Preface

THE FRASER INSTITUTE IS ABOUT TO PUBLISH ITS fourth book dealing with Canada's health care system. Åke Blomqvist, The Health Care Business, 1979; Ronald Hamowy, Canadian Medicine: A Study in Restricted Entry, 1984; Malcolm C. Brown, Caring for Profit, 1987; and W. McArthur, C. Ramsay and M. Walker, eds. Healthy Incentives: Canadian Health Reform in an International Context, 1996.Note All are concerned with the impact of economic arrangements on the quality and quantity of health care services delivered to Canadians. The latest book will make recommendations for health care reform in Canada which reflect an awareness of the emerging problems and the solutions proposed-and in some cases implemented-in other countries.

One of the health systems reviewed in this upcoming Fraser Institute publication is the United Kingdom's. The U.K. experience is especially noteworthy for Canada as it was the system upon which Canada's health care system was modelled. It is not surprising, then, that Canada is beginning to experience some of the same problems which led the U.K. to reform its health care system.

Years ago, local governments in the U.K. began producing publications documenting hospital waiting lists for a selection of operations as a guide for health care consumers so that they would be aware of which hospitals had shorter waiting times. The lists were much longer than could be justified by the desire to avoid unused capacity or to permit patients time to arrange their affairs prior to admittance, indicating that waiting was being used to ration health care in the U.K. One result of the health reforms has been a substantial reduction in the waiting times for surgical procedures in the U.K.

The Fraser Institute has been documenting hospital waiting lists in Canada since 1988. We began producing such measures because, at the time, there was anecdotal evidence that hospital waiting times were becoming significant. However, there were no systematic measurements of the extent of waiting. Partial waiting list measurements made by hospitals and government departments were seen as politically sensitive and were not made generally available. While these "official" waiting lists are now more readily available, they are still incomplete and there are no comprehensive measures by which to measure the length of waiting lists in Canada other than those produced by The Fraser Institute. With increased concern in Canada about the cost to government of continuing to supply the level of health care services that has been the norm, there is the possibility that waiting lists are being used in Canada as they were in the U.K.-to control health care expenses in a system where prices have been systematically eliminated and neither physicians nor patients have any economic incentive to consider the costs of their decisions.

The current Critical Issues Bulletin is the Institute's sixth attempt to document the extent to which queues are being used as a means of adapting to the conflict between limited budgetary allocations and potentially unlimited demand for free health care. The contents of the survey have been corroborated to the extent possible by recourse to other sources of information on rationing. In particular, copies of the preliminary drafts of the study were sent to all of the provincial Ministers of Health for their comments. Also, where there are facilities-based estimates of waiting times, such as in the case of cardiovascular surgery, we have used these to supplement the survey results.

The study has been enthusiastically supported by The Fraser Institute, but the work has been independently conducted, so the views expressed may or may not conform with those of the members and trustees of The Fraser Institute.

The Institute is pleased to again offer the research results for public consideration and debate. That many provincial governments now produce "official" hospital waiting lists is an indication that our work has stimulated concern about this public policy issue. Measurement is the key to finding solutions, as was revealed by the dramatic reorganization of the U.K. health care system. A similar search for solutions has begun in Canada, and we hope that the heightened "official" interest in waiting lists helps to ensure that the search continues and that innovative solutions will be considered.

About the authors

CYNTHIA RAMSAY is Health Economist at The Fraser Institute. She has a B.A. (Hons) in Economics from Carleton University and an M.A. in Economics from Simon Fraser University.

MICHAEL WALKER is Executive Director of The Fraser Institute. He received his Ph.D. in Economics from the University of Western Ontario. He has written, edited, or co-authored dozens of Fraser Institute publications.

Acknowledgements

This edition of Waiting Your Turn draws extensively from previous editions. We are pleased to acknowledge the work of Professor Steven Globerman, Ms. Lorna Hoye, and Ms. Joanna Miyake in the completion of earlier versions of the survey and in building the base of knowledge which is incorporated in this publication.

Executive Summary

"Waiting Your Turn" presents the only comprehensive measure of hospital waiting lists across Canada. The survey measures the extent of health care rationing in the provinces from year to year. Information for the survey was provided by 2,636 specialists nation-wide during the latter part of 1995.

This year's survey results show that Canadians waited longer in 1995 than in 1994 to receive medical treatment. According to the study, 165,472 Canadians are waiting for surgical procedures, a decrease from last year's (updated) estimate of 169,877. Although there are 2.6 percent fewer people waiting for treatment than there were in 1994, those waiting are waiting longer to receive their treatment-10.2 weeks from referral by a general practitioner (GP) to a specialist until the receipt of treatment in 1995, compared to 9.7 weeks in 1994.

GP to specialist

The waiting times for appointments to see specialists are shown in table 2. Most waits for specialists' appointments are less than two months. However, there are a number of 3-month or longer waits, mostly in eastern Canada. British Columbia and Saskatchewan have the shortest waits in the country for appointments with specialists, while Prince Edward Island has the longest. In every province, the waiting time to see a specialist has increased since 1994. For Canada, the waiting time to see a specialist increased by over 10 percent from 1994. If a person cannot visit a specialist, they won't appear on the waiting list for medical treatment because only a specialist can put a patient on the waiting list for surgical procedures. The rationing of health care in Canada is happening increasingly at the GP level.

A recent national survey by the College of Family Physicians of Canada College of Family Physicians of Canada, "Advocating on Behalf of Patients Survey," News Release, April 24, 1996.Note corroborates the evidence. Between 70 and 80 percent of family physicians cite waiting times to see a specialist, hospital waiting lists, and waits for diagnostic tests as reasons why they are now having to spend more time fighting for the care their patients need than they did five years ago.

Specialist to treatment

Once patients have seen a specialist, they then have to wait to receive medical treatment. The data clearly show that equal access to medical care in Canada is a myth. The number of people on surgical waiting lists and the amount of time they are waiting for treatment varies substantially from province to province. In Prince Edward Island, the province with the longest median waiting times, patients wait almost 12 weeks (table 28a) for surgical procedures, almost 2 months longer than people in Quebec, where the median wait for treatment is 4.7 weeks, the shortest waiting time in the country.

Total wait from GP to treatment

In Canada, patients generally wait more than two months after seeing their GP before receiving treatment for their ailments, from 8.6 weeks in Quebec to 19.3 weeks in Prince Edward Island (table 31). The longest waits for treatment tend to be for three specialties where the total wait a patient can expect to face exceeds 4 months: ophthalmology (17.8 weeks), orthopaedic surgery (18.5 weeks), and elective cardiovascular surgery (16.5 weeks). The shortest wait is for cancer patients being treated with chemotherapy. These patients wait approximately 2.8 weeks to receive treatment.

Clinically reasonable waits from specialist to treatment

The survey also measured what specialists consider to be clinically reasonable amounts of time to wait for surgical procedures. In almost every instance, the responding specialists thought patients were waiting too long for treatment. Chart 4 compares the actual median waiting times to the clinically reasonable waiting times for the different specialties. The largest difference in these two periods is for ophthalmology, where the actual waiting time is 4.6 weeks longer than what is considered to be reasonable by specialists. The smallest divergence is in medical oncology, where the median actual waiting time is 0.5 weeks shorter than the clinically reasonable waiting time.

This comparison of actual waits with clinically acceptable waits shows that a very large number of specialist physicians believe that Canadians are having to wait longer for care than is healthy. The College of Family Physicians of Canada survey shows that the majority of GPs also believe that their patients are waiting too long.

The wait for diagnostic testing

The wait to see a specialist and the wait to receive treatment are not the only delays that patients face. Patients experienced an increase in the waiting times for various diagnostic technologies across Canada: computerized tomography (CT) scans, magnetic resonance imaging (MRI), and ultrasound (chart 9). The median wait for an MRI in Canada of 8.4 weeks is more than twice that for a CT scan (3.7 weeks). Ultrasound tests are quite common and many specialists have their own machines, which resulted in a median wait for ultrasound in Canada of only 1.8 weeks in 1995, a relatively short wait compared to those for CT scans and MRIs, but still a 6 percent increase from 1994.

Rationing through waiting

One plausible explanation for the waiting times is that governments are using them as a way of controlling health care expenses by rationing access to health care. If this were the case, longer waits would be associated with lower rates of provincial spending on health care. An analysis of per capita costs adjusted for the age of the population and waiting times (chart 7) is consistent with this view, but the correlation is far from perfect.

