“Failing to Deliver” Report Actually Fails to See the Bigger Health System Picture

Texte d’opinion publié en primeur sur notre site.

Every Canadian province decreased the number of surgeries performed during the pandemic.

In fact, Canada-wide, 14% fewer surgeries were performed during its first 31 months. Scheduled surgeries were the most likely to be delayed or cancelled, leaving many Canadians waiting longer to receive knee or hip replacements or undergo cataract surgery.

However, a new report titled “Failing to Deliver: The Alberta Surgical Initiative and Declining Surgical Response” is singling out the Alberta Surgical Initiative (ASI) for blame, even though the province simply reported what was seen across the country: decreased surgeries over the course of the pandemic.

The ASI aims to make sure that all Albertans needing surgery receive it within clinically appropriate targets, or benchmarks. These benchmarks indicate the maximum amount of time, based on clinical evidence, a patient should wait for a specific procedure.

The ASI was modelled after the 2010 Saskatchewan Surgical Initiative (SSI), which had dramatically reduced wait times by 2016, and outsources certain publicly funded procedures to chartered surgical facilities (CSFs). Ultimately, by shifting some less acute procedures to community clinics, the idea is that operating rooms in hospitals are freed up to provide more complex surgeries. And in Saskatchewan, surgeries performed in community clinics cost 26% less that those performed in hospitals.

In Alberta, more contracted surgical procedures were performed in CSFs in 2021-2022 than in 2018-2019. Forty-eight per cent more, to be exact, while total provincial surgical volumes have declined (which is common across all provinces). This is while the share of the same surgeries performed in public hospitals declined 12 per cent.

The “Failing to Deliver” report claims that surgical outsourcing comes at the expense of public hospitals and undermines efforts to reduce surgical wait times. However, when CSFs are absorbing less acute procedures, at an assumed same or lower cost to the public system, it seems more logical to surmise they are reducing the burden on hospitals, freeing them up to take on additional or more complex cases.

In 2022, 65 per cent of cataract patients in Alberta received surgery within the benchmark, up from 44 per cent in 2019. This is better than all provinces except British Columbia and Quebec. For a fractured hip repair, this value is 89 per cent, down just slightly from the 91 per cent it was in 2019, but still the highest success rate in Canada after Prince Edward Island.

It’s when we look at knee and hip replacements that we see where Alberta lags other provinces. In 2022, only 27 per cent of Alberta knee replacement patients received their surgery within the benchmark, ahead of only Manitoba and Saskatchewan. For hip replacements, 38 per cent received their surgery within clinically acceptable timelines—better only than Saskatchewan and tied with New Brunswick.

This trend, of improving in some areas and backsliding in others, is evident in other provinces as well, though. BC, for example, is the worst province for meeting the target for hip fracture repair (worse since 2019) and the best for cataract surgery (improved since 2019).

Surely the global pandemic that disrupted health systems Canada-wide is to blame for at least some of the rising wait times for these surgical procedures.

The “Failing to Deliver” report also attempts to stoke the fears of American-style health care that come up anytime the word “private” is used in relation to this sector. The fact is, though, that these are still publicly funded surgeries, and the patients come from the same pool of patients on the waitlist, province-wide. CSFs provide privately delivered but publicly funded health care, something that has been around for decades in one form or another.

Your family doctor, for instance, is a private for-profit provider. It’s the delivery that’s private, while the funding is public.

The report concludes that the ASI is a failure as it has not increased total provincial surgical activity to pre-pandemic levels. However, this was not the overarching policy goal when the ASI was announced in late 2019. Comparing today’s system, which is still reeling from COVID-19 and its additional strain and added complexity, to what prevailed just before the pandemic is simply disingenuous and misleading.

Krystle Wittevrongel est analyste senior en politiques publiques et leader du Projet Alberta à l’IEDM. Elle signe ce texte à titre personnel.