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Thursday, 22 August 2013

Queue jumping – reaching to the heart of Canadian health equity.

Tired of waiting in line?  

How do you react when somebody butts into the line ahead? Anger, frustration, blame on the organization that put the line there anyway? 

Of course, if this was in some other countries, paying for privilege to jump lines is normal.   Fast tracking across borders, airport security express lanes, personalized banking service, have all become markers of class differential in Canada and while annoying, are integrated into our society.

Try to jump the line at Tim Horton’s and you might be assaulted.  Likewise, queue jumping in health services is almost a criminal offence.  Hence absolute outrage at the Alberta public inquiry final report findings.  Alberta Health Services Access Inquiry Calgary Herald coverage

Read the details though.  Individuals Albertans had little control over influencing their position in time.  The queue jumping problems were systems issues which saw certain service providers get greater access to resources.  It had little to do with the status of the recipient and more to do with the status of the provider.
Duh.  As if we as consumers didn’t know, if you want to get your hip done faster, choose the surgeon with the shortest wait list.  Want to spend less time in emergency, shop around for a shorter wait time facility – and that might mean driving an hour to save 3 hours of waiting. 

Waitlists are the culmination of numerous steps.

·         Identification by the patient of a need for something
·         Action by the patient to seek a health professional
·         Where it occurs, the time from visit to primary care provider to referral to specialist
·         All of the above can be prolonged by requests for lab tests or specialized diagnostic imaging
·         It is only at this point that the specialist may add someone to a waitlist for an intervention

When we measure a waitlist, we are only measuring the final step in a process that has many more opportunities to be manipulated by both the practitioners and the patient.  Its not surprising that we find rural residents, those from lower socioeconomic categories, marginalized patients etc that compared to other users of the system tend to have prolonged durations at every step of the way.

So why the outrage when only the last of the steps leads to a perceptions of inequity? Fixing it doesn't address the already well documented inequities of the earlier steps. 

And, who benefits the most from the measurement of the fifth step of waitlists? it is the specialists who can argue for more resources, more access, and even more money. In this respect the inquiry falls desperately short – it speaks to reducing wait times for medical procedures – but fails miserably in modifying a system that will provide equality in access.  Inquiry recommendations

Special note to public health folks of the mention in the report of pandemic vaccine access, but some will recall the Alberta boondoggle on handling vaccine when other provinces used clear priority methodology to attempt to address equity. It was an Alberta political decision to go with first come first served, and health care providers became opportunistic in misusing the scarce resource for their own purposes.    A sad footnote on equity and queue jumping.

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