For example, both Quebec and Newfoundland have had below average costs and waiting times for the last few years. However, the Quebec government has a policy limiting the extent of joint replacements, J. Ivan Williams and C. David Naylor, "Paterns of Healthcare in Ontario #5, Hip and Knee Replacement in Ontario," Institute for Clinical Evaluative Studies in Ontario, October 18, 1993.Note and, in general, Newfoundland has lower major surgery rates than the other provinces. Statistics Canada's Health Report No. 82-217, "Surgical Procedures and Treatments 1992-93."Note These and other factors contribute to what appear to be lower waiting times for these provinces since patients in need of these operations simply do not receive them and, hence, do not appear on a waiting list. In general, though, those provinces that have median waiting times above the national median are provinces that spend less on health care per capita than the national average.

Waiting your turn: hospital waiting lists in Canada (Sixth edition)

Introduction

"Waiting lists are not going to disappear in Canada. They're an accepted part of our system." Then Alberta Health Minister Shirley McClellan quoted in R. Walker, "Waiting Lists are an Accepted Part of Canadian Health System," The Medical Post, February 20, 1996, p.66.Note

Such comments from government officials show how prevalent waiting lists have become in Canada. Generally, waiting lists are blamed on an aging population and costly new advances in technology, two trends which seem likely to continue. Preserving a universal health care system through a "reasonable" amount of rationing is openly discussed, as is the need to restrict the amount of new technology provided to hospitals in order to keep hospital costs down. What is not as openly discussed is how such an approach to health care management may adversely affect the health of Canadians, and the health of the Canadian economy.

The existence of waiting lists for medical procedures and treatments is one manifestation of the rationing of health sector resources which is taking place in Canada. To the extent that non-price rationing of hospital capacity is occurring, monetary and non-monetary costs may be borne by Canadians even though these costs are not explicitly recognized. These unrecognized costs may include, for example, lost work time, decreased productivity associated with physical impairment and anxiety, and physical and psychological pain and suffering.

A working person incapacitated by an illness bears the costs of the loss of work. These costs are not included in those associated with running the health care system. Cancer patients needing radiation therapy who must drive long distances either to regional health centres or to the United States bear costs in terms of lost time that are not included in health costs nor in any way compensated by the health care system. A woman with a lump in her breast who is told she must wait four weeks for a biopsy to determine whether the lump is cancerous finds little comfort in the advice from her physician that epidemiological research shows that it doesn't matter to the outcome if the biopsy is delayed that long. The woman's anxiety and tangible psychological pain are not included in the costs of operating the health care system. All of the foregoing represent actual cases in Canadian health care experience. Details are available from the authors on request.Note

In each of these cases, the savings to the government's budget are real and are matched by real though uncounted costs to Canadian health care consumers. While it is difficult or impossible to measure these costs, it is possible to measure the extent of queuing or the length of waiting lists to approximate the extent to which these costs may be mounting.

A number of health sector administrators are sceptical about the meaning and usefulness of waiting lists. They are sceptical both of the relevance of waiting lists as an indicator of the performance of the health care sector and of the reliability of such data as a measure of the extent of rationing of health care services. D.H.A. Amoko, R.E. Modrow, and J.K.H Tan, "Surgical Waiting Lists II: Current Practices & Future Directions. Using the Province of British Columbia as a Test Study," Healthcare Management FORUM, Vol. 5, No.4, 1992.Note An earlier Fraser Institute publication evaluated various theoretical issues related to hospital waiting lists, including their relevance as measures of "excess demand." Steven Globerman with Lorna Hoye, "Waiting Your Turn: Hospital Waiting Lists in Canada," Fraser Forum, May, 1990.Note The discussion defended the proposition that waiting lists are a potentially important barometer of performance in the health care sector. It also provided estimates of waiting lists for a set of hospital procedures in British Columbia. That study was followed in 1991 by a five-province study similar to the initial B.C. study. Since 1992, all ten provinces in Canada have been surveyed.

This report builds upon our earlier studies by updating waiting list estimates for all of the provinces. In the next section, we briefly review the relevant theoretical issues before turning to the 1996 survey results.

Waiting lists as measures of excess demand

One interpretation of hospital waiting lists is that they are indices of excess demand for medical treatments performed in hospitals and that they represent the substitution of "non-price" rationing of scarce resources for rationing by price. The rationing, in this case, takes place through enforced waiting for the available capacity to perform a given treatment or procedure. That waiting is a form of rationing and not simply the "postponement" of a service can be seen by the fact that there are costs involved for those who are forced to wait. If the people waiting had their choice, they probably would not wait in most cases. To the extent that this is true, the wait amounts to a denial of service, and that means rationing. (It is, of course, difficult to know exactly the extent to which people are happy to wait. However, it can be presumed that those who are in physical pain or who are unable to work would prefer not to wait. Data published recently by Statistics Canada indicate that 45 percent of those who are waiting for health care in Canada describe themselves as being "in pain." Data taken from Statistics Canada's Public Use Microdata File, General Social Survey-Health, 1991.Note While not all of this pain would be alleviated by a visit to the doctor or by the surgical procedure for which the patient is waiting, some of it is clearly the direct result of waiting.)

A 1993 study by the Institute for Clinical Evaluative Studies at the University of Toronto categorized all patients waiting for hip transplants according to their level of pain. J. Ivan Williams and C. David Naylor, "Patterns of Healthcare in Ontario #5, Hip and Knee Replacement in Ontario," Institute for Clinical Evaluative Studies in Ontario, October 18, 1993.Note The study found that in Ontario 40 percent of those who were experiencing severe disability and 40 percent of those who had severe pain were waiting 13 months or more for hip surgery. A further 40 percent of those who were in severe pain waited 7 to 12 months while only 14 percent of those in severe pain waited less than four months. While some of these patients might have been postponing their surgeries for their own reasons, the fact that they were experiencing severe pain probably means that most were being denied prompt access to treatment.

To put the issue somewhat differently, war-time rationing of refrigerators or automobiles could be reinterpreted as simply waiting. Those who wanted "fridges" in 1940 but didn't get them until 1946 were not denied the fridges, they only had to wait. Obviously, the issue of time is an important one in the matter of goods provision. It is also important-in some cases crucial-in the case of waiting for medical services.

Economists generally believe that non-price rationing of scarce resources is less efficient than rationing through the price system. In particular, prices are efficient mechanisms for signalling the relative scarcity of any good or service, thereby encouraging both producers and consumers to modify their behaviour accordingly. A rise in price occasioned by an increase in the demand for a particular medical procedure does cause some health care users to be deterred-effectively rationing the existing supply. The price rise also sends out the signal that not enough health care is being supplied. Assuming that the price rise makes additional profits possible, there will be an increase in the supply of health care as suppliers change their behaviour to take advantage of the new profit possibility. This supply response does not necessarily occur if waiting is the system of rationing employed.

Non-price rationing is also inefficient because it obscures differences in intensities of demand across different sets of consumers. To the extent that some consumers desire a given product more than other consumers, strict non-price rationing might result in those consumers who desire the product less actually obtaining it. All other things being constant, efficiency is promoted when those consumers who most value a product obtain it. For example, while a non-working spouse and his wife may be equally rationed by a system of waiting lists, the working wife might be willing to pay a little more to be able to get back to work. This would be quite rational behaviour on her part even if she and her husband were suffering the same disability. The reason is that she is suffering the additional costs of lost wages, which are not included in the cost of health care and which are not compensated by the universal health care system. With identical illnesses, the wife and husband do not have the same intensity of cost, nor the same need for the medical service that they are both being denied by waiting.

At least two prominent qualifications can be raised about the social inefficiencies of rationing by waiting. One is the claim that many procedures and treatments are performed where the social costs outweigh the social benefits. In these cases, it would be more desirable to discourage the consumption of a given amount of medical services by price rationing rather than by non-price rationing. In other words, let the working wife pay the increased costs of earlier treatment so that she can get back to work and let her husband wait for an opening on the "elective" surgical waiting list. That is the appropriate approach unless one is prepared to argue that patients will pay any price to receive specific treatments and that government bureaucrats are better able to determine whether treatment is warranted at any cost of providing it.

A second qualification is that non-price rationing of a vital product such as medical services is fair and is perceived to be fair by society. To the extent that fairness is an objective, one might argue that non-price rationing provides collective benefits that outweigh the inefficiencies identified above. However, depending upon how the non-price rationing occurs, the resulting distribution of benefits may not be any improvement upon the price-rationing outcome. If, for example, in a rationing circumstance, personal acquaintance with the head of surgery leads to less waiting, then rationing by waiting simply becomes a cover for a system of personal privilege. Even if the probability of knowing the chief of surgery were not related to income, the replacement of rationing by price with rationing by acquaintance will only create a different form of unequal access.

