Doctors see promise in Alberta’s dual-practice health-care proposal

When Dr. Trevor Brooks thinks back to the early days of his surgical career in Medicine Hat 11 years ago, the image that comes to mind isn’t a gleaming operating room. “They were done in a patient’s room, like on a patient bed with a food table acting as my hand tray because there was never a setup for a minor facility here,” he told The Hub. Those procedures—skin cancer excisions, wound repairs, carpal tunnel releases—may have been labelled elective, but they weren’t casual. They should have been done in a proper theatre. Instead, Brooks performed them on the sixth floor of the local hospital, which serves a catchment area of more than 110,000 people in southern Alberta. When that space was reclaimed, he says he was moved to a curtained-off alcove outside the old emergency department. “There were no walls, and I still had no access to normal OR (operating room) equipment,” he recalled. A specialized, dedicated space for minor operations didn’t exist until the hospital’s expansion several years later. Since then, Brooks has also built his own private facility. “So now we have a full, minor OR setup that I have access to, that is very underutilized right now,” Brooks said about the hospital due to resource allocation. “And I also have—as the other part of my practice—a surgery centre, which I’m a part owner of,” he said about his private clinic. As a plastic and reconstructive surgeon, Brooks has always toggled between public and private spheres—providing cosmetic procedures like breast implants and tummy tucks through private billing, while also performing hand surgeries and burn repair through public billing. But the public half of his service is constrained by limited OR access and a shortage of anesthesiologists. Working at the hospital also means he has no control over staffing. Fortunately, Brooks is able to shift some of the publicly funded work into his own surgical centre because the province contracts specific procedures, including plastic surgery, to accredited non-hospital facilities. “Nothing is private about that other than the location where it’s happening,” he said. What he absolutely cannot do under the current rules is accept private payment from patients who want a medically necessary procedure done sooner. That would put him in breach of medicare rules and could risk his licence—even though, he says, at least once a week, a patient asks to pay out of pocket for a quicker treatment. Alberta’s Bill 11 would change that. More flexibility, more choice, more pay If passed, the legislation would allow physicians to work in both systems. Brooks would be able to complete a set quota of public surgeries, then perform a limited number of medically necessary procedures for private pay. “It would be a good thing for me,” he said. “I wouldn’t be as beholden to the hospital… in regards to the limiting number of cases that I have.” Such reform would likely also appeal to orthopedic surgeons, ophthalmologists, and other specialists who already operate in a hybrid world and are increasingly frustrated by the limits of the public system. In fact, Premier Danielle Smith’s own explainer video highlights knee and hip replacements, as well as cataract procedures, as the sort of surgeries that could easily shift into a regulated private stream as long as no patient gets left behind. Brooks doubts that most of his patients would actually pay. In his line of work, he’s used to hearing people profess they want something done, until it’s time to pull out the credit card. But since many lower-acuity cases already take place in his surgical centre through existing government contracts, he believes a dual model would simply give him more flexibility to take on additional cases privately. “It’s just an addition of more ability, not a distraction from current resources,” he said, adding that some of the patients on his waitlist are already looking to go elsewhere for help. “If we could retain the patients who are travelling to the [United] States or the patients who are travelling to other provinces and keep it part of our GDP, then yes, it would make my surgery centre more successful,” Brooks said. “That would allow me to bring on more nurses or get more accreditations for different procedures.” Cumulatively, it could free up more of his limited hospital time to concentrate on the more urgent melanoma removals and complex reconstructions—the kind of surgeries that cannot be done anywhere else. A bit of extra cash wouldn’t hurt, either. While Brooks approaches the proposed dual-practice model from the vantage point of a surgeon pinched by limited OR time, another doctor sees the consequences of that bottleneck from the triage end: the emergency room (ER). Justin Rashad Chin, an emergency physician based in Edmonton, supports the dual model, even though he has no financial stake in private facilities or private surgeries. The proposed legislation doesn’t apply to emergency care. “What’s funny is that