A version of this commentary appeared in the Calgary Herald, the Huffington Post and the Edmonton Journal
It’s a mug’s game but we appear as inexorably caught in it as the weatherman in the movie Groundhog Day, who realizes he is hopelessly condemned to spend the rest of his life in the same place, seeing the same people do the same thing day after day after day.
Dr. Robert Hollinshead’s announcement before Christmas that he will become the first surgeon in Alberta offering for-hire surgery in a private clinic outside of the public medical system has sparked needed discussion among physicians. Behind his decision are years of pent-up frustration with long waits for surgery. He proposes “a functioning private option” as a way of making more beds and operating rooms available, thus reducing waiting times.
But we’re afraid it will be Groundhog Day again as discussion gets bogged down in a debate about public vs. private services.
Maybe it’s easier to spill our emotions than it is to get down to the hard slogging required to fix what we have. But the public needs to know that, contrary to what is often stated, we can fix public health care, not with ever larger doses of taxpayer dollars, but with intelligent, innovative ideas founded on evidence and clinical experience.
The first thing to understand is that our public medical system was built for an age when life-threatening acute illness dominated the medical landscape. In response, we built large hospitals suitable for dealing with episodes of acute illness.
Today, our number one medical challenge is chronic disease — diabetes, hypertension, osteoarthritis and even some cancers, to name a few. Chronic disease is long-term and requires care best delivered in the community by a multidisciplinary partnership, rather than a provider-to-provider handoff.
Do we need to introduce a parallel private system to cope with this development? We have evidence this is not necessary. And the evidence comes from one of the most demanding areas of orthopaedic care: osteoarthritis leading to hip or knee replacement.
Over the past three years, we have succeeded in embedding an evidence-based model of care as the standard practice for hip and knee replacements across Alberta. Patient referrals are centralized. Care is delivered by multidisciplinary teams. A case manager navigates the patient through the system and coordinates services. At hip and knee clinics, referred patients are advised of their surgeon’s waiting time and offered the next available surgeon, thus moving patients from those with the longest wait lists to those with the shortest.
In addition to these improvements in process and practice, Alberta has begun to make waiting time measurement parameters reflective of real-world circumstances. Where the wait for hip and knee replacements has routinely been measured from the date the patient decides to have surgery, it is now also being measured from the date the patient is actually ready for surgery.
As we have discovered, “decided” and “ready” can be months apart.
The patient who decides in March to have surgery may also decide in summer to take a vacation, postponing surgery to do so. The clock is not reset for these patients. Their wait beginning from decision date becomes part of the publicly reported average.
This occurs frequently. The numbers tell the story: for the 12 months ended October 31, 2013, the wait from decision date to surgery was approximately 42 weeks for hip or knee replacement in Alberta. However, measured from the ready date, wait times dropped dramatically — to 23 weeks. This is one of the lowest wait times in Canada.
Length of stay in hospital is also down. Patients — better prepared for surgery and recovery under the model of care — are going home sooner, opening up bed space for the next patient. Alberta has, as a result, gained 33,000 bed-days since 2010.
Hip and knee replacement is but one area of orthopaedic care, albeit a major one. But the point is this: the model can be expanded to other areas of orthopaedics, and to other areas of medicine. It is the right model for today’s chronic disease challenge. And it is working without inducement from a parallel private system.
Let’s not wake to Groundhog Day . . . the same emotional debate about private vs. public health care. The system we have can be made much better. It requires hard slogging. But it works.
Don Dick is an advisor with EvidenceNetwork.ca and Edmonton orthopaedic surgeon and Senior Medical Director of the Alberta Bone and Joint Health Strategic Clinical Network (BJHSCN). Dr. Linda Woodhouse holds the David Magee Endowed Chair in Musculoskeletal Clinical Research and is Scientific Director of the BJHSCN.
This work is licensed under a Creative Commons Attribution 4.0 International License.