The fairness argument can be further qualified if we recognize the potential for providing direct cash transfers to poorer people to enable them to compete in the marketplace for any specific good or service. The argument against direct subsidies is that it is easier to target subsidies-in-kind to appropriate recipients. In the context of health management, this would mean that one would subsidize lower income people needing specific health care services. However, given the unexpected nature of many illnesses or accidents, it will be difficult to identify these people before the fact. Furthermore, given the potential for catastrophic illness and the associated high costs of treatment, some amount of direct subsidization might have to be extended to a large portion of the population and not just to low-income groups. In this case, the deadweight efficiency losses associated with a system that provides direct cash transfers to poorer people may not be significantly different from those associated with transferring income in-kind through non-price rationing.

To take the analysis a step further, the government might consider subsidizing purchases of private health care insurance by lower-income individuals and families thereby indirectly "targeting" health care assistance. The subsidy could be geared to a family's ability to pay so that it could approximate the full cost of the insurance premium for some buyers. At the same time, prices would be relied upon to "clear" the market for medical services.

To be sure, there are many arguments that have been made both for and against private medical insurance systems. These are considered in The Fraser Institute books, The Health Care Business and Healthy Incentives.Note For the purposes of this report, we accept that the public provision of and payment for health care services is an institutionalized feature of Canadian society for the foreseeable future and that extensive use of market pricing mechanisms to ration scarce capacity is unlikely. Under these circumstances, the extent of any excess demand, as well as how that excess demand is rationed, are relevant public policy issues, since the social costs associated with non-price rationing should be set against whatever benefits are seen to be associated with it.

Non-price rationing and methods of adapting

There are several ways in which non-price rationing can take place under the current health care system and many ways by which individuals adapt to rationing. One form of non-price rationing is a system of triage-the three-way classification system developed by Florence Nightingale for sorting the wounded on the battlefield in wartime. Under such a system, the physician sorts the patients into three groups: those who are beyond help, those who need and will benefit from immediate care, and those who can wait for care.

In peacetime, there may also be a shortage of resources, which requires physicians to employ the triage system to make choices about the order in which people should be treated. In such a selection process, physicians effectively ration access by implicitly or explicitly rejecting candidates for medical treatment whom they would otherwise treat. In the absence of well-defined criteria, doctors might be expected to reject those candidates least likely to suffer morbid consequences from non-treatment and those whose life expectancy would be least improved by treatment. The British experience suggests that some doctors use a foregone present value of earnings criterion for selecting patients for early treatment, thereby giving lower priority to critically ill patients. See Henry J. Aaron and William B. Schwartz, The Painful Prescription: Rationing Hospital Care, Washington: D.C.: The Brookings Institution, 1984.Note The experience of Canada's largest cancer treatment centre suggests that doctors are giving priority for radiation treatment to people whose cancers may be curable, as opposed to using the radiation machines to provide palliative care or limited extensions to life expectancy. See "Cancer Patients Face Wait For Treatment," Globe and Mail, September 13, 1989, p. A1.Note

Although both males and females can expect to live, on average, about five years longer than they did 20 years ago, the number of years that Canadians can expect to live in good health has actually declined, by 2.3 years for females (chart 1) and 0.4 years for males between 1978 and 1991. Organization for Economic Cooperation and Development Health Data, Electronic Version #3.6, released May 1995.Note The reason for this decline is not obvious, however, it is consistent with the findings of recent surveys showing that there is an increasing amount of rationing in the health care system. It has long been known that when rationing emerges in a health care system, the elderly are the most likely to feel the impact. E. Binney and C. Estes, "The Retreat of the State and Its Transfer of Responsibility," International Journal of Health Sciences, vol. 18, 1988, pp. 83-96; A. McKinnon, "We've Got the Best Cared For Seniors in the Country," Canadian Association on Gerontology Meeting, Vancouver, B.C., October 28, 1995; O. Agbayewa, "Suicides Among Elderly Linked to Societal Factors," Medical Post, vol. 7, no. 26, October 7, 1995.Note The reason is that in a classic triage system, older patients tend to get placed at the end of the queue as they will benefit less from treatment (i.e. for fewer years).

Click here to view Chart 1: Female Good Health Life Expectancy from Reporting OECD Countries

It is unlikely that medical practitioners would acknowledge that they are, in effect, rejecting (as opposed to queuing) specific patients who in their medical judgment do need treatment, so it would be difficult to identify this behaviour if it were occurring. Patients who have a lower priority or who are not destined to get the care they need simply find that their turn never comes as others take their place in the queue. In this regard, there is no persuasive evidence that mortality rates in Canada are increasing significantly owing to a failure to provide medical services. However, if one regards the elimination of pain and suffering as the objective of medical care, then any additional pain suffered by patients because of delays is medical treatment denied.

Canadians may be adapting to non-price rationing by substituting private medical services for unavailable public services, specifically by going outside the country for health care. Provincial health care plans cover emergency medical services and other services only available outside Canada. Possibly as a reflection of the increasing prevalence of waiting in the health care system, a Winnipeg-based company began to market an insurance product that provides private insurance for non-emergency treatment outside of Canada. "Insurance Plan Skirts Lineups," the Vancouver Province, April 6, 1993, p. A19.Note Similarly, there are companies in Ontario which will facilitate a patient's receipt of diagnostic testing in the U.S., and U.S. medical centres have advertised in Canadian newspapers. Our survey of specialists (reported later in this study), found that about one percent of patients inquired about treatment in another country.

Measuring rationing by waiting

Observers who argue that hospital waiting lists are not a particularly important social issue believe that waiting lists tend to be inaccurate estimates of rationing and/or that there is little social cost associated with enforced waiting.

One frequently expressed concern is that doctors encourage a greater demand for medical care than is socially optimal. As a result, waiting lists exist for specific treatments. However, there may be no significant social costs associated with rationing since many (perhaps most) individuals on waiting lists are not in "legitimate" need of medical treatment. In a related version of this argument, doctors are suspected of placing a substantial number of patients on hospital waiting lists simply to exacerbate the public's perception of a health care crisis so as to increase public funding of the medical system.

The available evidence on the magnitude of supplier-induced demand for medical services is, at best, ambiguous. The view that this is a modest problem is supported by the fundamental economic argument that competition among physicians will promote a concordance between the physician's interests and those of the patient. General practitioners usually stand as agents for patients in need of specialists. Specialists carry out the bulk of hospital procedures. General practitioners who can mitigate medical problems while sparing patients the pain and discomfort of hospital treatments are more likely to be perceived as doing a good job than those who encourage short-term or long-term hospitalization as a cure. This suggests that general practitioners have an incentive to direct patients to specialists who will not "overprescribe" painful and time-consuming hospital treatments.

Placing excessive numbers of patients on hospital waiting lists may also have direct costs for opportunistic specialists. For example, the latter may come to be seen as using a disproportionate share of hospital resources. This may make it more difficult for them to provide quick access to those resources for patients who are in more obvious (to themselves and to their general practitioners) need of hospital treatment. Similarly, patients facing the prospect of a relatively long waiting list may be tempted to search out other doctors with better connections to hospital facilities.

As an additional consideration, there is no concrete reason for any single physician or group of physicians to believe that an individual physician's waiting lists will significantly affect government funding policies or that they will be net beneficiaries of any increased funding that does occur. In the face of obvious incentives to "free-ride" on the strategic behaviour of other physicians, there may be no significant bias for physicians to inflate hospital waiting lists or even to over-report the number of patients they have waiting for admission to hospital.

An often-mentioned concern about measuring waiting is that hospital waiting lists are biased upward by a failure of reporting authorities to identify individual patients listed by more than one doctor and by a failure to prune waiting lists of individuals who have either already received the requested treatment or who, for some reason, are no longer likely to require treatment. Our survey results indicate that doctors generally do not believe that their patients have been booked on waiting lists by other physicians.

In summary, while there are hypothetical reasons to expect that hospital waiting list parameters will overstate true excess demand for hospital treatments, the magnitude of any resulting bias is unclear and is probably relatively small, given countervailing factors that may reduce measured amounts of waiting.

Hospital waiting list survey

In order to develop a more detailed understanding of the magnitude and nature of hospital waiting lists in Canada, the authors of this study conducted a survey of specialist physicians. Specialists were surveyed rather than hospital administrators because a substantial number of hospitals either do not collect waiting list data in a systematic manner or do not make such data publicly available. See Amoko, Modrow, and Tan, "Surgical Waiting Lists II," p. 36.Note In those instances where hospital-based data are available they have been used to corroborate the evidence from the survey data.

