The greatest interest and passion about low ER, surgical and health care wait times is undoubtedly coming from the United States. They care about the technology, the business of health care (practice management), and the impact on patients. At first I thought that it was because so much of the US is on a fee-for-service model and they benefit financially from it. But that is too superficial an explanation. Because, the bulk of health care workers are not compensated on a fee-for-service model (such as the nurses). And if my blog stats are to be believed, they are just as, if not more passionate, than those that stand to benefit from lowering wait times. Nor do I think it's a matter of a fee-for-service system creating greater accountability to the patient. Because, in all of our systems, there is a deeper moral accountability to someone who is suffering. On deeper reflection I think there is much more to it and something that both Health Canada and the NHS should learn from.
The first major meeting I attended about hospital costs was between an outside financial consultant and our surgical service (incidentally the consultant had closed our program when I was a resident and she was a VP of an inner-city hospital). She was amazed that we had little or no “cost awareness”.
She started in on the group of surgeons, “don’t you want to know how much you’re supplies cost?”
We all sat their like scolded school children (or pissed off teenagers – the debates’ still open), until one of the senior orthopods piped up, “No”
“Because it doesn’t matter.”
“How could it not matter! If you know how much supplies cost and you choose a less expensive option you save the hospital money and it costs you nothing.”
“Because”, he responded, “I’ve been doing this for 25 years and I’ve already been through cost awareness programs. I’ve saved the hospital thousands and you still take my programs’ money away. On the other hand, a colleague costs the hospital tens-of-thousands, and you give him more”
“There’s no logic or control to how the money flows so why should I care? I’d rather just do my job”
That ended the conversation. Let me add, that this is one of the nicest most dedicated community surgeons I’ve had the pleasure of working with. And I’ve heard it from others as well,
“I just wish they’d make the government contact responsible for all the money without any levels of bureaucracy. At least that way, they’d feel some responsibility for what’s happening”. Or from a friend in the NHS when I asked him to pass the word of my blog around,
“Most of the control of patient flow is pretty much out of the hands of the clinicians over here. Not that I do much clinic work, but for the most part, the docs end up just being work horses. We show up to the out-pt [sic] department, get allotted a room for the session and plow through the stack of patients until they are all gone. We don't tend to have our own offices and staff when working in the NHS.”
And with those stories in mind, I think I know why clinicians in the US are so much more passionate about wait times; control. Because in the US, there are very few layers between the purse strings and the patients compared to countries with socialized medicine. The patients’ pay the hospital, and the hospital pays the employees. I am not making a plug for privatization. I believe that in a developed country you should have access to health care no matter your level of income. And, I will leave it to the economists, bureaucrats and politicians that study such things, to determine the most economical model.
But there is a fundamental difference between how clinicians view wait time problems in the US compared to other societies. I think it is a matter of their passion for efficiency. Since efficiency in health care is proportionate to life and death it doesn’t matter what role you play, you need to be passionate about it. But when you loose control it’s difficult to retain the passion. Without it, the managers are reduced to paper pushers and the clinicians to work horses. For there is no truer observation than that “when work, commitment, and pleasure all become one and you reach that deep well where passion lives, nothing is impossible”. So, when our countries reconnect the people that control the money with the patients that need the care, the impossible will happen.