David Gomez and David Urbach
Access to elective surgery has been decimated by the COVID-19 pandemic. The first three months alone were responsible for over 28 million elective surgeries being delayed or postponed worldwide. The Canadian Institute for Health Information (CIHI) estimates that 560,000 fewer surgeries than expected were performed across Canada between March 2020 and June 2021, and that doesn’t include data from Quebec.
This is catastrophic. Without significant intervention, many Canadians who are waiting for elective surgeries may never have an operation. The burden of suffering and its impact on our mobility, vision, fertility and quality of life will be felt for years to come.
Formulating a surgical recovery strategy is an urgent policy priority. But addressing the crisis will take more than time and money; it will require a radical overhaul away from traditional individual surgical practice toward integrated group models of care.
The need to conserve hospital and critical care capacity for COVID-19 illnesses resulted in public health directives to stop all elective surgery in many Canadian provinces. The resulting backlog of unmet need has continued to grow as healthcare professionals are redeployed away from surgery to care for COVID-19 patients, are sick with COVID-19 themselves, or have left the profession altogether.
But we can’t only blame the pandemic for poor access to elective surgery. Our surgical wait time woes predate the pandemic.
The Commonwealth Fund 2021 report ranked Canada second to last among 11 similar economies in access to care. Even before the pandemic, approximately 30 percent of patients awaiting joint replacements or cataract surgery, for example, exceeded Canadian wait time targets.
Long wait times for services have long been grudgingly accepted by Canadians as an acceptable tradeoff in our single-payer, universal, publicly funded healthcare system. However, patience with the status quo will be tested once the real impact of the COVID-19 pandemic on elective surgeries becomes apparent.
How do we recover? We need to begin first by changing our mindset.
The term “elective surgery” is frequently misunderstood. In Canada, “elective” does not imply optional surgery. “Scheduled surgery” has been suggested as a more accurate term for operations that may be required for conditions such as cancer, cardiovascular disease, vision loss or debilitating chronic joint pain. While different wait time targets are acceptable for different types of scheduled surgeries — for example, cancer surgeries were prioritized throughout the pandemic given the potential of cancer progression — prolonged wait times for non-cancer surgeries can cause deterioration in health that may be life or limb-threatening, lead to poor quality of life, major economic burdens, and potentially even render a patient ineligible for scheduled surgery.
Canada needs a surgical recovery strategy. But increasing health care spending without fundamentally re-engineering how surgery is coordinated and delivered in Canada will not be enough. In fact, throwing more money into the existing system will only exacerbate systemic inequities that currently discriminate against disadvantaged patient groups, as well as certain health care providers, such as women surgeons.
At its core, access to surgery is determined by three factors: supply, demand and coordination. Most backlog recovery strategies focus on increasing the supply of surgical services: broader use of hospital payment models, increased hospital efficiency and rebuilding the health care work force.
We could also reimagine the way we use hospitals, incorporate new anesthesia techniques and anesthesia care providers, and expand virtual care for recovery at home, which can all reduce costs and free up hospital beds to further increase the supply of surgical procedures.
These would all be important steps. But without first addressing the lack of system-wide coordination of surgical services, this won’t be enough.
Importantly, we need to implement single-entry models for surgery and move away from traditional independent surgical practice towards integrated group models of care. By aligning doctors within groups, patients can enter a single referral queue and can be seen by the next available surgeon, slashing wait times and creating a more equitable system of care. Almost every other industry where people wait for services — banks, call centres, amusement parks — uses single-entry models to manage wait times.
Reimagining our system of surgery must begin with ensuring that all patients have faster and more equitable access to surgical services.
We have a once-in-a-generation opportunity to redesign the way Canadians receive surgical care and restore the public confidence that is required to preserve our unique health care system for future generations.
David Gomez is an Assistant Professor of Surgery at the University of Toronto and a Scientist at the Li Ka Shing Knowledge Institute of Unity Health Toronto. David R. Urbach, MD is the Lead Medical Executive and Head of the Department of Surgery at Women’s College Hospital, Toronto and Professor of Surgery and Health Policy at the University of Toronto.
David Gomez and David Urbach