No mystery behind surgical wait times

The supply of surgical procedures available to the population can be increased in a variety of ways. Doing more surgeries requires an appropriate clinical space (either within a hospital or in a nonhospital surgical facility), skilled staff like nurses and technologists, as well as surgeons and anesthetists. The bottleneck today is a lack of skilled staff, especially nurses.

An even larger problem is the lack of co-ordination surrounding specialized health care in Canada. Many people are unaware that most specialists — including the vast majority of surgeons — are in effect operating their own small business. Hospitals themselves have little influence over the flow of patients, and even surgeons who do the same type of work at the same hospital usually do not work as a team or share patients, even when one surgeon has a much longer wait-list than another.

What this means, ultimately, is that there really is no such thing as a wait-list for surgery. Although Ontario Health reports surgical wait-lists for public hospitals in Ontario, these lists never actually existed. They are calculated in retrospect by tallying the length of time that people ended up waiting for surgery done by different surgeons at different hospitals, without any underlying co-ordination, and often subject to the workday shuffling that is required to fill operating room blocks.

The result is not only wait times that are long, but also huge differences in waits for the exact same surgery. Prior to COVID, average wait times for cataract and knee replacement surgery in Ontario varied from less than one month to over one year according to which surgeon you happened to be referred to.

There is a solution. A common way of reducing unnecessary variation and long wait times is the use of single entry models, where patients are seen by the next available provider, just like a bank or a telephone queue for customer service. These models have enormous potential to reduce wait times.

The reason they have not already been widely adopted is that surgeons have not pushed for them, preferring the historical model of an independent practice where referrals come directly to the surgeons, who control their own wait-lists.

While the current debate about new delivery models to increase the supply of surgical services is welcomed, key perspectives are missing. For example, as medical director of perioperative services at Women’s College Hospital, a public outpatient-only hospital that performs over 4,000 surgical procedures annually, I would love to see a broader role for additional investment in Ontario’s public hospitals. Many hospitals have created innovative projects that have improved surgical care delivery and have established trusted relationships within their communities as safe places to receive high-quality care.

While there are many possible approaches to increasing the supply of surgical services, not every approach will have similar effects on access to care. Adding additional capacity beyond what can be delivered in public hospitals will help reduce wait times for at least some people, but it is not at all clear that this extra capacity will be integrated into the broader system so that it goes where it is needed most.

Some people will always get fast service for one reason or another, but these outliers do not represent the experience of the majority of people waiting for surgery in Canada. Our focus should be on improving the circumstances for the people waiting the longest, not those waiting the shortest.

Absent a concerted effort to actually co-ordinate the system by which people access surgical services, any effort to add capacity into the system — whether public not-for-profit, private not-for-profit, or private for-profit — will never solve that problem.

Dr. David Urbach is a professor of surgery and health policy, management and evaluation at the University of Toronto and the head of the department of surgery at Women’s College Hospital.