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Hunter Prize: Modernizing access to specialized treatment is critical to curbing health-care wait times

Commentary

The Hub’s first annual Hunter Prize for Public Policy, generously supported by the Hunter Family Foundation, focused on solving the problem of long wait times in Canada’s health-care system. A diverse group of ten finalists have been chosen from nearly 200 entries, with the finalists and winners chosen by an esteemed panel of judges, including Robert Asselin, Dr. Adam Kassam, Amanda Lang, Karen Restoule, and Trevor Tombe. The Hub is pleased to run essays from each finalist this week that lay out their plans to help solve this persistent policy problem. The winners of the first-ever Hunter Prize for Public Policy will be announced on Friday, September 29.

“Problems cannot be solved with the same mindset that created them.”

– Albert Einstein

Canada’s health-care system, a source of national pride, has long grappled with extensive wait times for specialist care and medically necessary elective surgeries. Despite substantial health-care spending and a commitment to universality, Canadian patients continue to experience the longest wait times among commonwealth and OECD countries—waits made longer by the COVID-19 pandemic. The consequences of these protracted wait times are far-reaching, negatively impacting patients’ quality of life, psychological well-being, financial stability, and even the progression of treatable conditions into chronic illnesses or disabilities. Urgent policy action is needed to address this crisis.

We can’t continue to use 20th-century technology to manage wait times. A modern and coordinated approach to tackling fundamental problems is required. Two core issues stand out as critical drivers limiting the reduction of wait times: outdated referral systems and a lack of coordinated health data. 

The current referral system in Canada is plagued by fragmentation, variability, and inefficiency. Patients navigating the health-care landscape find themselves lost in a maze of referrals and waitlists. The referral process lacks standardization with primary care providers and specialists operating in isolation, leading to substantial disparities in wait times across medical specialties and geographic regions. The reliance on obsolete communication methods like fax contributes to breakdowns in the referral and booking processes, resulting in significant delays and disruptions in patient care.

Furthermore, Canada’s health-care data infrastructure is in dire need of modernization. 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. Other countries have shown that improved wait times correlate with transparent and standardized data reporting. Yet, Canada’s approach has fallen short, leaving decisionmakers without the necessary information to address bottlenecks effectively.

To address these pressing issues, we need to shift to a pan-Canadian mindset: the creation of a transformative institute to Modernize Access to Specialized Treatment (MAST) is recommended to capitalize on modern technology, spread and scale international best practices, and foster interprovincial collaboration. This independent institute would have a clear mandate to modernize, measure, and monitor health-care access. 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.

Coordinated electronic referrals—A critical need

The MAST Institute’s role in facilitating the streamlined implementation of single-entry referral models is crucial to ensuring patients are matched with the right specialist in a timely manner. By working with provinces and territories to transition to this evidence-based model that centralizes referrals and optimizes patient flow, health-care systems can reduce wait times while improving transparency, administration, and patient and provider outcomes and satisfaction. The elimination of paper-based fax referrals would also enhance communication and reduce the chances of referrals getting lost in the system. This centralized approach has broad stakeholder support and requires system-level leadership to accelerate its adoption across all provinces and specialties.

Addressing deficiencies in digital health data systems

A MAST Institute would tackle Canada’s data deficit head-on by establishing common data governance, reporting, and interoperability standards across all specialties and regions. Drawing inspiration from successful international models, such as Healthcare Improvement Scotland, the institute 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 providers. This would involve establishing national reporting standards with common definitions and synthesis of critical information to create a cohesive digital ecosystem encompassing scheduling, referral management, patient portals, electronic medical records, and wait time reporting. This standardized approach would enable provinces and territories to facilitate evidence-based decision-making and targeted policy interventions. 

Fundamentally, the success of a MAST Institute’s initiatives hinges on a participatory and transparent co-design approach. Engaging key stakeholders, including decision-makers, health-care providers, and patients across Canada, is essential to ensure that the implemented solutions balance local needs, patient privacy, transparency, and rapid data turnaround. Fortunately, most providers and patients are already eager for such an approach. 

A path forward: Accountable, feasible, and cost-effective leadership

The problem isn’t solely a matter of how to provide faster care—it’s a systemic issue rooted in the lack of a coordinated approach. Canadian health-care data infrastructure is in dire need of centralized leadership and policies to streamline the patient journey and reduce wait times. While technical knowledge and evidence-informed pilots already exist in Canada, system-level reform requires national leadership to address resistance to change and lack of political will in a time of fiscal restraint.  

The establishment of an institute to Modernize Access to Specialized Treatment (MAST) could be the critical pan-Canadian mindset shift needed to tackle the fragmented individualized approach fostered by the troubled romance between provincial healthcare and Canadian federalism. The proposed MAST Institute is rooted in a pragmatic approach and alignment with existing federal financial commitments. By consolidating resources and expertise from the Canadian Institute for Health Information and Canada Health Infoway, the Institute’s establishment can action recommendations from past federal reports for a more focused mandate without significantly increasing financial burdens. 

Furthermore, the Institute would give needed purpose, structure, and accountability to the recent $46.2 billion Federal agreement prioritizing critical deficiencies in digital health data systems. The MAST institute would leverage this commitment, bolstered by fiscal accountability tools akin to early learning and child care bilateral agreements, ensuring provinces’ adherence to necessary systemic enhancements. 

