Illustration by Tim Boelaars
The Fixing Health Care series presents 10 common problems faced by patients in Canada, along with 10 solutions that the authors argue can be achieved within our existing publicly funded health system. While the ‘problem’ scenarios in the series are fictional, the authors offer these examples to echo the patient experiences they have encountered through their work in health care and social services.
READ MORE • Fixing Health Care: 10 ways to transform Canada’s public health care systems • About the authors
The Problem: Getting complex care for a serious illness can seem very convoluted and, without a co-ordinated system, treatment can be unnecessarily and dangerously delayed
Mylène is 49 years old and recently felt a lump in her breast. She waited several weeks for a mammogram and then waited to see her family doctor for results of the test. The GP told her she needed a biopsy; she waited again to see a surgeon who did the biopsy. Two weeks later, she told Mylène she has breast cancer.
It is now about 10 weeks after Mylène first noticed the mass. She’s sure that the tumour is bigger now, and she recently felt a lump in her armpit. Mylène’s family doctor tells her there can be a long wait for surgery. She also told her that she will likely need chemotherapy and radiation treatment after surgery. Mylène is very worried that she may die if she needs to wait time after time, first for surgery and then for all of the other treatments. She is terrified and doesn’t know what to do.
The Fix: Provinces need to invest in systems that efficiently link practitioners and diagnosticians
Many Canadians, especially during the pandemic, have faced prolonged waits for diagnosis like the experience that our patient reported above. On the other hand, more fortunate patients referred to breast diagnosis expert centres may have their breast mass diagnosed within 24 hours. The difference between a 30-day wait and access to diagnosis within hours is that the expert centres are designed and resourced to rapidly co-ordinate all steps in the diagnostic process. Unfortunately, attention to the co-ordination of diagnosis and/or therapy is often lacking in Canadian health care.
To ensure high-quality results, certain conditions require well co-ordinated treatment from multiple specialists. For example, the diagnosis and best treatment of cancer requires the seamless interaction of radiologists, pathologists, surgeons, medical and radiation oncologists, radiation physicists and therapists, as well as nurses, social workers and physiotherapists. Unless these various services and professionals are linked together into an expert-designed system of care, the patient risks getting substandard treatment. The rapid diagnosis and treatment of cancer is especially important since delay may result in reduced cancer survival.
Systems designed by experts are also needed for intensive-care services, heart disease, stroke care, kidney disease, organ transplantation and trauma care. The importance of appropriately resourced, expert-designed intensive-care systems (such as the leadership provided by Critical Care Services Ontario) was evident during the pandemic, when each province needed to rapidly expand ICU capacity and constantly upgrade COVID-19 therapies depending on the latest evolving clinical research. Critical-care leaders in the province continuously monitored best practices to ensure that ICU practitioners could deliver the best treatment. With expert systems in place, a province can respond to rapidly changing and potentially lethal clinical challenges across its whole jurisdiction. At the moment, only Alberta, among all the provinces and territories, has an ongoing process to build and resource these systems.
In most cases of serious illness, providing standardized care within expert-designed systems not only provides better outcomes but is also more cost effective for taxpayers because these best practices ensure that expensive treatments are only provided to patients who are likely to benefit from that therapy.
Most of the conditions that require expert-designed care are serious, possibly fatal illnesses. However, systematic care is also useful when treating a few conditions that are less risky. Back and joint pain is not life threatening but is a very common cause for referral to a specialist, since family doctors often require help diagnosing and treating these conditions. Currently, these patients may wait months to see a bone or spine surgeon, even though most do not need surgery. They do, however, need someone who has more expertise in the field than their family doctor.
Ontario and Saskatchewan have resourced successful expert-designed systems of care wherein patients with back, hip or knee pain are seen within weeks of referral by experienced physiotherapists, nurses or chiropractors to determine whether they are in the minority of people who require surgery. If not, the patient and family doctor are provided with pain-management advice.
Ontario and Saskatchewan’s rapid-access clinics are designed by orthopedists, neurosurgeons, rheumatologists, physiotherapists, nurses and chiropractors who are experts in health system delivery as well as clinical care. Along with providing faster and better outcomes, this expert-designed system is less expensive than routine care in Ontario since it eliminates about 30 per cent of expensive, unnecessary MRI tests often ordered by primary-care providers while patients are waiting to see the surgeon.
However, provincial resources are required to implement these changes in care delivery.
Going back to our original example, why do some Canadians get rapid diagnosis of a breast lump while others wait over a month? Rapid-diagnosis breast clinics are not common in Canada because provincial health authorities rarely provide the administrative resources to co-ordinate primary-care providers with mammography, surgery and pathology services. Achieving high-quality care for complex illnesses requires the capacity to develop, implement and ensure the delivery of appropriate treatment protocols. This systematic approach requires administrative resources, which governments are generally eager to reduce. However, the money spent on implementing expert systems of care is repaid many times over with higher-quality outcomes and ensuring cost-effective practices.
Provincial ministries are, unfortunately, tending to downgrade expert provincial systems by reducing the independence and authority of agencies such as Cancer Care Ontario or the BC Cancer Agency. Many provinces have adopted single “super agencies” (like Ontario Health or the Nova Scotia Health Authority), which attempt to manage all health services delivered in the jurisdiction. The transition to these “super agency” models has often received critical reviews, in part because of the lack of focus and attention on complex care delivery systems.
The Ontario systems described earlier were all developed prior to the origin of Ontario Health. As one example of the loss of focus, after Cancer Care Ontario was taken over by Ontario Health, one of the first steps taken by the super agency was to eliminate funding for a quality management program designed to improve cancer diagnosis in the province. This program had been initiated after a woman had undergone a needless mastectomy because of a cancer misdiagnosis. The small administrative savings resulting from this budget cut cannot compare to the tragedy of an unnecessary mastectomy.
Currently, Alberta is the only province or territory in Canada that has a system in place to resource and empower teams of experts to design these superior systems of care. Alberta’s Strategic Clinical Networks are unique in incorporating new clinical and scientific discovery into ongoing provincewide treatment.
Provincial agencies should consider adopting the Alberta model of strategic clinical networks to ensure that adequately resourced and co-ordinated expert systems can deliver what Canadians need when we require complex treatment – both to improve outcomes and to increase confidence in our health care systems.
About the authors:
Dr. Robert Bell is professor emeritus in the Department of Surgery at the University of Toronto, former deputy minister of health for Ontario and former CEO of the University Health Network. Anne Golden is past president of the United Way of Greater Toronto and the Conference Board of Canada. Paul Alofs is former CEO of the Princess Margaret Cancer Foundation. Lionel Robins is past chair of the Princess Margaret Cancer Foundation, and a board member for the United Jewish Appeal Federation and the Betel Senior Centre.
Illustration by Tim Boelaars
More from the Fixing Health Care series:
Canada’s specialist referral system needs to be boosted into the 21st century
Four ways to make the universal pharmacare dream a reality
Transitional-care facilities will stop Canada’s ERs from resorting to ‘hallway medicine’
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