Moving from Wait Times to Timely Access to Care

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Moving from Wait Times to Timely Access to Care

• Michael M. Rachlis MD MSc FRCPC
• (www.michaelrachlis.com)
• Timely Access to Care Gender Issues
• Ottawa March 1, 2007

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Outline

• Access is one dimension of Quality
• Elective surgery and diagnostics are just two
  dimensions of access
• We could have seamless access to most services
• How do we move forward?

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Access is only one Dimension of Quality, but
Canadas access scores poorly compared with other
countries
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Attributes of High Performing Health Systems
Ontario Health Quality Council. April 2006.
(www.ohqc.ca)

• Safe
• Effective
• Patient-Centred
• Accessible
• Efficient
• Equitable
• Integrated
• Appropriately resourced
• Focused on Population Health

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Elective Surgery and Diagnostics are just Two
Dimensions of Access
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Services

• Acute
• Procedures
• Critical care
• Emergency Room
• Long term care
• Home care
• Primary health care
• Medical Specialists

• Pharmaceuticals
• Emergency care
• Diagnostic imaging
• Palliative care
• Rehabilitation
• Mental health
• Addictions treatment
• Etcetera

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Populations

• Gender
• Age
• Income
• Education
• Insurance Status
• Disease
• Disabilities

• Geography
• Aboriginal status
• Race
• Ethnic Group
• Language
• Etcetera

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There are significant disparities in access
between different groups

• Poorer Ontarians have less access to
  arthroplasty, stroke rehab, and ambulance care
  for chest pain.
• E. Van Doorslaer et al. Inequalities in access to
  medical care by income in developed countries.
  Canadian Medical Association Journal.
  2006174177-183.

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Waiting for care Fresh ideas wanted!
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What causes queues?

• Usually there is enough overall capacity
• Queues usually develop because of temporary
  capacity demand mismatches

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Endoscopy Queues in Birmingham
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Capacity and demand for Endoscopy in Birmingham
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Variation mismatch queue
Cant pass unused capacity forward to next week
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We Could Have Seamless Access to Almost all
Services
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Advanced (thinking about) Access

• Does capacity match demand?
• If yes, work down the backlog and go to
  just-in-time service
• If no, first, shape demand and re-engineer
  services
• If there is still increasing demand, then add
  capacity

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Same day service Primary Health Care

• Cambridges Grandview Medical Centre and
  Torontos Rexdale and Lawrence Heights CHCs have
  gone on Advanced Access
• Ten MDs in Penticton and Prince George
• The Saskatoon Community Clinic (20,000
  patients) went on Advanced Access in 2004.
• Saskatchewan is aiming for 15-20 of family
  practices on Advanced Access this year and 100
  by 2010

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Reducing waits for specialty care

• The Hamilton HSO Mental Health Program increased
  access for mental health patients by 1100 while
  decreasing referrals to the psychiatry
  outpatients clinic by 70.
• Capital Health Edmonton decreased delays for
  diabetic education from 8 months to 2 weeks by
  not insisting patients see a diabetologist on the
  first visit to the centre

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Reducing waits for diagnosis

• Toronto East General Hospital reduced the overall
  time from a suspicious x-ray to definitive
  diagnosis of lung cancer from 128 days to 31 day
  a reduction of 75

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Waiting for a Series of Diagnostic Tests and
Therapies

• Need to apply the same techniques as with
  Advanced Access but through the entire process of
  care
• Wherever possible, perform tests and treatments
  in tandem rather than in series

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I have a good doctor and were good friends. And
we both laugh when we look at the system. He
sends me off to see somebody to get some tests at
the other end of town. I go over there and then
come back, and they send the reports to him and
he looks at them and sends me off some place else
for some tests and they come back. Then he says
that I had better see a specialist. And before
Im finished Ive spent within a month, six days
going to six different people and another six
days going to have six different kinds of tests,
all of which I could have had in a single
clinic.

• Tommy Douglas

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Reducing waits for treatment

• Alberta Orthopedic pilot project
• From 82 weeks to 11 weeks from family doctor to
  arthroplasty
• Richmond Hospital Hip and Knee Reconstruction
  project
• 63 decrease in those who waited gt 24 weeks

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What doesnt work (usually)

• Focus on a limited of services
• Internet postings of wait times
• Temporarily increasing capacity and clearing
  backlogs
• Prioritization and carve outs for urgency

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How do we move forward?

• We dont need many new resources, although we do
  need to re-allocate
• Improving efficiency
• Sticks
• carrots
• We need to reduce demand
• We dont need to go for-profit to improve

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Many attribute the quality problems to a lack of
money. Evidence and analysis have convincingly
refuted this claim. In health care, good quality
often costs considerably less than poor quality.

• Fyke Report 2001 (Saskatchewan)

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Removing the financial barriers between the
provider of health care and the recipient is a
minor matter, a matter of law, a matter of
taxation. The real problem is how do we
reorganize the health delivery system. We have a
health delivery system that is lamentably out of
date.

• Tommy Douglas
• 1982

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We need to reduce demandOnly through the
practice of preventive medicine will we keep the
costs from becoming so excessive that the public
will decide that medicare is not in the best
interests of the people of the country.
Tommy Douglas

1979
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For profit patient care is no panacea for
medicares problems

• PJ Devereaux et al
• FP hospitals had 2 higher death rates and 20
  higher costs
• FP dialysis clinics had 8 higher death rates
• FP hospitals are 20 more expensive
• Quality is difficult to measure

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For profit patient care tends to be more
expensive and of poorer quality BUT the most
effective argument is that its not necessary
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Innovation and the Canada Health Act go
together.

• Tony Clement
• 2006

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Summary

• Access is only one dimension of Quality
• Elective surgery and diagnostics are just two
  dimensions of access
• We need to look at disparities in health and
  health care
• We could have seamless access to almost all
  services
• Canada is awakening to queueing issues. There are
  a number of examples of Canadian queue management
  but so far they are Islands of Excellence
• We need to focus on improving quality, especially
  prevention to improve access

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Courage my Friends, Tis Not Too Late to Make a
Better World! Tommy Douglas