Surgical Wait Times in Canada — Dr. Etienne Belzile

Alya Niang

Access to elective surgery was decimated by the COVID-19 pandemic.

New analysis just released by the Canadian Institute for Health Information shows that 930,000 fewer surgeries than expected were performed across the country in the first 31 months of the pandemic.

That’s almost one million Canadians who did not have recommended surgeries.

Many people are waiting, and this worries surgeons like Dr. Étienne Belzile.

Dr. Belzile

It’s huge, actually. It’s almost a catastrophic version of the health care system.

Stopping these procedures will have an effect over the coming years, and we have not seen the end of these effects on our patients.

Alya Niang

Dr. Belzile is the head of orthopedic surgery for the level 1 trauma centre in Québec and an associate professor at Université Laval in Québec.

Today, he is talking about the latest CIHI data on wait times for surgeries such as hip and knee replacements, cataracts and other critical procedures by asking whether there’s a better way to clear out the backlog for good.

Dr. Belzile

I believe that there is a certain positive side to realizing that there are limits on our capacity to treat everything in the public system, the way we do today, and that the time has come to find new solutions.

Alya Niang

Hello and welcome to the Canadian Health Information Podcast.

I’m Alya Niang, the host of this conversation.Please bear in mind that the opinions and comments of our guests do not necessarily reflect those of the Canadian Institute for Health Information. But this is a free and open discussion, and today’s show is about how to help the thousands of Canadians whose surgeries have been delayed and who are waiting longer than they should. Perhaps longer than is safe and healthy.
Hello, Dr. Belzile, welcome to the Podcast.

Dr. Belzile

Hello.

Alya Niang

Dr. Belzile, I would like to know, for the first time in history — correct me if I’m wrong, but health systems around the world stopped doing most surgeries because of the pandemic.

Why exactly did this happen?

Dr. Belzile

Well, this is the first time in history that we’ve had to reallocate our resources.

It was a sudden crisis that caught all the systems off guard, and we had to allocate resources directly to one cause and then, by default, shut down some of the other hospital functions and allocate them to COVID. This was the first time this happened, and hospital managements decided to shut down operating rooms for 2 reasons.

The first was to reallocate staff to the acute care treatment of COVID patients. And then, partly to protect resources, starting at the beginning of the crisis in March 2020, it was a matter of protecting our inventory of medication for general anesthesia, which might have been needed in intensive care, which was being used, at that time, to support the very, very sick patients of the first wave.

Alya Niang

The latest CIHI data show that 930,000 fewer surgeries were performed in Canada, not counting Quebec, between March 2020 and September 2022. Nearly a million fewer operations — that’s a lot.

I’ll just give some numbers: 6% fewer cancer surgeries than usual, 8% fewer heart surgeries, almost 36,000 fewer knee procedures, 11,000 fewer hip replacements and the list goes on. There are many more details and some differences between provinces, and you can see all this on cihi.ca.

I’d like to know how you feel when you see these figures.

Dr. Belzile

It’s huge, actually. It’s almost a catastrophic version of the health care system.

Stopping these procedures will have an effect over the coming years, and we have not seen the end of these effects on our patients.

And that’s just the tip of the iceberg. Ultimately, it’s surgical activity. We’re not talking about all the diagnostic activity that underlies all this, which will have an effect for the next few years.

It’s completely unprecedented. I don’t think anyone was able to predict the impact of this abrupt stop. But it is like a traffic jam on the highway. A few vehicles stop and then we have a rebound effect for the rest of the day because of the first incident.

Unfortunately, we realized that some surgeries were very urgent, and they were done, but late.

Some other surgeries were perceived to be less important for some patients, and unfortunately it will take almost a year for them to be done in an orderly fashion.

Alya Niang

And do these surgical delays result in deaths, Dr. Belzile?

Dr. Belzile

It’s very difficult to pinpoint the statistic.

Because if you look at it, the death rate won’t necessarily have changed particularly, but now you’re going to operate on patients who were probably healthier at the time they first presented with the initial health problem, and you’re operating on them later.

The operation has less of an effect on their health or the effect comes too late, which means we end up with patients who have more complications.

We have seen patients come in with a very advanced state of disease that we have not seen in a very long time.

It won’t necessarily result in an immediate death, but if you take a 70-year-old and you stop treating them completely for 2 years, it’s going to have an effect on their functional capacity, their cardiac capacity and, eventually, it will probably lead to an earlier death than if they had been treated in a timely fashion.

Alya Niang

Dr. Belzile, the data also show that 40% to 50% of people are not treated within the recommended time frame for best results.