The survey was conducted in all ten Canadian provinces. Mailing lists for the specialists polled were provided by Southam Business Lists. The specialists on these lists are drawn from the Canadian Medical Association membership lists. Specialists were offered a chance to win a $2,000 prize as an inducement to respond (without regard to whether they actually chose to complete the questionnaire). Though answering physicians were undoubtedly motivated in part by the lottery, the large percentage of answering specialists indicates concern about waiting lists for surgical procedures in Canada. Quite clearly, the medical profession has a collective interest in promoting an increased flow of financial and other resources to the health care sector. Nevertheless, it should not be assumed that the survey results are, therefore, unreliable. In particular, it should not be assumed (for reasons suggested earlier) that individual physicians responding to the survey have skewed their responses in a particular direction since physicians were not pre-selected as to their views about the adequacy of current funding or their views about current health care arrangements. There is a wide dispersion of views amongst physicians about the desirability of greater ease of access and there is no reason to believe that those who want to create the impression of longer lists are either more likely to distort their responses or more likely to respond to the survey than those who do not.

The authors chose to survey specialists rather than general practitioners because the former have primary responsibility for health care management of surgical candidates. Survey questionnaires were prepared for twelve different medical specialties: plastic surgery, gynaecology, ophthalmology, otolaryngology, general surgery, neurosurgery, orthopaedics, cardiovascular surgery, urology, radiation oncology, medical oncology, and internal medicine. For the 1990 survey, the questionnaires were pre-tested on a sample of individual member specialists serving on the relevant British Columbia Medical Association specialty committee. In each subsequent use, suggestions for improvement have been made by responding physicians and these modifications have been made to the questionnaires. Adhering to the questionnaire format of the ten specialties originally surveyed, radiation oncology and medical oncology were added to the survey in 1994. The survey used for general surgery is included in Appendix 1 of this report. The questionnaires for all of the specialties follow this format, with only the procedures surveyed differing between specialties. The data were collected in December 1995.

For the most part, the survey was sent to all specialists in a category. In the case of internal medicine in Ontario, 500 names were randomly selected. The response rate of 30 percent overall was considered quite high for a mailed survey. The response rate in the five provinces initially surveyed (British Columbia, Manitoba, New Brunswick, Newfoundland, Nova Scotia) was 20 percent. This year, the response rate for these same provinces is 33 percent. This year, the response rates for the Atlantic provinces were: 38 percent in Prince Edward Island, 35 percent in Newfoundland, 33 percent in New Brunswick, and 32 percent in Nova Scotia.

Methodology

The treatments identified in all of the specialist tables represent a cross-section of common procedures carried out in each specialty. They were suggested by the British Columbia Medical Association specialty boards in 1990, with some procedures being added since then (at the suggestion of survey participants).

At the suggestion of the Canadian Hospital Association, median measures of waiting have been used for the last two years rather than average measures. "CHA Comments on The Fraser Institute's Latest Waiting Lists Survey," Leadership in Health Services, Nov./Dec. 1994.Note In using average waiting times, there is the problem of outliers: the presence of a specialist whose patients must wait an especially long time will skew the specialty average upwards. If such a specialist responds to the survey one year and not the next, the difference between years will be large but will not necessarily be an indication of an actual change in the province's waiting times. The use of medians avoids this problem. A median is calculated by ranking specialists' responses in either ascending or descending order, and determining the middle value. When the middle of the ranking lies between 2 responses, the median is the average of these 2 responses. So, if the median wait reported is 5 weeks for a procedure, half of the specialists reported waits of longer than 5 weeks while half of the specialists reported waits of less than 5 weeks.

The major findings from the survey responses are summarized in tables 2 through 44. Table 2 reports the median time a patient waits for an appointment with a specialist. This period is measured from the time a general practitioner refers the patient to the specialist. The wait for an appointment with a specialist is calculated as the median of the weeks indicated by responding specialists. These appointment medians are then weighted by the ratio of the number of specialists surveyed in each specialty in a province to the total number of specialists surveyed in the province, to obtain the weighted median reported on the last line of table 2.

Tables 3 through 14 report the time a patient must wait for treatment after having seen a specialist, where the waiting time per patient is the median of the survey responses. The weighted medians reported in the last line of each table are calculated by summing the products of the median wait for each operation, and the ratio of the number of persons undergoing each operation and the total number of operations performed in each specialty by province.

Tables 15 through 26 report the estimated number of patients waiting for surgery. To allow for inter-provincial comparisons, these tables also report the number of people waiting for surgery per one hundred thousand population.

The number of people waiting for treatment is estimated using the average of the weeks waited for treatment as reported by responding specialists and the Statistics Canada's Health Report No. 82-217, "Surgical Procedures and Treatments 1992-93." This report provides a count of the total number of surgical procedures performed annually by each province. To estimate the number of individuals waiting for surgery at any given point, we divide the average weeks waited for a given operation by 52 and then multiply this number by the total number of persons undergoing this operation annually. Thus a waiting period of, say, one month, implies that on average, patients are waiting one twelfth of a year's total capacity to get their surgery. The next person added to the list would find one twelfth of a year's patients ahead of them in the queue. The main assumption underlying this estimate is that the number of surgeries performed will neither increase nor decrease within the year in response to waiting lists.

There are a number of minor problems matching Statistics Canada's operation categories to the ones reported in our survey. In several instances, an operation such as rhinoplasty is listed for more than one specialist. In these cases, average waiting times are identified with the classification of the responding specialist. Hence, the flow or number of patients annually undergoing this type of operation is divided between specialties according to the proportion of overall surgery performed in each specialty. In other instances, an operation polled in our study has no match in the Statistics Canada report. For example, there is no match for the urology operation, "ureteral reimplantation for reflux," in the Statistics Canada report. In these cases, we make no estimate of the number of patients waiting for these operations.

Tables 28a and 28b offer a comparison of median waiting times and the estimated number of patients waiting across specialties and provinces. Of course, our calculation of the estimated number of patients waiting in each specialty includes only those patients waiting for the operations surveyed. The operations we surveyed represent between 56 and 73 percent of non-emergency surgery performed in each of the provinces studied.

The final row of table 28a shows the weighted medians of the 12 specialties listed above. These weighted medians are calculated by summing the products of median waiting and the proportion of polled surgery. To estimate the number of people waiting at any time for non-emergency surgeries that were not included in our survey, we found the residual operations for each province. The estimate of residual waiting is the product of the residual number of operations in each province and the provincial weighted averages divided by 52 (weeks). The estimates of residual waiting are reported in table 28b, as are the estimates of the total number of patients waiting in each province at any given time during the year.

Tables 32 through 43 report the median number of weeks that specialists consider to be clinically reasonable to wait for treatments. The methodology of these tables is comparable to that of tables 3 through 14.

Data verification with government, hospital, or other sources

All of the data were sent across Canada to provincial ministries of health or the regional health authorities (if applicable), in March 1996. Replies were received from British Columbia, the Calgary Regional Health Authority, the Capital Health Authority (Edmonton), Saskatchewan, Manitoba, Newfoundland and Nova Scotia. In general, the data provided by these sources indicate that our survey results, to the extent that they are comparable with the data from these sources, underestimate the amount of waiting in Canada.

The Ministry of Health and the Ministry Responsible for Seniors in British Columbia estimates that there are approximately 1,500 patients waiting, on average, just over 13 weeks for hip or knee surgery in the province. Our survey results indicate that about 1,200 British Columbians are waiting for joint replacement surgery, and that they are waiting about 16 weeks. The Ministry's data, however, confirm our estimate that there are about 350 people waiting for cardiac surgery and that most patients receive their bypass surgery within 10 weeks. While our survey results underestimate the number of people waiting for radiotherapy in B.C., the Ministry waiting list confirms our results that patients are waiting approximately 4 weeks for radiotherapy treatment of breast cancer, and 6 weeks for treatment of prostate cancer.

The Calgary Regional Health Authority provided data on the numbers of people waiting for surgery at hospitals within its jurisdiction. The Capital Health Authority, which serves Edmonton and most of Northern Alberta, provided us with data on the waitlists for major joint replacement surgery and cardiovascular surgery. The data from these sources indicate that while our survey results succeed in capturing the length of time that Albertans are waiting for surgery, they tend to underestimate the number of patients waiting for surgery in Alberta. The greatest divergence between the survey results and those of the health authorities is for hip or knee surgery; our estimate of the number of people waiting is about half that of the health authorities.

