How can Canada reduce the surgical backlog without expanding privatization?

A growing backlog of surgeries during the COVID-19 pandemic has revived debate in Canada about the merits of allowing patients to pay privately for faster access to care.

However, speakers at the first Canadian Physicians for Medicare Summit argued that a parallel private system would relieve pressure on public health care was a myth.

Investments in the public system, including team-based care, centralized waiting lists and better compensation for nurses, will bring more “returns,” says Jasmine Guitt, a family medicine resident in Hamilton and board member of Canadian Doctors for Medicare.

Hospitals across Canada have come forward 600,000 fewer operations during the first 18 months of the pandemic, according to the Canadian Institute for Health Information.

Since then, surgery volumes have recovered, but waiting times have increased for some elective surgeries, such as joint replacements and cataract surgeries. health care systems prioritized procedures that are considered more urgent, including cancer operations and radiation therapy.

At the latest count last year, only 62% of hip and knee replacements and 66% of cataract surgeries took place within the recommended waiting time, compared to 71% and 70%, respectively, before the pandemic.

Proponents of privatization have long argued that patients should be able to pay privately for faster access when the public system is unable to provide care within benchmarks.

In one recent case, a British Columbia teenager waited nearly two years for scoliosis surgical intervention while his condition rapidly deteriorated.

“When you have a deformity like that that’s progressing, it’s just unacceptable,” said Brian Day, orthopedic surgeon in a CBC report, who lost an appeal for the right to pay for private health care in Britain earlier this year.

Speakers at the Canadian Physicians for Medicare Summit acknowledged that the expansion of private health care could reduce waiting time for people who can afford to pay, but it will not improve the overall quality or efficiency of care or relieve pressure on the public system.

Canada need only look south to see the problems inherent in parallel public and private health systems, says David Himmelstein, distinguished professor of public health and health policy at the CUNY School of Public Health in New York.

“It gives the impression that people in the United States are not waiting for help, and that’s clearly not true,” Himmelstein said.

one a recent survey of clinics in 15 cities across the country found that the wait for an initial appointment with a doctor or surgeon could be as long as 45 days in some cities, and nearly half of the clinics refused to accept low-income patients with public insurance. “You had to tell them more about your insurance status before you could even get an answer,” Himmelstein said.

However, it is worth noting that the share of publicly funded health care in the US is increasing, while public sector health care spending in Canada has increased has declined over the past four decades.

In 2021 an overview of international health systemsCanadian researchers found that increased private funding was not associated with improved health and did not reduce rising health care costs. It has also been found to negatively impact the equity, accessibility and quality of care.

In another article published this year in The Lancet Public HealthResearchers at the University of Oxford found that every 1% increase in NHS England’s transfer of health services to the private sector corresponds to an annual increase in treatable mortality of 0.38% in the following year.

“The NHS is now increasingly contracting out its services, especially for diagnostics and surgery, but people also have to pay because the waiting lists are still very long,” said Alison Pollock of the University of Newcastle in the UK.

As the private sector “selects” patients, public hospitals are left to care for older, sicker and more complex patients, Pollack said. “But of course the waiting lists there are really huge and growing.”

Geet said multi-payer systems are also more complex and expensive to administer than single-payer systems. “In the US, for example, 31% of all health care spending is spent on administrative costs, while in Canada the figure is 16.7% for all [health services] but only 1.3% are in favour [services covered under] Medical assistance”.

She quotes Another example is Taiwan high-income countries with comprehensive universal health care systems and low administrative costs. “They have one of the lowest administrative costs less than 2% of total health care spending in the world. So to make our system more efficient, we need more, not less, health care.”

David Urbach and Danielle Martin of Women’s College Hospital in Toronto suggested centralized waiting lists as one possible solution in Comment by CMAJ.

A centralized list would allow health systems to triage all patients waiting for a given operation and connect them to whatever specialist is next available, rather than waiting in separate lanes for the specialist their family doctor recommends.

“We need to move as quickly as possible to single-entry, central fence models,” Urbach said at the summit. “It doesn’t have to be done on a large scale. Even just creating groups of providers in hospitals that share the same intake will go a long way in getting rid of some really long waits.”

According to Urbach, there also needs to be a way to allocate resources so that select operations can continue during systemic shocks like the COVID-19 pandemic.

Because surgeries are mostly performed in hospitals, they are “very vulnerable to health system disasters” that affect hospital capacity, Urbach said. “It would be great if we could find a way to maintain our potential… at least with some degree of independence [from other hospital services].”

However, it is not clear how the government system could do this.

Many provinces are considering the idea of ​​expanding private provision of publicly funded surgeries, but Urbach argued that this approach ends up “diverting human health resources public hospitals.”

“If all our orthopedic surgeons are in these private hospitals doing joint replacements, how can I get an orthopedic surgeon to work in a public hospital and treat hip fractures?”

Now more than ever, Urbach said it’s important to build confidence that public health protection the system can meet the needs of the population.

“That’s what’s driving the provinces to experiment so much with different models of privatizing health care. As long as there’s that uncertainty or concern in the public, the Canadian Health Care Act principles are really vulnerable.”