I would like to know what the human cost is and what you have seen.
Dr. Belzile

If I approach it practically… I’m a career orthopedist, so I can really answer you in terms of people who have musculoskeletal problems.

The human impact is at every level. People’s lives are affected at the family level.

People who suffer from a problem for longer than they should experience an impact on their quality of life at home, the ability to be a spouse, to be a parent, the ability to work, the ability to earn money and be able to provide services and fulfil their role, basically, in Canadian society.

All that is put on hold during the wait time, and then, quite often, if that wait time is extended — let’s say only 50% of the people are treated in a timely manner — that means the rest of the people are at a complete standstill and it diminishes the overall quality of life for Canadians, waiting like that.

Alya Niang

That brings me to my next question.

You are a surgeon and an obesity researcher. So I imagine that it probably had an impact on you, personally.

What was your experience?

Dr. Belzile

In Québec, our surgical department was deeply affected and we were down for almost 8 months.

Surgery was on hold, as was our capacity to meet new patients.

In fact, we still haven’t quite finished the wave of people we were due to see in that time period. We haven’t seen them all yet, and we’re struggling to recover from the crisis.

And then on the research side, we had several research projects underway at the research centre and we were forced to stop recruiting. In some cases, fortunately very few, some research follow-up was suspended during the COVID crisis.

Alya Niang

Dr. Belzile, what happened to your wait lists at the beginning of COVID?

Dr. Belzile

We have seen a dramatic increase in our wait lists, because we were already in a bit of trouble in terms of wait times before COVID, somewhat chronically over the last 5 years.

Then the pandemic really made it a lot more difficult because while we were down for almost 8 months, needs continued to arise. We still managed to see some patients who needed surgical services. And those people were increasingly acute, as well.

As a result, our lists are growing at an incredible rate. In some departments, there has been an 85% increase in wait times. In our department, we have had up to 60%.

Alya Niang

The question posed in the latest report is whether hospitals have been able to catch up on surgeries affected by COVID-19. And the answer seems to be no.

According to the CIHI report, while the monthly number of scheduled surgeries is approaching pre-pandemic levels, it is insufficient to clear the backlog and improve wait times.

Dr. Belzile, is this a contained backlog or a growing backlog?

Dr. Belzile

There is a little bit of both.

In 2021, many hospitals or health services implemented a strategy to catch up on the backlog and increase surgeries.

There was a reallocation of certain resources to people who had been waiting for a long time, and that was relatively effective. We were able to return to pre-pandemic volumes.

On the other hand, there was a rebound effect, that is, a loss of medical staff. Human resources have had great difficulty in maintaining nursing support in all hospitals across Canada. As a result, there was a rebound effect and a surgical slowdown.

That means that wait lists continue to grow because our volume capacity went back down again in 2022–2023.

And, unfortunately, in the plans that we are looking at for 2023–2024, we have this same shortage of personnel which means that despite all our attempts to be more efficient or to allocate more resources specifically to surgical sectors with long waits, we will not be able to catch up.

Alya Niang

So, we could say that it’s going to take a lot of overtime to clear out those backlogs and avoid creating more?

Dr. Belzile

I think that each hospital has its own way of working, but overall, a lot of work has been done on better classification in order to operate on the people who are in the worst situation in a timely fashion. In other words, classifying patients more intelligently and strategically.

Work is also being done at the hospital level to be able to provide access to the services that are most needed in relation to demand.

That wasn’t necessarily something that was well understood before the pandemic. There wasn’t necessarily a direct allocation based on demand in a given sector.

It became clearer during the pandemic that there was a need for our society to concentrate on the sectors in greatest need in order to achieve a fair allocation of resources to each pathology.

Alya Niang

In terms of data, prior to the pandemic, 70% to 75% of patients requiring knee or hip surgery were operated on within the recommended time frame. Today, that percentage is 50% to 55%.

To what extent is the pandemic responsible for this situation?

Dr. Belzile

It certainly had an impact. That is, the pandemic served as a massive shock to the health care system.

And then, the rebound effect was that many people in human resources and hospital staff changed careers or changed work sites. That means that now our capacity to produce a certain volume in a hospital is affected. There is a lack of operating rooms because there is a lack of staff and a lack of access to beds. The beds are physically accessible, they are in the hospital, but there are no nurses able to provide the service as they did before.

There is a whole re-questioning of work schedules, teamwork methods that comes into play here. And the pandemic is a direct cause of that. Now, not everything will be resolved just because COVID gets better. We need to re-examine the way we work.

Alya Niang

So, we could say that the pandemic is not entirely responsible, but it made the system worse.

Dr. Belzile

Exactly.

