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I've been waiting on you

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Wait times remain a major concern for Canadians accessing our public health care system. This was highlighted an important report that came out yesterday by the Wait Times Alliance (the WTA is an alliance of physician specialists' organizations), Eliminating Code Gridlock in Canada's Health Care System. The report is a part of a year over year study to track and monitor provincial wait times. Unfortunately, the level of reporting varies between provinces and wait times on many procedures are not monitored. As a result the report is a valued attempt to track progress in reducing wait times, but not without its limitations.

The report highlights that since the (now lapsed) 2004 Health Accord, wait times for hip and knee replacements, cataract surgeries, bypass surgeries, radiation therapy and diagnostic imaging have all improved since the accord was introduced. The Globe and Mail reports that, "The Alliance is calling on elected provincial and federal leaders to help fashion a 'new national vision for health care,' one that sets national benchmarks that go beyond the 2004 initiative." Former CMA head Dr. Chris Simpson stated that when the health ministers meet in January in Vancouver, "he hopes a partnership to establish such standards will be part of the discussion, rather than just the level of federal funding."

In Atlantic Canada the report highlights people there wait longer than the national average. Council of Canadian, Atlantic Organizer, Angela Giles spoke with the media and outlined that, "We know that under the previous federal government, the equalization payments for the Canadian Health Transfers (CHT) got changed so that they're per capita basis and we know Atlantic Canada has suffered because of that," meaning each province will receive an amount that corresponds only to its population. Income level, demographics, degree of urbanization and any other aspects specific to a Atlantic provinces needs are ignored. In the year since the Health Accord expired, the Conservatives reduced funding by $987 million nationally and if not changed this will amount to $16.5 billion cut to health care equalization payments on top of $43.5 billion with the loss of the Health Accord.

                              

What is clear is that to make positive changes in our Medicare system to reduce wait times it takes leadership and a real desire to put patients first. This leadership needs to be actualized at both the provincial and federal levels to build the quality (and timely) services patients deserve. What is needed is a long-term commitment at both levels of government to look systematically at complex problems and address the root cause of the wait time problem. Targets and goals are meaningless if both levels of government don't address the roots of the problems and don't commit to a long-term sustained focus. As the provinces sit down with the federal government in the near future to start renegotiating a new and improved national Health Accord, it is essential that wait times, reporting, and national standards get the focus they deserve -- this means sustained funding for our universal public health care system that puts people before profits, and need before ability to pay.

While there is a lot of important information in the report, there are also some problems that go beyond data reporting (it should be pointed out that provinces like Quebec or British Columbia who have been aggressively privatizing public health services do not report all the possible data or do not measure up well in comparative analysis. A release by the Ontario Health Coalition highlights some of these issues ranging from extra/over billing, Alternative Level of Care figures (ALC), private clinic cream skimming, and bed shortages among others. The release also mentions another report from the Fraser Institute which came out at the same time as the WTA report. To put it simply, the methodology is so flawed, the variables so biased, and the correlations are so spurious on the Fraser Institute report that it is embarrassing. That is unless you are the Premier of Saskatchewan, Brad Wall.

Both reports do however point out that Saskatchewan has had some success in cutting wait times, yet this is only half the story. The WTA report (the only report worth recognizing of the two) took wait time data were taken from provincial wait time websites in the spring and early summer of 2015. The media for their part also trumpeted Saskatchewan's success without looking in depth at the current situation.

Saskatchewan did make an attempt to cut wait times which should recognized, but it was an attempt that did not address systemic problems or the need for long term funding. There is no magic bullet or quick solution to shortening wait times. Now after years of prosperity it seems the Brad Wall government has left nothing in the bank as oil prices plummet and the result is health care is being cut across the province.

Recently I undertook a speaking tour in Saskatchewan and heard from people around the province that they are tired of their public health care being eroded by the Brad Wall government (see: fighting privatization in the heartland of Medicare). Now, along with ushering in costly P3 projects in health care and forcing in two-tiered MRIs (in what is likely an illegal violation of the Canadian Health Act), the government has started cutting millions more dollars out of health care in the province. In the Regina Qu'Appelle Health Region (RQHR), the government is cutting $8 million of costs by reducing surgeries (around 1000 surgeries a year) and almost $13 million in salaries by eliminating 152 full-time jobs -- totalling a $38.3 million cut in the RQHR this year.

