Recent discussions between federal and provincial First Ministers and Health Ministers have once again emphasized issues relating to waiting times for elective medical care in Canada. There has been increasing interest in waiting times for both diagnostic and therapeutic procedures in many different jurisdictions. Ad hoc rationing of medical care has occurred in various settings, primarily due to lack of resources, human and physical.
A number of provinces and the federal government have promoted the concept of acceptable waiting times for both diagnostic and therapeutic intervention. Unfortunately, selection bias has been evident.
Hip and knee replacement surgeries have been targeted for a long time by the Canadian Orthopædic Association and many provincial orthopedic associations as having waiting times that are unfortunately prolonged. These waits, frequently documented at a year or more, cause considerable distress for patients and anxiety in physicians, both referring and consulting. Establishment of the Canadian Joint Replacement Registry has enabled orthopedic surgeons to document actual wait periods until both the initial specialist consultation and the hip and knee replacement surgery, as well as their patients’ degree of disability prior to surgerical treatment.
A concerted effort by the Canadian Orthopædic Association and the Canadian Joint Replacement Registry has helped to promote a move to national standards for wait times for hip and knee replacements. All of this has taken place in an emotionally charged milieu in which provincial governments are increasingly pressed to control health care costs; various advocacy groups are promoting or opposing more private spending in health care; and a case has reached the Supreme Court of Canada alleging human rights violations because of prolonged waiting for hip replacement surgery. It is within this context that decisions are being made on how best to produce standards for uniform wait times for hip and knee replacement surgery, monitoring waiting lists, and prioritizing wait-listed patients according to their degree of disability.
Unfortunately, what’s missing from this discussion is a determination of where the resources will come from, to allow for changes in the delivery of these specific types of orthopedic surgical intervention. Are the resources to come from within the orthopedic community? Is it anticipated that we will discriminate against patients with spinal disease, shoulder instability or foot and ankle deformity, making them wait longer for treatment so that hip and knee arthritis patients receive more timely intervention? This is not an option, since the waiting times for treatment of musculoskeletal disease tend to be excessively long in every area of orthopedic surgery.
Are the resources to come from other surgical specialties? Should patients with breast cancer, for example, have their biopsies delayed in order to provide more resources for patients with hip or knee arthritis? Should patients with cardiac disease, now usually dealt with promptly, be made to wait “a little longer” to provide more resources for orthopedic patients? Neither option would be acceptable to the patients, their care providers or to health care planners. I use the example of hip and knee replacement because it is the area in which I am most familiar, but I could advance the same argument for areas such as cataract surgery, mental health, magnetic resonance imaging and computed tomographic examination, and a myriad other therapeutic or diagnostic procedures.
The point must be made to health care planners and hospital administrators in the strongest possible terms that decreases in wait times and increased access to service for some patients can not occur at the expense of others equally deserving of care. The debate around waiting periods and proposals to decrease them in certain areas has been unfortunately limited to some extent by the advocacy skills of patient groups. A program to reduce wait times and increase access to medical care should not be advanced for specific groups of patients but for patients as a whole.
The mechanics of decreasing wait times and increasing access are multifactorial. They must include an acknowledgement by health care planners and provincial Ministries of Health that an investment in increased personnel and matériel resources is required to bring about the desired change in health care delivery. The allocation of scarce resources from one type of patient to another, to the detriment of the former, should be unacceptable to physicians and surgeons in this country.