There were risk factors already in place in our system that were perhaps a little less understood. The pandemic was really the main stressor that brought about a lot of consequences afterwards.

Alya Niang

Dr. Belzile, let’s talk about team care.

If studies show that it works, that it speeds up care for patients and improves surgery wait time for those who need it, why aren’t we doing it?

Dr. Belzile

I don’t think that’s exactly it. We are doing it, but not to the same extent throughout the system.

There are teams that are champions at being able to adapt and that have been able to increase their volume. It requires several conditions: political will is one, good funding is another. After that, there are also the good intentions of the various union teams to change the work model and to be able to optimize it.

There are teams in the world that are capable of doing twice the work that we are capable of in Canada with half the resources, but it takes a special kind of motivation, and their system is already prepared for that.

I think that a lot of the big centres, the big university centres, for example, or the big hospitals, are not succeeding in guiding their teams and developing effective teams to increase volume.

In a health care system, we never talk about efficiency and volume of work. Which is something all other kinds of industries do. I think it’s really a change of mentality that will do it, and always keeping the human factor and service to the patients as the number-one criterion.

Unfortunately, over the years, there may have been some deviation from this ultimate goal of patient service.

Alya Niang

What about the 4 provinces that have decided to open private clinics to deal with the backlog of cases that are covered by provincial health plans?

What are the risks, in your opinion?

Dr. Belzile

One thing is certain, there are values that are immutable: the number of patients will remain the same and will not change. The number of surgeons able to perform the operations will not change either. I do not expect an influx of surgeons from other provinces or countries.

So we are limited to surgical sites. How many facilities in Canada are capable of doing the operations?

There have been a few clinics built across Canada, that’s for sure. Now, the most limiting resource is the effect of the potential exodus of nurses.

I think it’s normal for politicians to worry that if a nurse who is working in a public network is courted by the private sector, she might have some tendency to accept. We might lose her.

But we have to remember that in terms of the time that people currently have available, there are some who have time they can give in other parts of the day, for example, in the evening or on weekends, and who could go to the private sector.

And I think that’s what some provinces have been able to exploit better than others. For example, in Ontario, service is often provided in periods that are not the traditional 8-to-4 or weekday schedule. It allows the same workforce to be used in private service.

In Quebec, however, the choice was made to move more toward private clinics that are really separate from the hospitals. And that may generate a bigger transfer of the labour force to the private sector.

It’s all in the regulations, in my opinion. The more fluidity we allow from one vessel to the other, that is, from the private to the public, the more we’ll be able to achieve this volume and provide our services to the population.

If we look at France or Switzerland, they have parallel private systems that do not affect their volume of public work because they are communicating vessels and it is easy for professionals to switch from one service to another.

Alya Niang

Is that a fair and equitable solution to surgical wait times?

Dr. Belzile

I think the main inequity is going to come down to which population is going to be able to use private access.

There are certain pathologies that, unfortunately, occur in people who are sicker and who have less access to private service.

On the other hand, if the hospital is freed up because there are patients who go to the private sector, this will allow more space for those pathologies.

When I say pathology, I mean that if you’re doing abdominal surgery, you’re more likely to need a hospital bed than if you’re doing peripheral limb surgery, for example, in orthopedics. So, for sure, there is this side of medicine that we have to pay attention to.

But if we focus mainly on orthopedics, there is a high volume of patients that we can do as outpatients and who can be transferred to the private sector.

At that point, it’s really just a choice that’s going to be political, to make that choice and transfer that population.

Alya Niang

And would you say that all this will require a lot of overtime?

Dr. Belzile

If you look at the numbers, we haven’t really talked about volume here. They say that only 50% of the people receive service within the expected or at least hoped for time frame. We would probably need 30 to 40% more access to the operating room to be able to bring those times to 100% of the population within the required time frame.

I don’t think there is currently enough private access to do that work. It’s really going to be a matter of combining strategies. We were saying that just locally, in our hospital, if we add one case a day on a traditional day where we normally do 3, that’s a 25% increase. But to achieve that 25% increase, we would need to extend our day. That extension may be 2 hours a day.

And this is where we’re going to affect the workforce. We would have to reassign the same staff, for a longer time or in a different way.

On the other hand, if we have 5 working days and we do 4 cases per day, we have 20 clients. If we add a Saturday, we can do 4 more. The effect will be a little bit less, but we’re able to do more.

It still depends on access. Do we offer access in the evenings? Do we offer it on weekends?

Ontario has done volume increases like this outside of traditional hours in the past, and they’ve managed to burn through a good 20% or 30% more volume. But it comes at a cost. It’s overtime or it’s resources that are completely different from current budgets.

