more robust home care system across the country could reduce visits to the emergency department as well as support earlier acute care discharges for patients to return to their homes.
The federal government’s role in reducing wait times
To ensure all Canadians have timely access to medically necessary care, the WTA urges the federal government to continue to support efforts to provide timely care to Canadians through three primary roles.
The federal government as leader/facilitator
While provinces and territories are primarily responsible for health care, there is still an important role for the federal government to provide strategic leadership to this pan-Canadian issue. In addition, the federal government needs to ensure timely access to care for those Canadians that fall under federal jurisdiction (e.g., First Nations, Canadian armed forces). To date, we know very little about the degree to which these federal patient populations, significant in size, are able to access care in a timely manner.
As identified, the federal government has previously influenced and shaped the direction of Canada’s efforts to reduce wait times. However, with an increasing aging population and only partial progress thus far, lots more can be accomplished to reduce wait times in Canada.
- standardize wait-time data across Canada for all portions of the total wait experienced by the patient; and
- develop pan-Canadian health system performance measures featuring timely access indicators across the continuum of care that would be applied to all Canadians including those patients who are the responsibility of the federal government.
The need to foster health research by the federal government
The federal government has and continues to play a significant role in funding important research in the area of health care including wait-time related issues. In February 2005, the federal government announced funding for its National Wait Times Initiative (NWTI) designed to support research, knowledge development and dissemination to inform the development of policies, best practices, programs, and services aimed at improving access to care and reducing wait times. This program was responsible for creating and disseminating a considerable amount of valuable knowledge on wait-times (e.g., queuing theory) and the sharing of leading practices across Canada to reduce wait times. Today, there still is a need to develop more robust wait time targets for all of the wait time points from the patient’s perspective (e.g., referrals, diagnostics, home care and long-term care), as well as further developing wait prioritization methods.
The federal government also provides funding to the Canadian Institute for Health Information, the Canadian Institutes for Health Research and the Canadian Foundation for Healthcare Improvement. These organizations have contributed toward enhancing our knowledge on wait times including strategies to monitor and improve timely access to care for Canadians. In addition, the federal government provided funding for a Canada-wide project in 2007-2008 aimed at ensuring more children receive timely access to surgical care. The Canadian Paediatric Surgical Wait Times Project (CPSWT) has led to the tracking of over 850 medical conditions for children and youth at participating hospitals.
We still know very little about the total wait that patients experience to access care. Thus far, most of the attention and research has focused on the wait period from the decision to treat, made by the specialist and the patient, and the start of treatment. But patients wait at other points along their health care system journey such as the wait for a referral to see a specialist. In some cases patients wait longer to access a specialist than for the wait to start treatment.
Recommendation #6: Canadian Institutes of Health Research and Canadian Foundation for Healthcare Improvement Funding
The federal government as knowledge disseminator/collaborator
It is widely recognized that there are many innovative leading practices occurring across the country and internationally. The problem is that in most cases they are small in scale with few people elsewhere in Canada aware of their existence. The federal government can play a key role in supporting dissemination initiatives to spread leading practices across the country that have been demonstrated to improve timely access to care. This could also include the “lessons learned” coming from the different health care systems across the land.
Given that ensuring all Canadians have timely access to necessary medical care is a pan-Canadian issue and given the high economic cost of waiting to families and governments, the federal government should be an active partner/collaborator in working with provinces and territories and other stakeholders to improve timely access with the right care at the right place.
The WTA has shifted its approach from one that is focused solely as a wait-time watchdog to one of a solutions-focused partner. We continue to profile specialty-led innovations in health care access and advocate for more effective, integrated models of care (e.g., ALC prevention programs.) The WTA is also looking forward to collaborating where possible with officials from the Canadian Institute for Health Information (CIHI) and provincial governments in the measurement and collection of wait-time data, with a view to improving health care systems’ access and quality.
The WTA looks forward to working with the federal government and other stakeholders to take Canada to the next level in providing timely access to Canadians. Our aim is to have all Canadians getting timely access to necessary medical care comparable with leading high quality health systems elsewhere in the world. Both political leadership and medical leadership are required to achieve this reachable goal. Canadians should not be forced to settle for anything less.