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February 22, 2017: The real challenge to Canada’s health system is not wait times

Canada has some of the longest waits for medical care in the developed world. Same-day or next-day appointments with a doctor are difficult to get – and in the evening or on weekends, fuggedaboutit. Waits in the ER can be seemingly endless. Referrals to specialists result in lengthy waits. The wait for elective surgery is often painfully long.

These badges of shame are laid bare once again in a new report from the Canadian Institute for Health Information.

Worse yet, the CIHI data barely scratch the surface. The wait to see a doctor in the ER may stretch for hours, but if you need to be admitted to hospital, it can jump to days. The wait for home care services often stretches for months, and a patient needing a long-term care bed can languish in limbo for years.

Canada’s health-care system suffers from what experts call “code gridlock” – provision of care moves at a glacial rhythm because of clogs in the system.

Long-term care and nursing home beds are full. Home care hours are limited. As a result, thousands of patients who no longer need care can’t leave hospital, a reality so common we have an Orwellian term for it – alternate level of care. Because these patients are not discharged and beds are scarce, elective surgeries are cancelled, and those waiting for admission spend days on gurneys in the ER. The congestion this causes means that ambulances sometimes can’t off-load patients. Providing care to those in hallways slows provision of care to those in the waiting room. And many of the patients in the waiting room are there because they are unable to see their doctor promptly.

In Canada, our response – at least whenever things become serious enough to generate newspaper headlines and make politicians uncomfortable – is to throw money and bodies at the most visible problems.

With CIHI focusing attention on medical waiting times, you will undoubtedly hear that Canada has fewer physicians per capita than other countries – 2.2 per 1,000 population. But you may not hear that Norway, which has an equally lamentable record on same-day access to physicians, has twice as many docs, 4.4 per 1,000. Or that Canada has more physicians, in absolute numbers and per capita, than ever before, with seemingly little impact on access.

The solution to problems like waiting times is not always to do more of the same. For example, the CIHI report notes that Canada relies on doctors to provide care more than any other country; in other words, we underuse nurse practitioners, occupational therapists and the like.

More than anything else though, what Canada needs to fix its systemic health-care woes is to create a semblance of a system.

What distinguishes the countries that have markedly better results than Canada – like the Netherlands and the Nordic countries – is the cohesiveness of the system, and the emphasis on primary care.

Every Dutch citizen must register with a general practitioner, who acts as navigator and gatekeeper for the system. Furthermore, the roles and responsibilities of all the key players in the system – practitioners, insurers and government – are clearly defined, and complementary. Better still, politicians do very little micromanaging of the health system because that is not tolerated. In the Nordic countries, in addition, there is a particular emphasis on the socio-economic determinants of health, in tackling inequality, but spending more on education and social welfare, and less on health, with impressive results.

In Canada, by contrast, we have very much a sickness-care system, with many silos, and very little co-ordination. There is far more crisis management than planning and political interference is commonplace. And, as the data in the new CIHI study highlight, patients are often left to navigate the complex system on their own, and too often fall between the cracks.

Canada’s motto is a mari usque ad mare (from sea to sea). In our beloved health-care system, sadly, our motto has become a mora usque ad moram (from wait to wait).

But the real challenge we have is not waiting times. It is more fundamental: To provide the right care at the right place at the right time at an affordable price (to individuals and society). To do so, we need vision and we need a system; not just data, but a willingness to act on the data.