The department of health in Saskatchewan provided us with cardiovascular surgery waiting times for bypasses, valve and septa operations, and pacemaker operations. It also provided us with waiting list data for the specialties of urology and otolaryngology. It could not provide us with any data on medical and radiation oncology or internal medicine. With respect to the other specialties surveyed, our survey was relatively accurate in estimating the length and duration of Saskatchewan's waiting lists, with one exception. Again this year, according to hospital officials in Saskatoon, the number of people waiting for cataract surgery is largely underestimated by our survey as is the amount of time these patients are waiting. A total of 4,123 people are on the "active" waiting list for eye surgery in Saskatoon alone, and 655 people are on the "pending" waiting list. Patients on the "pending" waiting list have requested specific dates for their surgery or they have previously been offered a surgery date but have asked for it to be postponed.Note Patients requiring "elective" eye surgery have had to wait an average of 53.9 weeks, and patients classified as "urgent" have had to wait an average of 13.4 weeks.

Whereas many other provinces have started to collect waiting list data for certain specialties (mainly those of cardiovascular surgery and orthopaedic surgery), Saskatchewan was in the best position to comment on our survey results because they are well into the process of developing a provincial waiting list system. Saskatchewan is attempting to develop a system with standardized data that will be as comprehensive as possible and accessible. The continuing project is a collaborative effort between the Saskatoon and Regina health districts and Saskatchewan Health (the health ministry).

The Manitoba Ministry of Health and the Newfoundland and Labrador Department of Health responded to our request for data verification but, unfortunately, neither province maintains waiting list data. The Manitoba Minister of Health, however, indicated in his response that Manitoba is in the process of developing a centralized waiting list system for several specialties. Nova Scotia's Department of Health indicated that the responses to our survey from Nova Scotia were not representative. However, they could not provide us with any data that would support this claim. They did, however, indicate that they would be tabling a report on waiting times to the Legislature shortly. As of the writing of this document, no such report had yet been produced.

Our survey indicates that about 850 Ontarians are waiting 13 to 15 weeks for elective cardiovascular surgery. Ontario's Provincial Adult Cardiac Care Network, an advisory body created in 1990 to monitor waiting lists, estimates that are 1,192 patients waiting a median of 10.7 weeks for cardiovascular surgery in Ontario. Estimates are for the fiscal year 1995-96, as reported in S. Jeffrey, "Ont. Hikes Funding to Lessen Heart Surgery Lineups," The Medical Post, December 1995, p. 2.Note The Ontario Orthopaedic Association found that orthopaedic outpatients are waiting about 10 weeks for surgery, and that inpatients are waiting approximately 15.4 weeks. These data would suggest that our survey results underestimate the waiting time for orthopaedic surgery in Ontario by about 3 weeks.

Data comparability with other waiting list studies

In 1967, a survey of British Columbia hospitals was done by the British Columbia Hospital Insurance Service, the forerunner to MSA. Paul Pallan, A study of hospital waiting lists, Research Division, British Columbia Hospital Insurance Service: Department of Health Services and Hospital Insurance.Note This study was undertaken primarily to project bed needs in the future. Thus, its data were for individual hospitals and regions and do not allow for direct comparison with our study. However, some general comments can be made. In 1967, reported waiting times ranged from 2 to 300 days with an average time of about 5 weeks, though this figure varied substantially among hospitals. Our survey results show that waiting times in British Columbia range from 2 to 154 days, with a median waiting time of 9 weeks. Another difference between patients waiting today and those in 1967 is that today's patient is more likely to be classified as urgent. The 1967 study found that 93 percent of patients in their sample population were waiting for elective surgery, 7 percent for urgent and 0.5 percent for emergency. In contrast, figures made available to us by Vancouver General Hospital for 1988 suggest that 76 percent of the patients waiting are classified as elective and 24 percent are classified as urgent. Finally, the Hospital Insurance Service study estimated that in 1967 the total number of people on hospital waiting lists in British Columbia exceeded 12,000-0.6 percent of the population in B.C. that year. Our estimate of 26,984 people waiting for surgery in B.C., an increase of 291 from our updated 1994 estimate, represented 0.7 percent of the population in 1995. Although there were only slightly more people waiting for surgery in B.C., these people were waiting much longer. In 1995, they were waiting 22 percent longer than they were in 1994.

A brief survey of Ontario hospitals undertaken in October 1990 for the General Accounting Office of the United States Government General Accounting Office, Human Resources Division, Canadian Health Insurance: Lessons for the U.S., 91-90, June 1991, Report to the Chairman of the Committee of Government Operations, House of Representatives.Note suggests that patients waiting for elective orthopaedic surgery were waiting from 8.5 weeks to 51 weeks, that elective cardiovascular patients were waiting one to 25 weeks, and that elective ophthalmology patients were waiting 4.3 to 51 weeks. Limited as this survey was, its results are consistent with ours.

A study of waiting times for radiotherapy in Ontario William J. Mackillop, F.R.C.P., et al., Waiting for Radiotherapy in Ontario, The Radiation Research Unit, Queen's University, Kingston Regional Cancer Centre and Kingston General Hospital, 1993.Note found that the median waiting times between diagnosis and initiation of radiotherapy for carcinoma of the larynx, carcinoma of the cervix, non-small cell lung cancer, and carcinoma of the prostate were 30.3 days, 27.2 days, 27.3 days, and 93.3 days respectively. Our survey estimates of 28 days for the radiotherapy treatment of cancers of the larynx and cervix, and 24.5 days for radiotherapy treatment of lung cancer are consistent with these data (waiting times from referral, to meeting with a specialist, to treatment). However, our estimate that prostate cancer patients were waiting a median of 31.5 days for radiotherapy is not consistent.

Focus on cardiovascular surgery

More people in Canada will die this year of cardiovascular disease than of any other single cause. Because cardiovascular disease is a degenerative process and the decay of the cardiac surgery candidate is gradual, under a system of rationed supply some cardiac surgery candidates tend to be bumped by patients with other conditions that require immediate care. This is not a direct process but rather a reflection of the fact that budgets for hospitals are set separately for "conventional illness" and for other, high-cost interventions such as cardiac bypass. Only a certain number of the latter are included in a hospital's overall annual budget. Complicating matters is the on-going debate about whether cardiac bypass surgery actually extends life. If it only improves the quality of life there will be no statistics that point to a decay of health care in the population and, hence, no basis for increased funding.

The result has been lengthy waiting lists, often as long as a year or more, followed by public outcry, which in turn has prompted short-term funding. For instance, four years ago we reported that Newfoundland's waiting list for coronary bypass surgery was a year long. A year later, the hospital performing open heart surgery received a special temporary grant to deal with its waiting lists. This year, many provincial governments provided additional funding for heart surgery in their provinces: B.C., Ontario, Alberta, and Nova Scotia, for example. U.S. hospitals have also provided a convenient short term solution to excessive waiting lists for cardiac surgery. The British Columbia government contracted Washington state hospitals to perform some 200 operations in 1989 following a public outcry over the six-month waiting list for cardiac bypass surgery in this province.

Wealthy individuals are sometimes choosing to avoid the waiting lists by having their heart surgery performed in the U.S. A California heart surgery centre has advertised its services in a Vancouver newspaper. Our survey suggests that 2.5 percent of British Columbians with heart disease inquire about the possibility of treatment outside of the province. For Canada as a whole, about 0.5 percent of cardiac patients inquire about surgery outside of Canada while 0.4 percent actually have their heart surgery performed outside of the country.

Excess demand and limited supply have led to the development of a fairly stringent system for setting priorities in some hospitals. In some provinces, patients scheduled for cardiovascular surgery are classified by the urgency of their medical conditions. In these cases, the amount of time they wait for surgery will depend on their classifications. Priorities are usually set based on the amount of pain or angina that patients are experiencing, the amount of blood flow through their arteries (usually determined by an angiogram test), and the "shape" their hearts are in.

For the past three years, the cardiovascular surgery survey questionnaire has distinguished among emergent, urgent, and elective patients: the traditional classification by which patients are prioritized. However, in discussing the situation with physicians and by talking with hospital administrators, it has become clear that these classifications are not standardized across provinces. British Columbia and Ontario use a nine-level prioritization system developed in Ontario. Other provinces have a four-level system, with two urgent classifications. Decisions as to where to group patients was thus left to answering physicians and heart centres. Direct comparisons among provinces should, therefore, be made tentatively while recognizing that this survey provides the only comparative data available on the topic.

Efforts were made again this year to verify the cardiovascular surgery survey results specifically with hospital statistics and with data from provincial health ministries. We acquired the actual number of patients waiting for cardiac surgery in British Columbia from the province's Ministry of Health; our survey data are consistent with the Ministry's data. Hospital officials in Alberta, Nova Scotia, and New Brunswick provided us with provincial data, as did the department of health in Saskatchewan.

