Councillor Q&A: Weighing the work on wait times.
Dr. Les Vertesi has over 25 years clinical experience and 12 years experience as department head in a busy trauma referral emergency department. He earned a Masters Degree in Clinical Epidemiology at UBC in 1989, with special emphasis on computer modelling in management. Besides his clinical duties, he has made notable contributions in emergency medicine and standards, healthy policy and emergency systems design. Dr. Vertesi is one of the Health Council’s experts on wait times, so we asked him about the progress that is – or is not – being made on that front.
1. In November 2005, the Health Council of Canada published a background paper, 10 Steps to a Common Framework for Reporting on Wait Times.
Tell us about the main points of that piece, and in your view what aspects of that advice have been picked up by the provinces and territories?
The 10 Steps paper lists the basic points that require a common agreement before anyone can begin to make sense out of reports. Some things are obvious, like a clear definition of when waiting starts and ends. The Health Council of Canada believes (and so do the Canadian Institute of Health Information and others) that waiting should begin with the initial referral from the general practitioner to a specialist. Most jurisdictions do not even track that part of the wait time, yet it forms a major part of the frustration that Canadians experience. Some jurisdictions start the clock when the first consultation occurs, some when the booking is made, and some wait until later, when the hospital finally acknowledges the booking.
Other points in 10 Steps are less obvious but just as important. For example, some jurisdictions include emergency surgeries in their averages and some do not. Emergency cases have to meet a much shorter time standard, so lumping them all together artificially brings the average down to what might seem like a respectable wait time. The Council believes that emergency procedures should be excluded from the reported times, so the numbers more accurately reflect the real issues of waiting.
There are eight other points, some of which are more technical. Some have been incorporated into the reports by some jurisdictions, but not by all. This means we cannot be sure jurisdictions’ reports are measuring and comparing the same things, and until that assurance can be made, the Council does not feel the reports can be as meaningful as they could be.
2. There has been a lot of talk between the federal, provincial and territorial governments on a wait-times guarantee. Setting aside the merits or problems with implementing a guarantee, has enough progress been made in cutting wait times to implement a guarantee?
It must be understood that invoking a guarantee has a much higher cost than meeting the standard in the usual way. For example those costs have to include travel and additional staff time, not to mention the disruption of extra waiting and another assessment by a different surgeon far away from the patient’s home and family. This is why a guarantee must be something that is only rarely used, otherwise the cost would far exceed what it would cost if the wait-time benchmarks were met the proper way. It is a question not just of money, but of availability of staff and resources. If the vast majority of Canadians were already getting their procedures within the benchmark times, then that would imply sufficient capacity to deal with the rare ones that do not. So a guarantee that tries to be a substitute instead of an add-on for a reasonable mechanism for access, is a setup for a failed promise. The only context in which a guarantee makes sense is in a health care system where wait-times benchmarks are already met by conventional methods 99 per cent of the time. As most Canadians know, we’re not there yet.
3. Many experts have talked about the need to centralize wait lists. Can you explain how wait lists are currently compiled and how centralizing could be beneficial?
The current methods vary greatly from location to location. For the most part, each facility (hospital) collects its own list of people who are waiting, using a variety of different methods, some of which are electronic and some are not. Surgeons generally keep a list of their own, including a list of people who have not yet been officially booked at the hospital. With very long wait times, there is no reason to let the hospital know about any except the more urgent cases, otherwise surgeons may be accused of padding their wait lists in an attempt to get more resources. Some jurisdictions require hospitals to report their list of patients waiting and others do not. Even in those that do, there is rarely a systematic way of making sure they do or following up on patients who have not yet received their surgery, which means that names can accumulate even when the patient has died or gone elsewhere to have their procedure. Since there is no real consequence to any hospital for ensuring their reports are complete, it is difficult to know how many cases are missing completely.
Even in those regions that do have more rigorous reporting and tracking, the data structures are such that comparing across communities is often not possible. A centralized wait list tracking system would make sure that data on waiting is rigorous, correct and timely. A real-time system similar to what the airlines employ that can give accurate up-to-the-minute information and provide automatic prompting when cases fall behind pre-set thresholds is what the Council supports. Anything less simply will not provide a benefit consistent with the technology of this century, and in line with what Canadians expect.
4. Late last year, the jurisdictions produced benchmarks for wait times. What is the next step?
The next step is to go back and ensure that the points in 10 Steps are all addressed for the reasons outlined above. After that, jurisdictions must do a realistic assessment of how far away they are from meeting those benchmarks, and how much time and resources would be needed to meet them a substantial percentage (i.e. more than 90 per cent) of the time. And finally, governments will need to be as honest as they can about what they can realistically achieve because the major impediment will be not the money as much as the health care staff and facilities space required.
5. As someone who has made a study of wait times, can you identify the most common misconceptions about the subject?
Perhaps one of the most common misconceptions lies in the way statistics are used and quoted. The median is the most commonly quoted statistic, because it is often the most impressive-seeming number, but not necessarily the one that most accurately reflects the reality of wait times. The median is always less than the average, and the average is always less than the 90th percentile. Knowing this, we should view any quoting of a median with suspicion because it is always the lowest number, and does not reflect in the slightest the number of people with the longest waits.