Embracing Efficacy
better results, faster and cheaper

Dennis Jeanes
Special to the Canadian Orthopaedic Association

So it begins. This year, the first cohort of Baby Boomers turns sixty. And for the next half-century or so, the largest generation in Canadian history (some nine million strong) will inexorably grow old and frail. And in keeping with the expected epic proportions of their health needs, to paraphrase Churchill, never before will so many elderly patients depend on so few health professionals for so much.

"Canada is low by international standards in terms of practicing physicians," says Dr. Robert McMurtry. "And there's also a worldwide shortfall in health providers, which the WHO estimates at around 10 million - an extraordinary number." In short, the current crisis in health human resources is global, and relief from offshore won't be coming any time soon. "We need to do the most with what we've got. It makes no sense for Canada to have orthopaedic surgeons who operate one-and-a-half days, or less, per month. They should be spending 50 per cent of their time in the OR. That alone would make a tremendous difference."

No stranger to the COA, of course, McMurtry, who was appointed to the Health Council of Canada in 2003 and is Chair of its Wait Times and Accessibility Work Group, continues to be an influential and articulate proponent for reform of Canada's public health care system. As such, he's continually looking for outstanding science that provides a solid foundation for moving forward or examining the long-term experience of jurisdictions abroad for models that work. Such evidence-based nuggets are few and far between. "Measuring Up: Health Care Renewal in Canada," the Health Council's 2007 annual report, calls upon all jurisdictions to cooperate and set national standards so that experts and citizens alike can easily see if progress is being made. Polls conducted by the Health Council indicate that Canadians feel frustrated by a perceived lack of progress since the First Ministers Health Accords in 2003 and 2004. "The fact of the matter is," says McMurtry, "it's very difficult for the public to know what is actually going on because of a lack of uniform reporting methods. And that was validated by CIHI last year in their report, ‘Waiting for Health Care in Canada: what we know and what we don't know,' which makes it absolutely clear that jurisdictions aren't reporting in a way that's comparable. The First Ministers made explicit commitments in the Accords, and it seems they're abandoning the effort."

Transparency and accountability are prerequisites for the hard data that helps drive successful health reform. All health systems are facing enormously complex issues involving not only the quality and safety of care but also the appropriateness of care and the measurement of treatment outcomes. If Canada's ministries of health started tracking these factors in uniform and practical ways, McMurtry says, then models such as activity-based funding or payment by results - where local health authorities retain control of hospital budgets and allocate resources to meet a given patient's needs - might have application in Canada: "It all depends on what you mean by ‘results.' If governments began to ask for performance and outcome data, I'd be right on side. On the other hand, if the only goal is volume, without consideration for the other aspects of care, then it would do more harm than good."

For a number of reasons, it's hard to judge whether the United Kingdom's experience with payment by results was the key to shortening wait times there, as sometimes claimed. The public/private mix of delivery of service doesn't help with transparency, since the private clinics, known as Independent Sector Treatment Centres or ISTCs, tend to view their performance and outcome data as proprietary. Certainly, the British Medical Association doesn't appear to be a fan of ISTCs, judging by an article from the British Medical Journal of July 2006: "The government's attempt to boost health care capacity by establishing a network of independent sector treatment centres offers no clear advantages over doing the same work in the NHS. This is the conclusion of the influential House of Commons health select committee." An earlier BMJ editorial in March 2006 complained that the NHS clinics are forced to deal with an unduly high rate of complications - such as incorrectly inserted prostheses, technical errors and infected joint replacements - after orthopaedic services delivered at the ISTCs. Wait lists have been eliminated in the UK, but at considerable cost to some patients, it seems.

Be that as it may, what really clouds any proper analysis of the UK's experience is an enormous investment of new funds by the Blair government just prior to introducing the payment-by-results model. "The UK was always below the OECD average in health care spending," says McMurtry, "and then they invested another two GDP points. It was bound to have an effect on wait lists." If Canada invested an additional two per cent of GDP, it would amount to around another $20 billion per year.

But that's not going to happen any time soon. "As a result of the two Accords, the federal government has pledged some $70 billion over about ten years," notes McMurtry. "I think we have to get really efficient before we start talking about more money, and I'm not at all convinced that we have achieved a level of efficiency that could make a real difference. It's not atypical that half the cases I see don't require my expertise as an upper-limb orthopaedic consultant. How unusual is it for a specialist to say that? It's pretty common, I imagine. We're just not getting a good match between patient needs and expertise delivered."

If few new orthopaedic surgeons are expected to reinforce the current workforce, the only way to become more efficient is getting help from trained case managers and physician assistants, says McMurtry, who views the current crisis in health human resources as an opportunity for health professionals' roles to evolve. He recalls how in the late Seventies the lowly ambulance attendants of that time evolved with a little training (six months) into the capable paramedics of today: "They could do intubations. They were helpful in the operating room. They could do life-saving interventions in a trauma situation."

In today's context, McMurtry notes that in some jurisdictions nurse-anesthetists have proven very reliable in uncomplicated cases. He also points to the 2005 Hip and Knee Replacement Project undertaken by Dr. Cy Frank and the Alberta Bone and Joint Health Institute, which tackled inappropriate referrals with a detailed referral form (that GPs were paid a fee to fill) and with case managers who managed patient triage. Along with other efficiencies, the Project achieved stunning reductions in average wait times: from 35 weeks to six weeks for a first orthopaedic consult, and from 47 weeks to 4.7 weeks between consult and surgery. Average hospital stays were reduced by two days. "It's often said you can have faster and you can have better, but you can't have cheaper. You can have two, but not three," McMurtry remarks. "Well, the Project did exactly that: faster, better, cheaper." Currently, the Alberta Bone and Joint Health Institute is waiting to see if the Project will receive permanent funding from the provincial government.

As to the role the COA can play in health reform, McMurtry feels strongly that the Association must continue actively advocating for timely access to orthopaedic care, as it did in the Chaoulli case. He cites the groundbreaking work by Drs. Gillian Hawker, James Wright and Elizabeth Badley and the Arthritis Community Research and Evaluation Unit, which was able to show conclusively that in Ontario the need for hip and knee surgery exceeds the demand. The research confirms "how there is a huge disease burden and a systemic under-recognition of musculoskeletal disorders. We need to bring this issue forward, because there are a lot of people who have disability and morbidity because of musculoskeletal diseases, and they're not getting the care they need. I really believe this should be part of the COA's core mission."