Informing the Process

the OOA has governments attention

In Ontario, however, keeping the governments attention is even more complicated than usual as it engages in a war of words in the press over who will make up the huge deficits the provinces hospitals are currently running. Health Minister George Smitherman is adamant that Ontario hospitals present plans to balance their budgets by 2006. The hospitals are just as adamant that balancing the books means cutting services and closing beds. As Schuringa points out, increasing TJR output will require that new beds be opened, not available ones closed: We have got a number of hospitals that are cutting beds. If we have got a hospital somewhere down the street that can do 200 additional joint replacements and another hospital that will do 300 less procedures, were still short a hundred. Nevertheless, he remains optimistic that such conflicts can be resolved: If theres anything thats going to obstruct the governments ability to deliver on the wait-time promise, it will be dealt with.

Schuringa expects that new resources are likely to become available in months (rather than years), and hes very much of the opinion that a hands-on approach to clearing waiting lists should begin without delay: We can sit all day around the table and hash out how were going to measure wait times and what our standards are going to be, but realistically, its going to take us a couple of years to get benchmarks and standards to accurately measure and reflect wait times. While were developing these tools, we have to begin implementing the programme to ensure that were actually delivering increased service. Give us the resources, and well do the work.

A top priority for the OOA amid all the wait-time tumult is negotiating higher consult fees for Ontarios orthopaedic surgeons. Noting that of course, weve never had a direct relationship with the ministry of health for discussion of fees until recently, Schuringa concedes that the Association wasnt paying much attention to the interprovincial fee differences until last year, when it discovered that Ontarios consult fee ranked ninth out of 10 provinces: We have collected reams and reams of economic data. We hired an economist to help us understand the economic environment that were operating under here and where we can legitimately apply pressure to meet our needs. There is no justification why the consult fee should be different from province to province. The fee is for exactly the same service across the country.

The OOA has also learned that the Ontario fees for hip and knee replacements and many other orthopaedic procedures are also among the lowest in Canada. Schuringa will be applying pressure on the ministry of health to ensure that there are reasonable incentives in the provincial wait-time strategy to make the remuneration for delivery of orthopaedic services, including hip and knee replacements, more competitive on a national scale.

Perhaps increased fees and better access to the OR will help retain more of the orthopaedic residents trained in Ontario, since about half of them leave for other provinces and the US. This drain on manpower is a chronic problem that is likely to be acutely felt during the next decade or so, when a double cohort of surgeons will retire. Right now, there are a lot of orthopaedic surgeons over 60, and many over 65, who are working full-time. My generation, guys who have probably practiced ten years or less, have no intentions of working past 60. Were all putting money in our RRSPs. If the health ministries dont get a grip on this problem really soon, they will be faced with a catastrophic gap in orthopaedic human resources in 20 years.

Even though the winds of change are blowing and the prospects of breaking the wait-time gridlock have never been better, Schuringa is deeply concerned by the governments complete focus on hip and knee arthroplasty, possibly at the expense of the many other procedures that also have long wait times: The key word in our discussions has become cannibalism. Our message has been, If you choose to fund only joint replacement, then thats all youre going to get, and youre just trading one nightmare for another. We have been trying very, very hard to deliver that message. We have to make sure that the wait-times strategy doesnt consume resources to such an extent that it prevents us from doing anything else.

Substantial new resources, not simply increased resources, are crucial for the wait-time initiative to succeed. And if all orthopaedic surgeons dont have access to these new resources, then it will be virtually impossible to gain the cooperation and participation of the entire OOA membership. However, Schuringa is reluctant to become stalled over the issue: I think we need to get moving forward on wait times for hips and knees, take advantage of the increased resources that are going to be available to make this happen, and champion inclusivity for all orthopaedic surgeons. We have to stay close to whats happening and stay involved. We have to be part of the decision-making process.

Schuringa points to recent efforts at Queensway-Carleton Hospital in Ottawa, where an expansion project is underway with increased OR time, beds and a rehab facility so that the community medical centre can double its output of total joint replacements starting in April 2005: This is a microcosm of what has to happen around the province. There have to be new physical resources, new financial resources, new OR time. Theyre hiring nurses and anaesthiologists, and matching the number of beds to the volume theyre hoping to achieve. They have solved their own problem. The Ottawa hospitals saw they had to do more to get wait times down and put the resources in place. Now theyre ahead of us all on wait times.