Modernizing patient referrals could be one way to eliminate Canada’s wait-time woes

Over the next few weeks, The Hub will be expanding upon the top five submissions for the 2023 Hunter Prize for Public Policy, which asked for proposals that would tackle the problem of Canada’s lengthening wait times for medically necessary care. In each of these dispatches, readers will get a closer look at the issues at play, as well as analysis from experts in the field.

Health-care wait times in Canada, especially for specialist care and medically necessary elective surgeries, are longer than in any other member country of the Organisation for Economic Co-operation and Development (OECD), and the COVID-19 pandemic made what was already a bad situation even worse. 

Health-care experts say the potential for reform is limited by both the structure and funding model of Canadian health care. In addition, the technology used to organize medical data and care in Canada is often obsolete.

In her submission for the 2023 Hunter Prize for Public Policy—“Modernizing Access to Specialized Treatment”—Jennifer Zwicker states that 20th-century technology cannot meet modern health-care demands. The director of social policy and health and associate professor at the School of Public Policy, University of Calgary, says Canadian health care needs a centralized, digital, interprovincial system that processes data across Canada and coordinates referrals to specialists. 

To illustrate her point, Zwicker notes that fax machines are still used for medical referrals, which slows the referral and booking process and leads to delays for patient care. 

“With no centralized national organization overseeing provincial initiatives, disseminating successful strategies, or assessing the impact of investments aimed at reducing wait times, the lack of cohesion results in fragmented progress and ‘perpetual pilot projects’ across different health regions,” Zwicker writes. 

Wait-time woes 

A 2022 report from the Fraser Institute found that the median wait time for referrals to specialist physicians in Canada stood at roughly 27 weeks—a 195 percent increase since 1993 when the average wait time was under ten weeks. 

Canada has been falling behind on specialist referral wait times for years. In 2016, the OECD found that 61 percent of Canadians were waiting more than one month for a specialist appointment, the worst showing in Canada’s peer group, followed by Norway. This compares to 36 percent in France during the same time, and 27 percent in the United States. 

Zwicker says the state of the infrastructure for Canada’s health-care information is blocking any improvement in wait times. 

“The absence of standardized data definitions and common reporting practices has hindered accurate measurement and monitoring of wait times, impeding the ability to make informed decisions, allocate resources, and implement targeted interventions,” says Zwicker. 

She notes that while other countries have implemented standardized data reporting that led to lessened wait times, Canada has not done the same. 

Could a MAST institute help? 

To help lessen Canada’s wait times and improve and modernize its health-care infrastructure, Zwicker calls for the creation of an institute to Modernize Access to Specialized Treatment (MAST). 

“This independent institute would have a clear mandate to modernize, measure, and monitor health-care access,” says Zwicker. “As an equalizer and capacity builder, it could facilitate the implementation of evidence-based practices to reduce wait times. Critically, it would also serve as a regulator, providing legislative, policy, and financial resources to hold Canadian health systems accountable.” 

The MAST institute would streamline the referral system and promptly match patients with the right specialists. In part, this would be made possible through cooperation with provincial and territorial governments. The effort would reduce wait times and improve transparency, administration, and overall satisfaction. 

“This centralized approach has broad stakeholder support and requires system-level leadership to accelerate its adoption across all provinces and specialties,” says Zwicker. 

Zwicker notes that models for such an institute already exist. Launched in 2011, Healthcare Improvement Scotland is an organization charged with improving the efficiency and effectiveness of Healthcare Improvement Scotland (HIS). HIS integrates several health-related functions under a single umbrella, such as assessing the National Health Service’s performance in Scotland, and also incorporates programs to improve health-care delivery.

The Canadian institute, says Zwicker, “would empower provinces to modernize their data infrastructure and promote the transparent reporting of wait times data that accurately represents the patient journey across provinces, specialties, and provider.” 

Establishing a uniform digital infrastructure—featuring elements such as scheduling systems, referral processes, patient interfaces, electronic health records, and wait-time reporting—is crucial, she adds. 

Referrals more complex than a click 

Shawn Whatley, a physician and Munk senior fellow of health-care policy at the Macdonald-Laurier Institute, calls for caution when it comes to overhauling the referral process. 

“A referral is not like entering a request into a vending machine for a particular product that you want the machine to spit out for you,” he says. “A referral is a professional transaction.” 

Whatley says that when he writes a referral for a patient, he does so based on an understanding of the specialist’s competency and behaviour. He does not believe that consideration is compatible with a digital referral system that automatically assigns patients to the physician with the shortest wait time.

