Surgical backlog must not be fixed at the expense of the healthcare system
As we breathe a tentative sigh of relief that COVID-19 numbers are stabilizing, the ripple effects of the pandemic are becoming more apparent.
Thousands of surgical procedures were cancelled when hospitals adjusted operations to brace for the wave of COVID-19 patients. Now, as governments grapple with this backlog, some have announced their intention to contract out care to private for-profit investor-owned facilities.
British Columbia is using all available beds to address its backlog. This now includes contracting out publicly funded care to for-profit surgical centres such as False Creek Surgical Centre, owned by Kensington Capital Advisers, a private equity firm. Manitoba recently announced that it, too, is considering contracting with for-profit facilities to address its backlog, as has Alberta with its recently announced Bill 30.
There is no doubt that COVID-19 has demanded healthcare systems adapt quickly, without the benefit of the long-term planning usually required for systems change. In the case of surgical backlogs, we should treat an acute wait list problem differently than we treat a chronic one. We must, however, ensure that short-term fixes don’t cause long-term harms – and that they ideally benefit the system.
Investor-owned, for-profit facilities may seem like an obvious solution to COVID-19 surgical backlogs. But what does previous experience tell us about these facilities?
Care delivered in for-profit facilities costs more than not-for-profit care and mortality and morbidity are worse. Past contracts in Alberta have paid higher prices to for-profit facilities than to public hospitals for the same services. Death rates from COVID-19 have been dramatically higher in for-profit long-term care facilities than in publicly owned or not-for-profit homes; in eastern Ontario, 83% of long-term care deaths occurred in for-profit homes. Why this discrepancy? Because investor-owned facilities owe a fiduciary responsibility to earn money for their shareholders, meaning less money is available for patient care. This must not be the way forward for our healthcare system.
So how do we create lasting capacity within the public system beyond the current crisis? Our response must be rooted in the solid evidence about system reform.
To clear the surgical backlog, we must scale-up hospital capacity by extending operating hours to include evenings and weekends. We should immediately implement team-based single-entry centralized wait-lists for the first available surgeon so patients can access care as quickly as possible. This approach has dramatically improved surgery wait times. “Surgical smoothing” would separate planned and unplanned surgeries into different operating room streams, eliminating the problem of emergencies bumping other surgeries. We must scale-up cost-effective, not-for-profit, publicly funded ambulatory surgical centres, such as rural and satellite sites, managed by hospitals.
In the short-term, if governments insist on using private investor-owned facilities in addition to, or instead of, exploring not-for-profit and public solutions, what are some critical elements that must be in place to minimize undermining the rest of our healthcare system?
First, provinces should only be turning to for-profit facilities after exhausting all efforts to increase capacity in the existing not-for-profit infrastructure. Where such for-profit facilities exist, government should consider purchasing them and bringing them under public ownership as B.C. did when it recently bought two private MRI facilities.
Second, any contracting out to investor-owned facilities must not delay or undermine initiatives to expand access to care within the public or private not-for-profit system (such as B.C.’s surgical strategy announced in 2018). Nor should new investor-owned facilities be built to address this pandemic-induced short-term backlog. This is the time to invest in our public health care system, not in a profit-driven industry.
Third, we must have full public oversight of investor-owned facilities. Governments must ensure they are transparent, operate within the law, and are subject to the same standards of inspection and certification as not-for-profit hospitals. This means not charging patients extra fees or selectively “cream skimming” healthier patients whose treatments cost less as a way to increase corporate profits. It means ensuring that proper personal protective equipment and infection control practices are in place.
We have a once-in-a-generation opportunity to learn from this pandemic and improve our healthcare system. We need to come out of this crisis with a stronger, more equitable public healthcare system, not a more fractured one.
As we recover from this crisis, we should be working toward a future that always puts patients above profits. If this crisis is instead used as an opportunity to expand and entrench for-profit investor-owned delivery of health services, it will be at our peril.
Lesley Barron is a general surgeon practicing in Limehouse, Ont. She is a health policy and gender equity expert.