Cue some fresh thinking about health-care queues
Winnipeg Free Press Thursday, December 2nd, 2004
OVER the last decade, concerns about long waits for health care have climbed to the top of the medicare policy debate.
Privatization supporters argue that the market can trim wait times. After all, you don't have to wait in line for service at your BMW dealer.
Others say the public system can handle the problem -- with a lot more money. The new federal-provincial health accord allocates $4.5 billion for wait-list reduction over a six-year period to bolster provincial initiatives such as Internet postings of wait times, temporary extra resources to clear backlogs and urgent prioritization of patients.
But it's time to recognize that, by and large, these strategies are dead-ends. It's past time for some fresh thinking about health-care queues.
British Columbia and the Ontario Cardiac Network have posted their wait times on the Internet for almost a decade. As of this summer, Toronto waits for elective heart catheterization varied from five to 56 days depending upon the hospital, while Vancouver waits for elective heart surgery varied from four to 27 weeks depending upon the surgeon. The wide variance means that people clearly aren't using this information to move from one provider to another.
Canadians tend to assume that if there is a wait for something, there isn't enough of it. But most waiting is not due to lack of resources. Even if there is a delay to get into a hockey arena, there will still be seats for all once everyone with a ticket gets in. There's just a bottleneck at the doorway. Doubling the number of seats will only make the delays worse.
In fact, most delays are due to poorly designed services. For example, many breast patients have to wait for a mammogram, then wait for an ultrasound, and then wait again for a biopsy. The Sault Ste. Marie breast health centre reduced the wait-time from mammogram to breast-cancer diagnosis by 83 per cent by consolidating the previously separate investigations.
It doesn't make sense to invest resources in prioritizing women for mammograms, then doing it again for ultrasounds, and finally doing it a third time for biopsies when it's more efficient to proceed directly from one test to another.
Queueing theory is a branch of mathematics, which deals with waits and delays. Applications of queueing theory are ubiquitous for traffic control, manufacturing processes and many other aspects of day-to-day life, including inventory control in hospitals. But, ironically, there has been little use of queueing theory to reduce patient delays.
Waits for doctors' appointments show the need for a fresh approach. Family doctors often have delays of four weeks for appointments. The wait is typically shorter just before vacation and longer thereafter, but overall it is fairly stable. So the doctor's capacity is close to meeting demand, but he or she is servicing last month's demand today while postponing today's work until next month. If doctors could clear their backlogs, then theoretically they could go to "just-in-time" servicing, sometimes referred to as "advanced access".
The Rexdale Community Health Centre serves 6,000 patients in a disadvantaged community in northwest Toronto. In 2003, patients faced a four- to six-week wait for appointments. The centre temporarily increased resources to clear its backlog and now provides same-day service.
Usually, services need to be redesigned as well. The Rexdale CHC enhanced the roles of its nurses, who previously spent a lot of their time telephone-triaging patients who were sent elsewhere for care!
This same plan can be followed for many health services. First, map the process. At each step, assess whether capacity is sufficient to meet demand. If it is, temporarily increase resources to clear the backlog and go to just-in-time servicing. If capacity is insufficient for demand, then redesign services.
If there is still unmet demand, then a bottleneck has been identified. It requires more resources. Example: We can't fix the delays for hip and knee replacements without paying for more artificial joints.
As much as possible, different steps in the diagnosis and treatment pathway are consolidated, as with breast health centres. The process should be seamless and guided by patient needs, not the needs of individual providers and their organizations. Patients want one-stop shopping. Most patients are more than happy to see the first available specialist, especially if that will save them months of waiting. After all, neither patients nor family doctors typically insist upon certain anesthetists even though that doctor may be as important as the surgeon to the operation's success.
Even when capacity appears to match demand, higher temporary demands can lead to long waits. For example, if a particular service always has the capacity for 10 patients and there are always 10 patients needing the service, there will be no waiting list. But if capacity and demand both average 10 but vary between nine and 11, there are sometimes only nine slots available when 11 patients are in need. The surplus two patients are added to the list. Conversely, when nine patients present and 11 slots are available, two slots are wasted. Unmet need continues forward as a waiting list, but unused capacity is wasted and lost forever.
Some variation is due to patients -- disease, age, genetics. But, typically the health system itself causes 80 per cent of the variation -- offering services on only some days, and especially, having multiple queues with different criteria such as priority rating and clinician. If a system creates a wait list because of frequent capacity / demand mismatches, then it will automatically recreate a list even after clearing a backlog.
The task of reducing health-care queues is not that daunting. The Modernisation Agency of Britain's National Health Service facilitates action on waits and delays throughout the agency. These initiatives have resulted in almost one-half of general practitioners offering same-day appointments, and more than 90 per cent of emergency departments discharging patients within four hours of arrival. The U.S. Veterans' Administration health service, a very public system, provides care to more than eight million mainly disadvantaged Americans. They don't wait for appointments either.
Canada just needs some fresh thinking to reduce health system queues.
Dr. Michael Rachlis is a Toronto-based health policy analyst. HarperCollins Canada published his third book, Prescription for Excellence: How Innovation is Saving Canada's Health Care System, in February 2004.
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