Alya Niang

Dr. Belzile, there has been a lot of talk in the last few months about health care and wait lists and the money that is now going to the provinces to help them manage those wait lists.

Ontario and Alberta are using private clinics to increase their capacity. Where do we stand?

Dr. Belzile

My answer will include my feelings about Quebec in relation to the rest of Canada. I believe that there is a certain positive side to realizing that there are limits in our capacity to treat everything in the public system, the way we do today, and that the time has come to find new solutions. Private access, in Ontario, for example, can permanently increase access and will decrease wait lists. But my skepticism is in terms of volume.

We’re going to shave off a little 10% or 15% maybe, and that’s excellent, but we’re still somewhat limited because we’re going to transfer the least serious cases to those centres. And that means we’re just increasing the complexity of the cases we’re doing in the hospital.

But in Quebec, we’re having a little more difficulty because lately, the licensing of private centres has all been withheld by the government.

Despite the increase in resources, I don’t understand the current strategy and how we will manage to increase our volume, especially when our hospitals are already not able to do the volumes we hoped for in the post-pandemic situation.

Most Quebec hospitals are forced to close operating rooms that physically exist due to lack of personnel.

So, the first goal here would be to really go out and get those human resources so we can do the job properly.

Alya Niang

How do you think we could catch up, right now? How do we get the right care to the right patients at the right time?

Dr. Belzile

I think, first of all, that we have to forget about past experience. Surgical production often used to be guided by what had been done in the past. In other words, last year, we did this volume, so we’ll reproduce that volume this year, and we just go on and don’t ask ourselves any questions.

This has created inequality of access among pathologies. For example, there was a growing demand for musculoskeletal surgery but the demand was never met in Canada or Quebec. And that created an inequality that persisted over time.

But if we start by looking at the demands, at the regional level for each hospital, what do we need to do?

Being able to allocate resources to meet these demands would be an excellent strategy to even out the wait lists. And there would be less asymmetry among specialties. For the average Canadian, their access would be guaranteed and it would be better.

Now, if we have to decide on government strategies, that is always a little more complicated, because we tend to issue ministerial directives to give orders throughout the system, but often the realities are not the same in each region.

Many of our civil servants waste their time responding to those ministerial directives and fail to respond to local needs.

Having a good understanding of each network is important. And the prescription will not be the same for one network or another.

In some regions, access is very difficult because of a lack of hospital resources. Hospitals are what they need. They cut beds during the ’90s. Now it is the lack of beds that is the problem.

In other regions, we can pinpoint the lack of resources. That’s where we have to recruit staff, train them and then we can provide access.

It has to start with the universities and CEGEPs that offer training, the colleges that train these people in order to facilitate access. Offer specific training so hospitals spend less time training these people once they arrive in the network.

That would make the system more efficient and more responsive, too. It can even go as far as medical resources. Sometimes specialties or physician positions were allocated to certain regions for a certain volume. And then, after 10 years, the volume changes, but we can’t change our resources.

That’s the locked-in aspect or rigidity of the system that doesn’t allow us to adapt very quickly. This has been going on for a long time, but now we realize that our system probably needs a little more flexibility.

Alya Niang

If you were in charge, what would your prescription be?

Dr. Belzile

Having an adequate transfer of funds between Canada and the provinces is a start.

I understand that on the federal side, there is always a reluctance to ask for accountability for this money, but Canadians need that accountability. It’s unfortunate, but taxpayers need a service.

I think that having certain scales to follow in each province is okay, whether they are uniform or not, but there should be scales so there is a way to hold politicians responsible for them.

And, unfortunately, today, they’re talking about it but no one is establishing scales, and we don’t really have variables we can rely on, as we do on the scientific side or on the research side, to give us statistics that are consistent and service that is adequate for everyone.

Alya Niang

Thank you, Dr. Belzile, for being with us today.

It was a pleasure to talk to you about this urgent and important subject.

Dr. Belzile

Thank you very much. Have a great day.

Alya Niang

Studies show that when patients need surgery, the less time they spend disabled and in pain, the better they recover, and the less the care they receive costs the health care systems.

Reducing wait times will lead to better health and better quality of life for Canadians.

Thank you for joining our discussion.

Our executive producer is Jonathan Kuehlein and special thanks to Ieashia Minott and Avis Favaro, the host of the CIHI podcast in English.

For more information on the Canadian Institute for Health Information, please visit www.cihi.ca.

Don’t forget to subscribe to the Health Information Podcast and listen to it on the platform of your choice.

This is Alya Niang, see you next time!