I have very little skin in the game,” he said. What he does have is a clear view of patients who are running out of options. They land in his ER. “I see the patients who are also waiting for surgeries,” Chin said. “They come in suffering in pain because they tell me they’ve been on the waitlist for months and years.” In other words, the ER has become a catch-all for a system that can’t keep up. That assessment is shared across political lines. Even defenders of public health care agree that waiting 10 hours in the hallways for problems that should have been solved weeks earlier through primary care, diagnostics, or elective procedures points to systemic failure. Where the consensus fractures is on what to do about it. Concerns and support for two-tier system Opposition parties and public-health advocates argue that the proposed dual practice model risks making things worse. Former NDP health minister Sarah Hoffman says the government “did not need more chaos” and warns that yet another restructuring will only “create a second path” without fixing the underlying issues around access. “There’s a lot of chaos, lots of restructuring, but I don’t think it leads to better health outcomes for anyone,” Hoffman said. Lobby groups like Friends of Medicare go further, calling Bill 11 “an unprecedented model of two-tiered access” and a means to “sneak through massive changes” akin to American-style health care that favours the rich. Other skeptics, like Jon Meddings, former dean of the University of Calgary’s Cumming School of Medicine, don’t oppose the idea on principle but warn that Alberta doesn’t have enough physicians to run two systems. Chin believes the proposed dual model can work, but only if it’s designed properly. It begins, he argues, by addressing the problem of health care in all its forms being too “far centralized.” In late November, Chin wrote an editorial for The Edmonton Journal making this point. “Simply pouring more tax dollars into the same centralized monopoly-delivery model has been tried for decades and has repeatedly failed to solve these problems,” he wrote. He sees Alberta’s broader restructuring—breaking up the central health authority, creating specialized agencies, expanding contracted surgical centres, and now dual practice—as a long overdue shift toward a more modern, mixed system that maintains universal public coverage while adding competition and choice. He’s also clear-eyed about the risks. Dual practice, he insists, needs “robust oversight,” with strict regulation, and guardrails to protect the public system. Those are reasons to design the model well, rather than arguments against adding private capacity. Brooks is less convinced dual practice will lighten ER loads. More surgeries—public or private—mean more complications. “Complications will ultimately end up in the ER,” Brooks said. “Because when the complications happen, they usually happen at 5:00 or 6:00 at night. You can try to get a hold of your surgeon, but he’s probably not going to be available.” Both physicians believe the dual practice model is just one piece of a much larger fix. Policy execution is key On one point, they find unexpected common ground with the NDP health critic: none of this works if the government bungles the execution. “It’s all about ‘trust us,’” Hoffman said about the UCP’s strategy. “‘Trust us. We’ll figure it out in the regulation.’ Uh, I think Albertans are right not to have blind trust in this.” For Hoffman, that skepticism is rooted in a growing list of operational misfires. She points to the government’s Turkish Tylenol procurement fiasco, the uneven billing of chartered surgical facilities, and the many rounds of sackings across provincial health institutions as examples. “So they’ll blame a CEO or a board member and try to fire somebody,” Hoffman said. Another former cabinet minister who served under a different conservative premier says Smith’s penchant for firing people DOGE-style is creating its own long-term problem. They’re worried Alberta will soon run out of qualified people to take on its most complex administrative jobs. Nobody ever said fixing health care was going to be easy. The system, as it stands, can’t meet demand. Costs are climbing, and ERs are absorbing failures from every other part upstream. The province already relies on contracted surgical centres that blur public-private lines, and a whole class of doctors already move between the two. In that sense, introducing more dual practice is not a radical departure from the status quo. More flexibility, more capacity, and more competition could help. But the Smith government needs to convince Albertans it can carry out the plan competently. And with other provinces eyeing Alberta as the test case for a modernized, mixed delivery model, the province simply can’t afford to botch this experiment. The Hub will publish a follow-up analysis on staffing and capital requirements. If you are an expert or health-care professional and would like to comment, email falice@thehub.ca.