The approach offers both carrot and stick to drag Canadian health data systems into the 21st century: modern standardized and interoperable digital infrastructure and referral processes, coupled with mandate-driven federal funding agreements to hold provinces accountable for measurable wait time reduction. The time is now because Canadians don’t have any longer to wait.

Richard Shimooka: Canada’s military is being left behind

Commentary

Looking back, one of the most difficult periods for the Canadian Armed Forces in recent history was the late 1970s and early ’80s. Successive governments had cut into the military’s budget, downsizing and reorienting the forces while also delaying modernization. By the 1980s the CF faced obsolescence in the face of significant advances by Warsaw Pact forces. 

But while downsizing had cut the military’s standing forces, it still retained a capable administrative system with enough institutional memory to execute the new programs. By 1990, the military had replaced a number of its key systems with platforms (like the CF-18, CP-140, and the Leopard 1) with other major ones, like the Halifax Class frigates and the North West Warning system that was on the cusp of delivery. 

On the surface, Canada today looks like it is in a similar situation to the 1980s, and may even seem to be on the same trajectory if 2017’s Strong Secure, Engaged is executed as envisaged. Unfortunately, looks are deceiving. The reality is far worse now than it was then.

Many of the same systems we acquired in the 1980s are now far beyond their rust-out date and are not anticipated to be replaced for another decade or more due to failing program execution. While defence spending has increased over the past eight years, much of it has gone to operational accounts due to growing international commitments. This has masked the growing dilapidated state of the military’s capital base.

In other words, our system of procurement is fundamentally broken. Deliveries of major capabilities can now be counted in decades where years should be the norm. The Remotely Piloted Air System (RPAS) program, which will deliver a medium-altitude unmanned aerial vehicle, is about to enter its 17th year of existence without delivering a platform. By comparison, many of our allies, such as the U.K., Germany, and France have brought equivalent systems into service in under four years.

These failures have occurred at an inopportune moment, as the international security environment has deteriorated rapidly in the wake of Russia’s invasion of Ukraine and China’s destabilizing efforts in the Indo-Pacific. Our allies have increased spending and launched broad modernization of their forces, whereas Canada’s efforts have largely stalled by comparison. 

The system of acquisition is fundamentally misaligned from the focus of delivering critical defence goods to our soldiers. Over the past four decades the system has become progressively slower and less able to meet our national defence needs due to several factors. First has been the increase in non-defence objectives in procurement, most notably delivering economic and social benefits to Canadian society through these purchases. Second, a number of perceived failures, such as the initial cancellation of the F-35 acquisition in 2012, resulted in ill-considered reforms. It added layer upon layer of unnecessary processes, diluting individual accountability, and increasing costs and delays in programs.

While our present situation is suboptimal, the real cause for concern is the CAF of the future (which in reality, is already here). Reflecting the rapid and fundamental evolutions our societies are experiencing due to the confluence of new technologies, warfare is undergoing a similar shift. What I outlined earlier reflects a 20th-century approach to war fighting and procurement. Canada must move into the 21st century. 

A core consideration is the information dominance strategy. In the United States this exists under the Joint All-Domain Command and Control approach, or JADC2. Simply put, this doctrine seeks to aggregate and integrate information from all available sensors, then analyze and disseminate it to units that can affect action. Canada’s major allies, including Australia, Germany, and the U.K. are implementing similar approaches and have already drastically affected force structures and doctrines among all of their services. On a granular level, a platform’s connectivity and integration to existing networks and command and control systems are often as important as its physical attributes.

Canada has not adjusted to this new reality. While Strong, Secure, Engaged did contain verbiage that acknowledged joint intelligence surveillance and reconnaissance’s utility for the battlefield, the Canadian Armed Forces has lagged far behind its allies in this area. For example, when we look at RPAS, the misalignment of focus is clear. The procurement was largely focused on its physical capabilities while minimal consideration was given to how the platform would play in a broader networked environment. It would be akin to buying a top-of-the-line smartphone and only using it to make phone calls. 

In many ways this shift, when it comes, will be a fundamental one for the department and the government. Its implications will be profound and widespread, affecting not only military operations but how we procure systems. For some systems, such as software-enabled capabilities, how we develop them will directly affect their military utility. It requires procurement approaches that are flexible and innovative, delivering capabilities rapidly to our soldiers in order to face unanticipated new threats. 

If there is one point to start, we need to develop a strategy and doctrine that clearly identifies the importance of this emerging revolution in warfare. While, ideally, this should have occurred in the Defence Policy Update, even some level of guidance would be a start. By identifying these first principles, the military, the Department of National Defence, and the government as a whole can start the process of aligning its thinking around this problem. That is the crucial initial step that must be taken before further reforms can follow.

The 21st-century battlefield is already here. It’s time our leaders seriously engaged with what that means. We must enable the military to field the systems it needs to operate and succeed there. Nothing less than our security and global standing are at stake.

This article was adapted from remarks given as testimony before the Standing Committee on National Defence. A recording of the remarks can be viewed here.