By Neel Mistry and Paul Rooprai
According to the Organization for Economic Cooperation and Development (OECD), healthcare around the world can be classified into five major categories: national health service, national health insurance, social health insurance, state social health insurance, and private health system (Böhm et al., 2013). Current research is focused on establishing frameworks for comparison of international health systems and ranking each country based on healthcare performance (Bauer & Ameringer, 2010; Murray & Frenk, 2010). Cross-national comparisons of health systems can facilitate policy changes to improve a country’s existing system. In this paper, we aim to analyze provision of healthcare in Canada, specifically with regard to wait times in hospital emergency departments (ED).
Hospital wait times do not impact all patients in the same manner. According to Chris Simpson, former president of the Canadian Medical Association and chair of Wait Time Alliance, waiting periods depend on where the individual resides (Weeks, 2014). Moreover, recent research suggests that secondary health impacts of wait times are not equitable from a socioeconomic point of view as individuals with poorer health are affected more by prolonged wait times (Harrington et al., 2014). Since the health of an individual is influenced by a multitude of social determinants, those who are disadvantaged most by these factors are affected more by wait times. Thus, within the context of wait times, we see that structural discrimination and spatial injustices exist.
Individuals often erroneously equate a nation’s economic stability with the quality of its healthcare. However, this is not always true, and definitely not in the case of Canada. The average waiting time for patients in Canadian EDs ranges from three to four hours (Hildebrandt, 2014). More preposterously, this “average” accounts for only a minority of the population. When asked up front, most patients claimed that they’d had to wait for at least five hours before consulting a physician. This is unfortunate and contradicts the purpose of an ED, which is to enable immediate medical attention.
Research conducted by Guttmann et al. (2011) concludes that patients subjected to prolonged wait times are at a greater risk of premature death. In fact, every extra half hour of stay in the ED is linked with increased seven-day mortality. At the core of this issue is the lack of access to a medical expert. Approximately 85% of Ontario residents are simply discharged from the ED without further diagnosis. Most physicians succumb to burnout after seeing too many patients in one day. Not only does this reduce their work performance, but it also results in undertreatment for patients. These hopeful individuals soon develop a false perception of the reality and, by the time they return for a follow-up, it is often too late.
In 2008, when the Ontario government implemented a policy to reduce hospital wait times, an emphasis on patient processing speed was noted. Webster et al. (2015) highlight how optimal patient safety is lost when the focus shifts to swift palliative care. Although this policy enabled faster referral time and access to physicians, it largely undermined patient safety. Rather than conducting a thorough analysis of the patient at hand, medical personnel were focused on the next person in line. In reducing wait times, patient health was largely compromised for two reasons: Physicians spent less time assessing each patient, and common patient complications were overlooked. As shown by this policy, quicker access to a medical professional does not guarantee optimal treatment or better patient outcomes.
At the core of this issue lies a common, but crucial, trade-off between patients and physicians. While patients want optimal care in the shortest time possible, it is slow and efficient processing that allows doctors to minimize medical errors. The conflicting interests of patients and healthcare professionals invoke a justice issue. Individuals often associate responsibility to physicians for lagging behind in their work. Although this may be true, the greater problem is at the regional and provincial level. If the medical workforce were expanded, patients would not have to wait as long and could still receive optimal care. However, this distribution of responsibility generates a whole new problem. For now, it is crucial to understand that resolving the issue of prolonged wait times is not something that can be done overnight. Rather, it requires conscious and deliberate evaluation from all those affected.
Efforts to combat prolonged wait times in Canadian hospitals have been developed over the years. Many of these solutions are rooted in Lean manufacturing principles, which focus on reducing inefficiencies of internal processes to increase customer value (Rotteau et al., 2015). This means that healthcare systems should aim to increase patient satisfaction in a manner that is expedient and utilizes minimal resources. When applied systematically, such methods do improve wait times. However, as access to healthcare is a critical justice issue that affects the well-being of all individuals, it is imperative to incorporate patient response and feedback into programs targeting reduced wait times, as proposed by the Ontario Wait Time Strategy (OWTS) (Bruni et al., 2010). Findings by Bruni et al. bring to light the idea that the public wants increased communication from hospital staff regarding physician availability and wait times. This study concludes that effective communication can facilitate successful public engagement and allows governments to begin to remedy the issue of justice with regard to inequitable access to healthcare.
As is the nature of any justice issue, inequities in access to healthcare and health resources are both critical and complex. Rather than blaming physicians for slow processing speed, patients must understand that they are trading their time in line for high-quality service. It is this give-and-take relationship that generates an effective healthcare system. However, regardless of the minutiae, there are solutions put forth to reduce wait times, such as incorporating patient feedback in health management and better communication among hospital staff regarding physician availability. Feedback, discussion, and engagement ensure that the responsibility to solve these issues is shared by everyone involved.
Neel Mistry is a medical student at the University of Ottawa who is passionate about medical education, public policy, and health management. Paul Rooprai is a medical student at the University of Ottawa who is passionate about evidence-based medicine, clinical research, and patient safety.
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