Estimates of the length of cardiac waiting lists were either taken directly from hospital or department of health information or were extrapolated from the survey results. The survey estimates of the numbers of people waiting for heart surgery were derived in the same manner as those for the other specialties, from the average wait times. The average waiting time for urgent patients was used in the calculation, rather than the emergent or elective wait times, because it provided a convenient middle measure. In provinces where the length of the waiting list was provided by the hospitals, it became clear that the average wait for elective surgery overestimated the length of the line while the emergent average waiting time underestimated it.

In a 1991 paper, an Ontario panel of sixteen cardiovascular surgeons attempted to outline explicit criteria for prioritizing patients. Naylor, C.D. et al., "Assigning priority to patients requiring coronary revascularization: Consensus principles from a panel of cardiologists and cardiac surgeons," Canadian Journal of Cardiological Medicine, June 1991, vol. 7, no. 5, pp. 207-213.Note They also suggested time frames considered safe waiting times for coronary surgery candidates. For comparative purposes, it was necessary to collapse their nine priority categories down to the three used in this study. Having done this, we found that they suggest that emergent patients should be operated on within 3 days (or 0.43 of a week). Five of the nine provincial median emergent wait times for cardiovascular surgery fall outside of this range. However, physicians in these provinces may define emergent to include patients that might be considered urgent in other provinces. Urgent surgeries should, according to the Ontario surgeons, be performed within six weeks. The median waits for urgent cardiac surgery in Alberta, Manitoba, and New Brunswick fall outside of this range. The Ontario panel suggests that elective surgeries be performed within a period of six months. All provinces except New Brunswick and Newfoundland fall within this time frame.

Survey results: estimated waiting in Canada

Waiting for an appointment with a specialist

Table 2 indicates the median number of weeks that patients wait for initial appointments with specialists after referral from their general practitioners or from other specialists. Most waits for specialists' appointments are less than 2 months in duration. However, there are a number of three month waits (or longer): to see a plastic surgeon in Nova Scotia, a gynaecologist in Prince Edward Island, an ophthalmologist in Manitoba or Nova Scotia, a neurosurgeon in New Brunswick or Newfoundland, an orthopaedic surgeon in New Brunswick or Newfoundland, a cardiovascular surgeon in Nova Scotia, and an internist in Prince Edward Island. The weighted medians, depicted in chart 2, suggest that British Columbia and Saskatchewan have the shortest waits in the country for appointments with specialists, while Prince Edward Island has the longest. In every province, the waiting time to see a specialist has increased since 1994. For Canada, the waiting time to see a specialist has increased by over 10 percent.

Click here to view Chart 2: Waiting by Province in 1994 and 1995
Weeks Waited from G.P. Referral to Appointment with Specialist

Time spent waiting for treatment

Several general observations can be made about tables 3 through 14 and tables 32 through 42. Residents of all provinces surveyed are waiting significant periods of time for hospital treatments. While some treatments have short waits, most procedures require waits of at least a month. For many procedures, the waiting time is at least 2 months. Seventy-nine percent of the actual weighted median waiting times are greater than the weighted median of what specialists considered to be reasonable waiting times. The median wait for orthopaedic surgery in Alberta is 12.9 weeks. A clinically reasonable amount of time to wait, according to Alberta specialists, is about 6 and a half weeks. In P.E.I., the actual time to wait for an otolaryngology procedure is about 15 weeks, whereas P.E.I. specialists feel that a wait of about 5 weeks is clinically reasonable. In Ontario, specialists considered 5 weeks a reasonable amount of time to wait for eye surgery. However, the median actual time to wait is 10.9 weeks, more than twice as long a wait. The differences between the median reasonable and median actual waits for the specialties are summarized in table 44.

Ranking the provinces according to the weighted medians reported in table 28a indicates that the longest median wait for surgery occurs in Prince Edward Island and the shortest in Quebec. There is more than a 7 week difference between the shortest and the longest weighted medians. Graphically, the median waits for treatment by province can be seen in chart 3. For Canada, the wait for treatment after having seen a specialist increased slightly from 5.8 weeks in 1994 to 5.9 weeks in 1995. The large decrease in the amount of time Manitobans are waiting for treatment comes mainly from the large drop in the waiting time for elective cardiovascular surgery in the province from 1994. For the purposes of comparing the 1994 and 1995 median data, the weighted median calculations for 1994 have been updated to include the waits for elective as well as urgent cardiovascular surgery. Thus, the 1994 figures in chart 3 will differ from those published in last year's "Waiting Your Turn."Note

Click here to view Chart 3: Waiting by Province in 1994 and 1995
Weeks Waited from Appointment with Specialist to Treatment

Table 30 presents a frequency distribution of the median waits for polled surgery by province and by region. In all provinces, the majority of polled operations have waiting lists of less than three months. The Atlantic provinces collectively have the greatest proportion of median waiting times over six months and the lowest proportion under three. In contrast, 96.6 percent of Quebec's median waits and 89.9 percent of Ontario's median waits are under three months long and none are over six months.

Number of people waiting for treatment

Last year, a new statistic was added to tables 15 through 26. Provincial populations vary greatly, thus it is hard to gauge the differences in waiting list length based solely on pure numbers of people waiting. A couple of examples should illustrate this point. In Quebec, there are 2,640 people waiting for surgery by a gynaecologist, while there are 3,845 people waiting for a gynaecological procedure in Ontario. The pure numbers of people waiting would imply that there are fewer people waiting for these types of treatments in Quebec. However, they translate into roughly the same number of people waiting per 100,000 in each province; 36 people waiting per 100,000 population in Quebec, and 35 people waiting per 100,000 in Ontario. In B.C., there are 2,118 people awaiting orthopaedic surgery, or 58 per 100,000 population, while in Prince Edward Island, there are 169 people waiting, the equivalent of 126 per 100,000 population. Table 27 provides a summary of these statistics.

Further comparison with last year's results

In order to compare this year's data with last year's, it was necessary to update last year's calculations using Statistics Canada's Health Report No. 82-217, "Surgical Procedures and Treatments 1992-93." The comparison of median waiting times is shown in table 29a. The number of people waiting for surgery or treatment in 1995 as compared to the number of people waiting in 1994 appears in table 29b.

Our study shows an overall increase in the waiting times for all provinces except Manitoba, New Brunswick, Nova Scotia, and Prince Edward Island. Manitoba shows the greatest improvement in waiting, largely due to the decrease in cardiovascular surgery waiting times, as was previously mentioned, while the median wait in British Columbia increased by 22 percent and in Alberta by 18 percent.

In contrast, most provinces experienced a decrease in the number of people waiting. The only provinces that had more people waiting for surgery were British Columbia, Alberta, Saskatchewan, and Quebec. There was a decrease in the number of people waiting for surgery in Canada from 169,877 in 1994 to 165,472 in 1995. However, although there are 2.6 percent fewer people waiting for surgery in Canada, they are waiting 1.7 percent longer to receive treatment after having seen a specialist. Specialists were asked to attribute the change in their waiting lists to the availability of operating room nurses, technical staff, beds, operating room time, a change in patient load, or to other factors. The main factors influencing the change in waiting lists were the availability of operating room time (30.5 percent), a change in patient load (21.9 percent), and the availability of hospital beds (15.9 percent).

Clinically reasonable waiting times

In almost every instance, the responding specialists felt that waiting times for treatment were excessive. When asked to indicate a clinically reasonable waiting time for the various procedures, specialists generally indicated a period of time substantially shorter than the median number of weeks patients were actually waiting for treatment. Table 43 summarizes the weighted medians for the specialties surveyed. These weighted medians were calculated in the same manner as those in table 28a. The variability among the provincial weighted medians is much less than it was in table 28a. Whereas the actual waiting times among provinces vary by as much as 7.1 weeks, the weighted number of weeks that specialists felt was reasonable to wait varies by 2.4 weeks at most between provinces.

Chart 4 compares the actual median number of weeks patients are waiting for treatment after having seen a specialist with the median number of weeks specialists feel are reasonable to have patients wait. The largest difference in these two periods is for ophthalmology where the actual waiting time is 4.6 weeks longer than what is considered to be reasonable by specialists. The smallest divergence is in medical oncology, where the median actual waiting time is 0.5 weeks shorter than the clinically reasonable waiting time.