These outrageous cuts come after years of prosperity and tax cuts for corporations.  At the same time, pay for executives in health care is up about 20 per cent just since 2012 (some regions are up as much as 37 per cent or even 46 per cent). The Regina Qu'Appelle Health Region had the largest increase in executive pay over the last three years -- a 46 per cent jump to about $3 million, compared to $2 million in 2012.

(Photo credit: Paul Chiasson/Canadian Press)

In other regions, like the Saskatoon Health Region (SHR), a $41.6 million cuts has been ordered. Along with massive staff layoffs to come in the SHR, it has decided to terminate $200,000 grant program in that last minute that helped with AIDS patients, at-risk single low-income mothers, inner city families needing fresh vegetables and seniors' physical activities. Dr Ryan Meili has stated that, "It's really disappointing. The programs being cut are ones that can make a big difference in the long term. They can reduce illness and reduce costs." These are upstream public health programs that reduce hospital admissions and as a result lower wait times. A new study released in November by the Canadian Institute for Health Information (CIHI) concludes the need for programs like the ones the grant provided as, "Little progress has been made in closing the health gap between the wealthy and the poor over the past decade in Saskatchewan." At the same time, all three Saskatoon hospitals are overcapacity. In the Prince Albert, the Parkland Health Region (PAPHR) issued a code burgundy and all surgeries where an in-patient bed was required had to be canceled.  Lastly, Hhalth workers in Saskatoon have now been given a manipulative script to help them convince hospitalized and vulnerable seniors waiting for a long-term care home space to move to a different hospital in a different city to alleviate overcrowding in Saskatoon hospitals.

The dire and avoidable situation above is also happening during a time where the prince of privatization, Brad Wall, continues to stubbornly implement his magic bullet solution of LEAN programs across the health sector. As a recent Ontario Health Coalition post mentions, "There is also a gratuitous positive mention of the LEAN methods in the [WTA] report, without any real analysis. We receive endless complaints about this Toyota management system that is now being used in public hospitals." It the wake of the drastic health cuts occurring, it is actually worth examining what these LEAN programs mean for the health system.

                        

Since taking office, the Brad Wall government has increased the use of private consultations by a whopping 228 per cent. The total Lean investment since 2010 includes,

"...More than $40 million for American consultant John Black and Associates; about $20 million every year for ongoing Lean Kaizen Promotion Offices; millions per year for staff exclusively devoted to Lean and millions more for Lean programming, events and training. There is also a minister and staff devoted to the province-wide implementation of John Black Lean... In addition to 97.6 full-time staff in the 12 Kaizen Promotion Offices in the health regions and the Saskatchewan Cancer Agency, there are at least four full-time Lean specialists in the Health Ministry, five in eHealth and at least another 17 devoted exclusively to Lean promotion in the Provincial Kaizen Promotion Office. That doesn’t include the Kaizen Operations Team staff within hospitals and seniors care homes. It also doesn't include Lean staff at the Kaizen Promotion Offices in 3S Health."

The Ministry of Health's annual report boasts that, "to date, more than 1,000 Lean projects have been launched in Saskatchewan's health system." One such example is the Saskatchewan Children's Hospital which is three years delayed and is costing an extra $56 million and growing due to Lean mismanagement.

Access to information documents show that for Saskatchewan Cancer Agency staff alone, roughly 2,300 staff days of radiation therapists, early detection physicians, oncologists and other health professionals were used to attend more the 40 LEAN events and 3P workshops. If we want to reduce wait times there are much be a better way to do it than spending over 16,000 hours of health professionals time in ideological indoctrination and re-education courses. The agency is also renting expensive warehouses in Saskatoon for Lean/3P events and typically sit empty, ready to host John Black 3P events. This is at a time the Saskatchewan Cancer Agency  building has seen collapsed pipes, forcing 100s of appointments to be rescheduled.

Yesterday the Auditor General of Saskatchewan, Judy Ferguson, came out with her second damning report this year that took aim at the Lean program. She highlighted that there is no evidence the Lean programs leading to better service, improving things, or getting good value for the money spent. In fact, the government is specifically not tracking the result of this multimillion dollar expenditure. She stated, "They're unable to show us whether or not Lean is achieving what they're hoping it's achieving." The auditor also points to hundreds of Lean events, continued use of Lean consultants, and 5,000 days of staff time spent on Lean, with no results recorded.