“People with the shortest wait times often have the shortest wait times for a reason,” he adds. 

Krystle Wittevrongel, a senior policy analyst at the Montreal Economic Institute, disagrees. “That’s subjective,” she says. “Just because a specialist trusts a surgeon doesn’t mean that surgeon should always be the one.” 

As well, Wittevrongel notes that the patient’s preference should be factored into the equation. For example, if a patient’s hip has been degrading for two years and is placing that patient in danger, leaving the referral solely to the physician removes an element of choice. 

“As the patient, you could select a specific surgeon, but then you’re subjected to a longer wait,” says Wittevrongel. “[But maybe] you’re in chronic pain and you’re just willing to take whatever surgeon is going to get you there earlier.” 

Existing digital referral models have a mixed record

“The presupposition is that all we need is better management and we just need to expand the ability of expert managers over as many areas within the health-care system as we can, and things will improve for patients,” says Whatley. “Every time I’ve seen that system developed and implemented, it has not worked out well for physicians, nurses, or patients.” 

As an example, Whatley points to the Community Care Access Centre (CCAC). A network of organizations in Ontario that coordinated community-based health-care services, the CCAC acted as a primary point of contact for people seeking in-home and community support services. It also handled referrals and medical assessments to determine eligibility for various services. 

Whatley says a digital computer system implemented by the CCAC in local emergency departments was poorly received by medical professionals. 

“We actually had to hire new nurses to input the data into the new system the CCAC designed,” he says. “Physicians refused to use it, and the CCAC saved money by dumping all this work onto their new computer program that we then had to use.” 

Whatley says that even if a digital referral system is introduced as a back-up option, it would probably become the default option with time.

Nadeem Esmail, a senior fellow of the Fraser Institute, wonders why the MAST suggestion proposes more government bureaucracy to manage a system that already isn’t functioning. 

“I think it just falls back into the old problem of more government management being somehow the solution to this, even if it is more intelligent management,” he says. “The health-care system suffers from a remarkable level of inefficiency in Canada, and I don’t see, necessarily, how having a digitized approach that better models and manages that inefficiency is actually the solution.” 

Esmail does note that there are centralized referral systems that have been successful. 

“We have seen, of course, [that] centralized referral systems can reduce waiting times,” he says. “It’s certainly one of the lessons from the Saskatchewan Surgical Initiative. 

Launched in 2010 by the Saskatchewan government, the Saskatchewan Surgical Initiative, reported significant reductions in surgical wait times just one year after its debut. The number of patients waiting more than 18 months for surgery decreased by 57 percent to just over 900, while those waiting more than 12 months dropped by 37 percent to under 1,500. 

In May 2011, out of the 24,366 patients then awaiting surgery, only about 3 percent had been waiting longer than 18 months. It marked the shortest surgical wait list in Saskatchewan since data tracking began in 2004. 

The Saskatchewan Surgical Initiative includes an online specialist directory to help physicians and patients choose the most appropriate surgeon, as well as avenues to streamline care for patients needing specific medical procedures such as surgery and cancer treatment. Additionally, the province upgraded its electronic surgical information system for hospitals to help coordinate staff, supplies, and scheduling. 

Structural reform still necessary to address existing problems 

Esmail says there is a severe imbalance between the demand and supply of health care in Canada, whether it be personnel or infrastructure. According to data from the World Bank, Canada’s ratio of physicians per one thousand people was 2.4 in 2019, comparable to Mexico and Uzbekistan. Countries with higher rates included Austria, Finland, and Germany. 

“We know we have one of the lowest physician-to-population ratios in the developed world; we have some of the lowest hospital bed–to-population ratios in the developed world; we have low medical technology–to-population ratios,” he says.

He notes that the global budgeting model used for Canadian hospitals is a serious impediment to any health-care reform—including proposals like Zwicker’s. With global budgeting, governments assign annual funding to hospitals based on yearly expenditures. Critics say global budgeting fails to respond to a hospital’s real-time demands and forces them to adjust procedures performed and number of patients seen to ensure they do not see their budgets curtailed.  

“Why do we have so little operating room [OR] time in Canada? They’re closed on weekends, they’re closed in evenings,” says Esmail. “Hospitals are not encouraged to provide more operating room time. More OR time equals a greater drain on the budget.” 

Esmail believes that shifting to activity-based funding would open the doors to health-care reform and would improve access to health care. Activity-based funding provides dynamic funding to hospitals based on the number of patients seen and the types of procedures performed. He notes that most of the rest of the developed world has embraced this funding model.