Click here to view Chart 4: Actual versus Reasonable Waiting by Specialty for Canada
Time Waited from Appointment with Specialist to Treatment in 1995

Estimated total waiting in Canada

While waiting times for surgery convey a mixed impression about the apparent extent of health care rationing, there is much less ambiguity when the overall wait for health care is considered. This overall wait, which records the time between the referral by a general practitioner to the time that the required surgery is performed, includes an additional wait for the appointment to see the specialist. Table 31 and chart 5 present the combined waiting times. They indicate that patients wait more than two months for relief of their ailments, from a weighted median of 8.6 weeks in Quebec to 19.3 weeks in Prince Edward Island.

Click here to view Chart 5: Total Waiting by Province in 1995
Weeks Waited from G.P. Referral to Treatment

Across Canada, the longest waits for treatment tend to be for three specialties: ophthalmology, orthopaedic surgery, and elective cardiovascular surgery. The median waits for these specialties exceed 4 months. As is indicated in Chart 6, the median wait for ophthalmology in Canada is 17.8 weeks, 18.5 weeks for orthopaedic surgery, and 16.5 weeks for elective cardiovascular surgery. The shortest wait in Canada is for cancer patients being treated with chemotherapy. These patients wait approximately 2.8 weeks to receive their treatment.

Click here to view Chart 6: Total Waiting by Specialty in Canada in 1995
Weeks Waited from G.P. Referral to Treatment

Health expenditures and waiting times

Consistently, Ontario performs better than most of the other provinces with regard to hospital waiting lists. The model of waiting lists that underlies our analysis, and which has been sketched out in this study, is that waiting is a manifestation of rationing. It would, therefore, seem to follow that one possible explanation for the result in Ontario is that the province is simply engaging in less rationing than are the other provinces. Rationing is not, of course, a necessary consequence of the way in which the health care system is organized, but merely a possible consequence of that organization if the budgetary allocations to the health care sector are insufficient to keep up with the demand. Budget constraint leads to constraints on the supply of health care services, to an excess of demand over available supply, and thus to the observed rationing by waiting.

It follows from this that one possible explanation for Ontario's superior performance is that Ontario simply spends more money on health care than the other provinces and that this enables it to respond more fully to the demands of patients than is possible in other provinces.

In order to determine whether actual experience accords to this theory, we calculated a crude measure of public expenditures on health care in the form of adjusted per capita expenditure on health care in each province by the public sector. (The per capita public expenditure figures for all of the provinces were standardized to the province of B.C. using an index calculated from the cost incurred by people in each age group in B.C. and the total per capita public sector expenditure on health. The reason for using this method of weighting is that if a population in a particular province has more people in age cohorts that are more in need of health care, i.e. the elderly, the same dollar amount per capita spent on health care in that province would yield a less effective supply effort than it would in a province with fewer elderly citizens.) This is displayed in chart 7, which shows the differences from the national average in weighted per capita expenditures for all provinces and the differences from the national median waiting time, by province. (Waiting time is measured from patients' appointments with their G.P. to the time they actually receive treatment.) The majority of provinces with public sector costs above the national average have waiting times below the national wait. As well, those provinces that spend less than the national average generally have waiting times above the national median. However, Quebec and Newfoundland have below average costs and waiting times while Manitoba and British Columbia have above average costs and yet have waiting times that are greater than the national median. A statistical test reveals that variations in health care spending explain about one quarter of the total variation amongst the provinces in the median time waited for treatment.

Click here to view Chart 7: Weighted Average Cost and Median Waiting Times (Divergence from the Canadian Values)

Obviously, there are many factors that influence the waiting times in the provinces and that operate in conjunction with the supply of resources, for example: the age of the population and, therefore, the underlying demand for health care (for which we have tried to make adjustments); the management of resources, including the extent of effort to decrease the number of patients on specific doctors' waiting lists; the extent of same-day surgery; the average length of hospital stays; and the extent of reliance on private clinics. It is also possible that Quebec's superior performance is due to yet other factors. For example, the above-cited paper by Dr. C.D. Naylor of the Institute for Clinical Evaluative Studies regarding hip replacement notes that the rate of joint replacement in Quebec is only one third that in the other provinces. This, Naylor remarks, is due to the fact that the Quebec government has a policy limiting the extent of joint replacement. The effect of such a policy is to produce lower apparent waiting times since patients in need of this operation in Quebec are simply denied it and hence, do not appear on a waiting list. If there are other such policies in Quebec or elsewhere, they would affect the comparative length of waiting times without leaving any trace in our survey.

A note on Newfoundland

As is the case with Quebec, Newfoundland has had below national costs and waiting times for the last few years of our waiting list survey. In past years, we have treated this anomaly as being the result of the small sample size. With a larger sample size, such as that of Ontario for example, there is little chance that one doctor with a very long or very short waiting list will influence the median waiting time. However, with smaller sample sizes, the length of each respondent's waiting list has a greater influence on the median. For example, although the survey response rate in Newfoundland was quite high for plastic surgery at 50 percent, this represented just one of the two plastic surgeons in the province. As discussed earlier, using a median measure will usually eliminate the problem of outliers which occurs when measuring waiting times using averages: a specialist whose patients must wait an especially long time will skew the specialty average upwards. However, when surveying one of two, or two of three specialists, the median measure will suffer from the same problem as the average. If a specialist with an especially long waiting list responds to the survey one year and not the next, the difference between years will be large but it will not necessarily be an indication of an actual change in the waiting times for a province.

Although this is no doubt part of the explanation it does not reveal the whole story. Another part of the explanation for Newfoundland's apparently superior performance mirrors that of Quebec's. Regarding hip replacement, for example, the rate of joint replacement in Newfoundland is even less than in Quebec. In general, Newfoundland has lower major surgery rates than the other provinces. Statistics Canada's Health Report No. 82-217, "Surgical Procedures and Treatments 1992-93."Note The effect of this is to produce lower apparent waiting times since some patients in need of an operation simply do not receive it, and hence do not appear on a waiting list. This theory was somewhat corroborated by the administrators of several Newfoundland hospitals who revealed in interviews with the authors that there were not lengthy waiting lists at the hospital stage, i.e. from specialist to treatment. Waiting lists for hip replacement surgery, for example, are approximately 6 weeks long, and the waiting list for cataract surgery is about 3 to 4 weeks long. These are approximate waiting times only. They are from the Health Care Corporation of St. John's and were determined from a brief analysis of their waiting lists and an informal survey of physicians.Note

One might expect that in healthier societies less hospital services would be used, and thus there would be lower rates of major surgery. However, health indicators show that Newfoundlanders are not inherently more healthy than their fellow Canadians. In fact, the reverse seems to be true. Newfoundland has the highest provincial age-standardized death rate, at 7.6 deaths per 1,000 population versus that of 6.4 deaths per 1,000 in Saskatchewan, and a Canadian average of 6.9. Statistics Canada, Births and Deaths, 1993, Cat. No. 84-210, pp. 4-5.Note Newfoundlanders also can be expected to live more than a year less, on average, than other Canadians. Life expectancy in Newfoundland was 76.7 years in 1994, down from 76.9 years in 1993. Canadian life expectancy was 78.2 years in 1994, up from 77.9 years in 1993. Newfoundland and Nova Scotia were the only two provinces to experience a decrease in life expectancy from 1993 to 1994. Statistics Canada, The Daily, May 24, 1996, p. 5.Note

For the most part, "Waiting Your Turn" measures waiting lists from the time patients see a specialist to the time they receive treatment. If there are problems in acquiring the services of a specialist, or if the route to surgical care becomes the emergency room, The number of visits to emergency rooms in the ten largest medical facilities in Newfoundland and Labrador have increased by approximately 8.6 percent since 1991/92. Department of Health, St. John's Newfoundland, 1996.Note then our survey will underestimate the amount of rationing taking place within a province.