                                      

With short-termed ideological management systems and massive cuts to health care in Saskatchewan, the current picture isn't pretty. Cutting through the smoke and mirrors that are occurring currently (it is an election year in the province), it is essential to take a closer look at wait times and patient well being. The Saskatchewan Party government recently admitted they will be cutting more that 3,420 surgeries this year. As a result of health care cuts, since March there has been a 73 per cent increase in patients waiting more than three months for surgery. The average wait for a medical specialist appointment has increased to 326 days in Saskatoon and 294 days in Regina, nearly 50 per cent longer than just a year ago.

The situation in the province's ERs is also worrying. The Brad Wall government has now walked away from its promise to reduce ER wait times to zero (an admirable if not over-simplistic goal it has to be said). Wall had previously made a promise in 2012 of a 50 per cent reduction in ER waits by March 2015 and the complete elimination of ER waits by 2017; but the government now says they will only attempt to reach a 60 per cent reduction by 2019. While Saskatchewan has stopped reporting its province-wide ER wait times to the CIHI in 2013, it can be gleaned from other sources that patients have now simply started walking away from the ER.

In Saskatoon for the 2014-15 fiscal year, it has been documented that at least 6,643 patients registered at the ER but never saw a physician (more than 550 every month). In only four of the health regions, more than 18,000 patients registered with a triage nurse and were put on the list to see an ER physician, but never did after experiencing long wait times. According to the Health Ministry's annual report, nine times in the past year there was a "delay or failure to reach a patient for emergent or scheduled services" resulting in a critical incident (a serious adverse health event including the actual or potential loss of life, limb or function). One such case in August of this year resulted in a 45 year old man with a history of heart problems waiting 3.5 hours the ER of Swift Current's Cypress Regional Hospital with heart attack symptoms before he collapsed on the floor and died without receiving treatment.

             

At the same time, the number of people heading to ERs has increased. In two emergency rooms alone, close to 10,000 more people were registered since April 2014. With hospitals often running at full or over capacity in Saskatchewan, patients also can't move from the ER to the wards because there are no beds available, creating further bottlenecks. This is a symptom of a bigger problem that cannot be oversimplified with lofty political showmanship to reduce wait times to zero. Even the Ministry of Health's annual report highlights that, "It is known that long waits in the ED are a symptom of multiple issues affecting patient flow across the continuum of care, and in order to reduce ED waits the root causes must be identified and addressed. It is widely recognized ED waits are driven by many internal (hospital) and external (community) factors. The literature suggests both hospital and hospital based strategies must work together to address this systemic problem." Yet, in reality the Brad Wall government is ignoring long-term policy and is instead cutting health budgets, upstream community grant programs, and reducing staff numbers.

Front line staff is already stretched to their breaking point, with more staffing cuts on the way (at a time when 120 full time staff have been hired by the government to solely promote the Lean Program costing millions of dollars in salaries alone). In 2014, registered nurses filed 868 work situation reports to identify situations like patients or residents being put in danger or not getting the care they need. In more than 700 of those cases, staffing concerns were the problem.

In summary, the result of the Saskatchewan Government's mismanagement of health care delivery to the people of the provinces is tangible, real, and very concerning. The WTA report's exclusions of current and publicly available data from Saskatchewan raises many questions. The national press for their part are also ignoring the situation on the ground for patients by making oversimplified claims that, "health care lag times are significantly shorter in Saskatchewan than anywhere else in the country, saying the province has adopted new measures in recent years that have brought about a remarkable turnaround." This completely ignores both the complexity of wait time challenges and the reality of the current situation in Saskatchewan.

What is needed is long-term investment throughout the health care system in order to reduce wait times. This includes both "upstream" and "downstream" investments, adequate staffing levels, reporting measure, and an multi-jurisdictional effort at both the provincial and federal levels of government to address the root causes of wait times through a renegotiated health accord. While the WTA and its chair Dr. Chris Simpson are no doubt aware of this fact, they need to be honest about the real situation in Saskatchewan. To put it another way, we need to stop using a band-aids when tourniquets are needed. 

Read Michael Butler's blog at Canadians.org.

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