Notes from the Editor-in-Chief
Wait Time Strategy
This issue of Healthcare Papers provides a succinct analysis of Ontario's Wait Time Strategy, which was initiated in November 2004 - less than two years ago - by senior leaders in the Ontario Ministry of Health and Long-Term Care. In the article, Joann Trypuc, Hugh MacLeod and Alan Hudson describe their recent actions to implement the changes and examine strategies to develop a culture to sustain Ontario's Wait Time Strategy over time. The paper begins with an overview of the Strategy followed by a discussion of the accountabilities of a wide range of individuals and groups. These include hospital boards and management, the public, healthcare providers, government and Local Health Integration Networks. The authors conclude by identifying three major tools that can help support a culture to sustain the Strategy over the next decade.
There is no doubt that "wait times" are perceived, rightly or
wrongly, to be the Achilles' heel to Canada's internationally
esteemed national health insurance program. Whenever Canada's
healthcare system is compared with other developed countries, the
recurring criticism is that Canada has "got it right" except for
the wait times for important medical treatments and procedures. Dr.
Brian Postl, chief executive officer of the Winnipeg Regional
Health Authority and national wait-times advisor appointed by the
previous Liberal government, recently released a report on wait
times to Canada's first ministers. The report suggests that the
whole system should be more focused on the patient's experience of
the system. For example, patients should have better access to
electronic registries and treatment information when they are on
wait lists so they can monitor their own progress within the
system. (see www.hc-sc.gc.ca/hcs-sss/pubs/care-soins
Historically, initiatives in western Canada (e.g., the Western Canada Waiting List project, 2000) have placed them further ahead in addressing the problem; only recently has Ontario become serious about waiting problems. But in a relatively short period the province has made tremendous progress. Its Wait Time Strategy is designed to improve access in the public system to healthcare services in five areas by December 2006 (cancer surgery, cardiac revascularization procedures, cataract surgery, hip and knee total joint replacements and MRI and CT scans). And it is only the beginning of an ongoing process to improve access to and reduce wait times for a broad range of healthcare services.
The Strategy is a significant change management initiative that has generated a great deal of momentum in its early stages. The rigour with which it is being implemented has been welcomed by hospitals and providers, even though it has not been easy for them to meet the requirements. The most important task now is to figure out how the early success and improvements can be sustained over the long term. Some analysts hope that these improvements will help meet growing demands for healthcare without bankrupting the system. It would be neither realistic nor desirable to increase spending at this time, considering that health already accounts for over 45% of Ontario's budget. Experience in other jurisdictions has shown that increased spending does not necessarily result in sustained improvements.
Many change management initiatives are successful at first, only to lose their momentum and impact over time. Trypuc et al. outline key elements they consider crucial to long-term success. In their view, the one element pivotal to developing a sustained culture is holding individuals and groups accountable for achieving results. The Strategy defines future roles for hospital boards and management with regard to managing access and waits for the current five and future expanded services in their organizations. Clearly defined roles are also identified for the future for the public, healthcare provider organizations, physicians and other individual providers, professional associations, governments and local health integrated networks.
We received excellent commentaries on the lead paper that have been helpful in widening the knowledge base on sustaining the culture. Of particular importance is the paper by Paul Walley, Kate Silvester and Richard Steyn from the UK. They comment that Ontario's Wait Time Strategy shows many similarities to the approach used in the UK. They point out that in the UK experience, wait times have been dramatically reduced, but at tremendous financial cost and not always to the benefit of patients. In their view, part of the issue is our incomplete understanding of the causes of excess wait times. Walley et al. suggest that to be sustainable an effective program must, as well having as the required systems in place, include a system of measuring behaviours resulting from the changes; a grasp of the root causes of waits and solutions; and an understanding of the management style and improvement culture. Cy Frank and colleagues recount the experience of the Alberta Bone and Joint Health Institute, which has developed systems to measure, analyze and give feedback to stakeholders about access, quality and cost of services. Their advice to the Ontario policy makers is to focus on a team, collaborative approach to accountability. Ida Goodreau of the Vancouver Coastal Health Authority elaborates on the interpretation of the meaning of access. She indicates that access is both a symptom and a cause of problems in health services. Lack of access is a symptom of demand for services overtaking the supply of services. Wait lists are a result of imbalance between the demand for services and the supply. She suggests the problem must be addressed in terms of the health outcomes for the population.
Ruth Collins-Nakai, Owen Adams and Marcel Saulnier provide a very thoughtful and insightful perspective from the Canadian Medical Association. As might be expected, they present the issue of wait lists as a national rather than a regional issue, and focus much of their commentary on the health human resources challenge inherent in any solution. These authors indicate that a "key dimension of a sustainable wait time strategy that has not, as yet, been fully addressed in any Canadian jurisdiction is the need to provide patients with recourse to alternative treatment options if the publicly funded system is unable to provide care within medically acceptable benchmark wait times." They reinforce Trypuc et al.'s point that better data and information systems are necessary if this issue is to be appropriately addressed. Christopher Carruthers of the Ottawa Hospital also focuses on the human resources problems in being able to respond to the increased demand for services. He points out that the number of joint surgeries would need to be increased by 12% a year over the next 10 years to ensure 70% of patients receive their surgery within six months of the decision to operate. Kingston healthcare consultant Peter Glynn suggests that often physicians feel "disenfranchised" from the decision-making structures in hospitals. He believes that physicians and administrators will need to work more closely together to sustain the Strategy and that this issue needs further elaboration.
Taking a broader perspective, Judith Shamian, Esther Shainblum and Jennifer Stevens of the Victorian Order of Nurses (VON) focus their commentary on the roles that sectors other than hospitals, such as home care, family caregivers and volunteers, can assume to address the crucial problem of wait times. While congratulating the Ontario team for their timely and speedy implementation of the Strategy, Shamian et al. point to the full continuum of care of what other providers beyond doctors and hospitals can do to alleviate the problem. They focus particularly on the importance of home care as an integral part of the solution.
Finally, Nuala Kenny of Dalhousie University helps us to place the problem of wait lists in the context of Canadian values. She elaborates on the meaning of accountability as a value and provides us with a list of those who need to embrace the values of accountability, including governments and hospital and regional boards, and providers including doctors, patients and citizens.
In conclusion, we can safely say that there are many challenges ahead for the Ontario government in keeping up with the rapid rate of change it has initiated. Clearly, the system will need to be continuously monitored and reinforced, or the good achieved to date will fade away. Perhaps we can learn more from the experiences of others such as professionals in the UK, and be constantly vigilant as with all complex change. This is only the beginning.
About the Author(s)
Peggy Leatt, PhD
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