President elect nominee of the Canadian Medical Association.
Yesterday afternoon, in my capacity as Cardiac Program Medical Director at my hospital, I met with Mr. B, a 72 year old man whose wife died in hospital.
I was expecting that he would want to talk about her hospital care; perhaps he wanted to explore why she died and if anything could have been done differently. I reviewed her chart thoroughly in advance so I could be sure I had all the facts I would need to discuss her case with him in a meaningful and productive way.
As it turned out, he didn’t want to talk about that at all. Instead, he wanted to talk to me about his wife’s experience leading up to her surgery. He told me her story chronologically. She’d had a series of encounters, each characterized by a wait. She had waited in the ER. She waited for diagnostic tests. She waited for consultations, she waited for decisions and she waited for her surgery.
“All of the doctors and staff were great”, he repeatedly told me, almost as if he were trying to protect those of us who work on the front line from critique, “but the system let her down.”
He went on to explain how all of these constituent waits in her health care journey left this very thoughtful, seemingly-empowered and articulate man and his wife feeling afraid, vulnerable, disconnected, anxious, demoralized and uncertain.
Canadians understand that when they require non-urgent health care, they will usually have to wait. When waits are appropriately brief and when patients feel connected and in control, they feel confident and satisfied. When waits are too long, however, and when people are left “in limbo” between encounters, patients and their families experience anxiety, economic hardship, needless pain and suffering, and perhaps even more serious adverse events, including death. Also important is the societal cost of excess waiting. The Canadian Medical Association has estimated that waits exceeding medically acceptable benchmarks for just four key procedures cost the Canadian economy $14.8 billion dollars in a single year (http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf).
As I reflect on the nearly ten years that have passed since the 2004 health accord was signed by the federal government and the provinces and territories, I find little reason to cheer. Despite all the goodwill, hard work and cooperation; despite the money committed to reducing wait times and the intense pressure from the public to improve, we have seen only modest progress. Over the past year or two, most discouragingly, we are now seeing the reversal of that modest progress. CIHI (http://www.cihi.ca/cihi-ext-portal/pdf/internet/HCIC2012_SUMMARY_EN), the Health Council of Canada, and the Wait Time Alliance (www.waittimealliance.ca) all agree that wait times have worsened again. Essentially, we’re regressing right back to where we started.
How is it that all this work and all these resources have not led to sustained improvements in wait times?
The reasons are many but they essentially boil down to one indisputable truth: the money that was invested didn’t buy change. All we did was to make the numbers look a little better for a short time. Our “success” was fleeting. The Senate Committee on Social Affairs, Science and Technology, in its review of the progress made since the 2004 Accord (http://www.parl.gc.ca/Content/SEN/Committee/411/soci/rep/rep07mar12-e.pdf) echoed this sentiment, recommending that investments must be used to buy change, not to maintain the status quo.
What would real, transformational change look like?
Well, it would start with the assembly of clear and timely information on outcomes and performance, the tools to measure these, and the establishment of a national body that is resourced and empowered to collect, analyze and present these data. We can’t change what we don’t measure.
Transformational change would also see more accountability to deliver the change that is purchased by the investment. We won’t change if the payers don’t hold us all accountable to deliver the change that the resources provided are intended to buy.
Transformational change means far less “siloism” in the system. It’s often said that we are a nation of health care pilot projects. Our jurisdictional and cultural silos impede the sharing of successes and best practices. We are forever “re-inventing the wheel” because we have diminishing national focus, standards, and goals.
And finally, transformational change means that all stakeholders in the system have to step up to do their part. Physician groups and other health care professional organizations must continue to advocate for individual patients but we also must embrace our civic professionalism – to help our system find better value for money and to help lead our collective responsibility to find a path to sustainability.
Putting my doctor hat back on, though, I see this as being about how to fundamentally change our approach to the provision of care from one that is provider-centric to one that is patient-centered. Mr. and Mrs. B wanted us to accompany them on their journey. Instead, we invited them to join us on ours.
Mr. and Mrs. B recognized the excellence embedded in the silos, but felt abandoned at the transition points in her care pathway. The transition points between each component are the wait times; it is at these bottlenecks where negative perceptions, inequities, and suboptimal outcomes are born. It is also where inefficiency and waste are generated.
They deserved better. All Canadians deserve better. And we can do better. Together, we can build a health care system that is truly worthy of Canadians’ confidence and trust.