A note on technology

The wait to see a specialist and the wait to receive treatment are not the only waits that patients face. Within hospitals, limited budgets force specialists to work with scarce resources. Chart 8 gives an indication of the difficulties that specialists in Canada have in gaining access to modern medical technologies compared to their counterparts in the United States. There are 234 computerized tomography (CT) scanning centres in Canada, about half as many per million people as in the United States. There are almost 5 times as many magnetic resonance imagers (MRI) in the United States per million people than in Canada. MRIs are not available in Prince Edward Island, and Saskatchewan, Manitoba, New Brunswick, Newfoundland, and Nova Scotia each only have one operational MRI. Readers should note that the disparity in available technology in Canada and the U.S. is probably even greater as the Canadian data are for 1995, but the most recent data for U.S. hospitals are from 1993.Note

Click here to view Chart 8: Selected Technologies per Million People in Canada and U.S. Hospitals

Our study looked at the wait for various diagnostic technologies across Canada. Chart 9 shows the median number of weeks patients must wait for access to a CT scanner, an MRI, or an ultrasound machine. The median wait for an MRI in Canada (8.4 weeks) is more than twice that for a CT scan (3.7 weeks) and is probably an underestimate of the actual waiting time since specialists who do not prescribe MRI tests because of the lengthy waits for access to a machine are not included in the calculation of the median. The longest wait for an MRI is in Ontario (11.2 weeks). "Official" waiting lists for B.C. put the number of people waiting for an MRI in the province at between 1,500 and 1,600, with most elective cases waiting up to 12 weeks. In Alberta, the wait for an MRI is 1,800 patients long. R. Walker, "Waiting Lists are an Accepted Part of Canadian Health System," The Medical Post, February 20, 1996, p. 66.Note Ultrasound tests are quite common and many specialists have their own machines, which resulted in a median wait for ultrasound in Canada of only 1.8 weeks in 1995, which is a relatively short wait compared to those for CT scans and MRIs, but which is a 6 percent increase from 1994.

Click here to view Chart 9: Waiting for Technology Median Number of Weeks Waited to Receive Selected Diagnostic Tests in 1994 and 1995

Conclusion

While the 1996 "Waiting Your Turn" survey indicates that the waiting list situation has improved with respect to the number of people waiting for treatment, waiting for health services in Canada is a reality-an indicator that rationing is taking place. On average, in all specialties, less than 10 percent of patients are on waiting lists because they requested a delay or postponement of their treatment. The responses range from a low of 1.8 percent of internal medicine patients requesting a delay of treatment, to a high of 10.6 percent of medical oncology patients requesting a delay of treatment. Conversely, the percentage of patients who would have their surgeries within the week if there were an operating room available is greater than 50 percent in all specialties except gynaecology, and otolaryngology. The percentage of patients in these specialties who would agree to having their surgery within the week is 46 and 37 percent, respectively. Internal medicine patients are the most anxious to receive treatment, with 89 percent of patients willing to receive their treatment within the week. Cardiovascular surgery and radiation oncology patients are the next most anxious, with 84 percent of these patients willing to have their surgery or treatment within the week.

As well, even if one debates the reliability of waiting list data, our survey reveals that specialists feel that their patients are waiting too long to receive treatment, up to three times longer than is considered to be reasonable. A recent national survey by the College of Family Physicians of Canada shows that general practitioners are also concerned about the effects of waiting on the health of their patients. College of Family Physicians of Canada, "Advocating on Behalf of Patients Survey," News Release, April 24, 1996.Note Between 70 and 80 percent of family physicians cite waiting times to see a specialist, hospital waiting lists, and waits for diagnostic tests as reasons why they are now having to spend more time "fighting for the care their patients need" Ibid., p. 1.Note than they did 5 years ago. Almost 70 percent of family physicians felt that the waiting times being experienced by their patients were not acceptable.

Click here to view Table 1: Summary of Responses, 1995

Click here to view Table 2: Median 1995 Patient Wait to see a Specialist after Referral from a G.P.

Click here to view Table 3: Plastic Surgery (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 4: Gynaecology (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 5: Opthalmology (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 6: Otolryngology (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 7: General Surgery (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 8: Neurosurgery (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 9: Orthpaedic Surgery (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 10: Cardiovascular Surgery (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 11: Urology (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 12: Internal Medicine (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 13: Radiation Oncology (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 14: Medical Oncology (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 15: Plastic Surgery (1995)
Median Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 16: Gynaecology (1995)
Estimated Number of Patients Waiting for Treatment after Appointment with Specialist

Click here to view Table 17: Opthalmology (1995)
Estimated Number of Patients Waiting for Treatment after Appointment with Specialist

Click here to view Table 18: Otolarygology (1995)
Estimated Number of Patients Waiting for Treatment after Appointment with Specialist

Click here to view Table 19: General Surgery (1995)
Estimated Number of Patients Waiting for Treatment after Appointment with Specialist

Click here to view Table 20: Neurosurgery (1995)
Estimated Number of Patients Waiting for Treatment after Appointment with Specialist

Click here to view Table 21: Orthopaedic Surgery (1995)
Estimated Number of Patients Waiting for Treatment after Appointment with Specialist

Click here to view Table 22: Cardiovascular Surgery (1995)
Estimated Number of Patients Waiting for Treatment after Appointment with Specialist

Click here to view Table 23: Urology (1995)
Estimated Number of Patients Waiting for Treatment after Appointment with Specialist

Click here to view Table 24: Internal Medicine (1995)
Estimated Number of Patients Waiting for Treatment after Appointment with Specialist

Click here to view Table 25: Radiation Oncology (1995)
Estimated Number of Patients Waiting for Treatment after Appointment with Specialist

Click here to view Table 26: Medical Oncology (1995)
Estimated Number of Patients Waiting for Treatment after Appointment with Specialist

Click here to view Table 27: Estimated Number of Patients Waiting for Treatment after Appointment with Specialist (1995)

Click here to view Table 28a: Median Wait to Receive Treatment by Selected Specialties in 1995 (in Weeks)

Click here to view Table 28b: Estimated Number of Patients Waiting for Treatment by Specialty in 1995

Click here to view Table 29a: Comparison of Median Weeks Waited to Receive Treatment by Selected Specialties, 1994 and 1995

Click here to view Table 29b: Comparison of Estimated Number of Patients Waiting by Specialty, 1994 and 1995

Click here to view Table 30: Frequency Distribution of Waiting Times (Specialist to Treatment)

Click here to view Table 31: Total Expected Wating Time from G.P. Referral to Treatment, 1995 (in Weeks)

Click here to view Table 32: Plastic Surgery (1995)
Median Reasonable Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 33: Gynaecology (1995)
Median Reasonable Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 34: Ophalmology (1995)
Median Reasonable Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 35: Otolaryngology (1995)
Median Reasonable Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 36: General Surgery (1995)
Median Reasonable Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 37: Neurosurgery (1995)
Median Reasonable Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 38: Orthopaedic Surgery (1995)
Median Reasonable Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 39: Urology (1995)
Median Reasonable Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 40: Internal Medicine (1995)
Median Reasonable Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 41: Radiation Oncology (1995)
Median Reasonable Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 42: Medicial Oncology (1995)
Median Reasonable Patient Wait for Treatment after Appointment with Specialist (in Weeks)

Click here to view Table 43: Reasonable Number of Weeks to Wait to Receive Treatment by Selected Specialties in 1995

Click here to view Table 44: Comparison Between the Median Actual Weeks Waited for Treatment and the Median Reasonable Number of Weeks to Wait for Treatment after Appointment with Specialist in 1995

Appendix 1: The Fraser Institute National Hospital Waiting List Survey

General Surgery

1.From today, how long (in weeks) would a new patient have to wait for a routine office consultation with you?

____________ week(s)

2.Do you restrict the number of patients waiting to see you in any manner? (i.e. Do you accept referrals only at certain times of the year?)

[] Yes [] No

3.Over the past 12 months, what percentage of the surgical procedures you performed were done on a day surgery basis?

____________ %

4.From today, how long (in weeks) would a new patient have to wait for the following types of elective surgery or diagnostic procedures? What would you consider to be a clinically reasonable waiting time for these types of surgery and procedures?



5.Has the length of your waiting lists changed since last year at this time?

[] Increased [] Decreased [] Remained the Same

6.If the length of your waiting lists has changed, what are the major reasons for the change? (Check all which may be applicable.)

_____ Availability of O/R nurses
_____ Availability of other technical staff
_____ Availability of beds
_____ Availability of O/R time
_____ Change in patient load
_____ Availability of ancillary investigations or consultations (i.e. MRI, CT scans)
_____ Other

7.What percentage of your patients currently waiting for surgery are on a waiting list primarily because they requested a delay or postponement?

____________ %

8.What percentage of your patients currently waiting for surgery do you think would agree to having their surgery within the week if an opening arose in O/R?

____________ %

9.To the best of your knowledge, what percentage of your patients that are listed on hospital waiting lists might also be listed by other physicians for the same procedure?

____________ %

10.Do you use the following types of diagnostic tests? If so, how long (in weeks) would a new patient have to wait for these tests?



11.Approximately what percentage of your patients inquired in the past 12 months about the availability of medical services:

Outside of the province? ______ % Outside of Canada? ______ %

12.Approximately what percentage of your patients received non-emergency medical treatment in the past 12 months:

Outside of the province? ______ % Outside of Canada? ______ %

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Last Modified: Wednesday, October 20, 1999.