“Quebec brings order to emergency rooms; no patient will stay more than 48 hours.”
This headline from La Presse could have been written last year, as suggested by the spring 2017 ultimatum from Health Minister Gaétan Barrette. It actually appeared on March 11, 1980. So where do things stand today?
Earlier this year, many rejoiced over the news that waiting times had declined. For the 2017-18 fiscal year, the average stay in Quebec emergency rooms overall was 7.3 hours, compared with 7.8 hours the year before, an improvement of half an hour. For patients on stretchers, the most serious cases, the average wait went to 13.7 hours from 15.6, an impressive decline of nearly two hours at first glance.
However, the true picture, as measured by the median stay, is not quite so rosy. This form of measurement is less heavily influenced by extremes at either ends and thus more closely represents what patients actually experience. According to Health Ministry data, the average stay went from 9.5 to 9.2 hours last year for patients on stretchers, a modest improvement of 18 minutes. For patients as a whole, the median time went up slightly, from 4.4 to 4.5 hours.
In other words, nothing has changed. Things are stagnating.
Even the apparent slight improvement for patients on stretchers may be inaccurate. Some health care workers say patients undergoing very long emergency room stays are moved to overflow units, where they are no longer counted. Even so, some 212,000 patients “officially” stayed more than 24 hours in an emergency room last year, and 30,000 stayed more than 48 hours.
The move toward activity-based funding, expected soon, will encourage healthy competition between hospitals and will reward those that attract more patients instead of punishing them, as occurs now. That’s because, instead of receiving set budgets, hospitals will be funded according to the number of patients treated and procedures performed. This is a good first step.
A second step, just as important, would be to call upon the private sector to manage a certain number of hospitals while maintaining public financing. This is the way things are done in most developed countries. Nearly all of them do better than Quebec and Canada when it comes to emergency room waiting times.
In concrete terms, a pilot project could involve turning over the management of some Quebec hospitals to private companies. Agreements would reward the fulfilment of performance targets while taking account of quality and access to care, as well as patient satisfaction.
Germany made this shift toward the private sector in the early 1990s. The share held by private for-profit hospitals nearly doubled in 20 years. The quality of care in formerly public hospitals improved following their privatization, along with their efficiency, without affecting access to care.
Only one per cent of patients wait more than five hours at emergency rooms in Germany.
In Sweden, the only private hospital with an emergency room, Saint Göran, in Stockholm, is also the hospital with the lowest waiting times. Fewer than one per cent of patients stay there more than eight hours. The hospital is regarded as one of the country’s best, and it is fully integrated with the government-financed public system. (It also costs the system less.)
In Quebec, the example of private long-term care facilities (CHSLDs) that are fully integrated in the public system shows that, here as well, the profit motive gives entrepreneurs an incentive to be more efficient while providing better care.
All the promises and goodwill in the world will come to naught unless the basic parameters of our health care system change; it is, simply, a matter of incentives.
After more than 40 years of public management that has created waiting lists, and then multiple reforms that have failed to eliminate them, Quebec is ripe for more innovation and entrepreneurship in its hospitals.
Patrick Déry est analyste en politiques publiques à l’Institut économique de Montréal et l’auteur de « Les hôpitaux du Québec ont besoin d’entrepreneuriat ». Il signe ce texte à titre personnel.