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A Look at the Saskatchewan Surgical Initiative

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Over the past year, many provincial governments in Canada have been hiring private clinics to help address their surgical waiting list backlogs.
 
A well-known example of where this approach was seen as a success is in the province of Saskatchewan. The prairie province launched its well-known “Saskatchewan Surgical Initiative” back in 2010 to reduce their waiting lists – some of the highest in the country at the time.
 
To learn more about this initiative we reached out to the Saskatchewan government for an interview. While they declined our interview request, they did answer our questions in an email.
 

Can you tell us about what led to the provincial government coming up with the Saskatchewan Surgical Initiative?

In 2008, the Government of Saskatchewan commissioned an independent, first of its kind in Canada, review of the issues and challenges facing the Saskatchewan health care system from the perspective of patients, their family members and advocates.  Entitled, “The Patient First Review”, this report’s findings confirmed that surgical wait lists were a primary concern for patients and their families. Work began immediately on a comprehensive and focused reform of how surgical services are coordinated and delivered in Saskatchewan and with the goal of addressing as many bottlenecks as possible.

The Saskatchewan Surgical Initiative was launched in 2010 as the government’s plan to implement the public’s desire to shorten surgical wait times and improve the experience of surgical patients in Saskatchewan.

How big of a problem were waitlists before it was put in place?
 
The Saskatchewan Surgical Initiative resulted in tremendous improvements in providing sooner, safer and smarter surgical care. On March 31, 2010 when the Saskatchewan Surgical Initiative was first launched there were 15,234 surgical patients in Saskatchewan who had waited longer than three months for their surgery. By March 31, 2015, there were only 1,751 surgical patients who had waited longer than three months for their surgery, a reduction of approximately 89 percent.
 
 
What led to the decision to partner up with private clinics to reduce the surgical backlog?
 

The first year goal of the Saskatchewan Surgical Initiative was to have no patients waiting longer than 18 months for surgery. The system was challenged to meet that goal and a year later, there remained more than seven hundred surgical patients still waiting 18 months for their surgeries.

It was decided that in addition to ramping up surgical capacity in publicly operated facilities, an expansion of publicly funded third-party delivery of selected surgical and diagnostic services should also be added to the Saskatchewan Surgical Initiative to further reduce wait times. Third-party facilities were contracted as a way to increase surgical volumes, without having patients jump the queue or pay for services.

Why not just hire more staff and do it internally?
 

Saskatchewan did hire more staff and increased surgical capacity in (its) publicly operated facilities. The Saskatchewan Surgical Initiative expanded both publicly and privately delivered surgical services to reduce wait times; however, additional capacity was required to address the backlog of those patients waiting longest.

Saskatchewan remains committed to publicly funded, publicly administered health care and maximizing surgical capacity in publicly operated facilities. By contracting third party facilities, this provided additional capacity for the Province to perform more surgeries in addition to those provided in hospital settings.

What were the results in terms of waiting list reductions?
 
The Saskatchewan Surgical Initiative resulted in tremendous improvements in providing sooner, safer and smarter surgical care.
 
On March 31, 2010 when the Saskatchewan Surgical Initiative was first launched there were 15,234 surgical patients in Saskatchewan who had waited longer than three months for their surgery. By March 31, 2015, there were only 1,751 surgical patients who had waited longer than three months for their surgery, a reduction of approximately 89 percent.
 
 
What about the cost? The Fraser Institute calculated a 26% cost savings versus doing the additional surgeries in-house. Is this similar to your own research?
 

During the five years of the Surgical Initiative (2010-11 to 2014-15) the Government of Saskatchewan provided a cumulative investment was approximately $235M. The goal of this initiative was to remove bottlenecks in the surgical system and reduce wait times. Potential cost savings were not prioritized for consideration.

Costing comparisons of the original contract awards for third party surgical facilities demonstrated all procedures were performed below the cost of the public system. More recently, comparisons using estimated public system costing for surgeries based on a resource weight methodology developed by the Canadian Institute for Health Information show costs per procedure can vary based on complexity of the patient, we do not calculate actual cost per each procedure performed.  Based on this more recent analysis, assessments showed that the difference between per-procedure costs in public hospitals and private surgical centres are roughly 35 per cent in plastic surgery and general surgery day procedures, and up to 45 per cent in orthopedic day procedures. Note that our private surgical partners typically perform less complex surgical cases as they are unable to keep a patient overnight or for an extended recovery, which contributes to some of the cost differences reported here.

How prevalent is the use of private clinics to this day in Saskatchewan?
 
Publicly funded, privately delivered surgeries are not new to Saskatchewan as we have a long-standing and successful relationship with a third-party provider. Since 2010, more than 135,000 publicly funded surgeries have been performed by third party providers in Saskatchewan, roughly 15 per cent of the total number of surgeries completed in the province each year. In 2021-22, this increased to almost 20 per cent as they were able to increase their surgical volumes during the pandemic when the health system was faced with response to the pandemic that necessitated utilization of inpatient surgical beds to support COVID patients.
 
Some critics say that private clinics are incentivized to cut corners. How do you make sure that private clinics stick to the same standards of care as government-run ones?
 
Private third-party surgical providers enter into contracts with the Saskatchewan Health Authority requiring that they meet the required standards of care.  They are also licensed and accredited by the College of Physicians and Surgeons of Saskatchewan which ensures the facility meets all requisite standards to provide quality and safe patient care. 
 
What’s your advice to other provincial governments that are considering the option of expanding or beginning to hire private clinics, as they deal with surgical backlogs?
 
Surgical backlogs and wait lists are a primary concern for the public. Delays in surgeries can often result in poorer health outcomes. In our on-going work to reduce surgical wait times, the Government of Saskatchewan’s approach is to ensure that all the tools available are being utilized, both in public and privately operated facilities. This combination of increased surgical volumes in publicly operated facilities, as well as increased third party provision of surgical procedures, has proven successful in reducing overall wait times in Saskatchewan.
 
The original email, provided by Dale Hunter with the Saskatchewan Ministry of Health, can be seen here.
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Prevention – reduce demand in the first place

If Canadians lived healthier lives, we could reduce demand for emergency services, orthopaedic surgeries, primary care and more. 

For instance, if you visit the Canadian Cancer Society’s website, you’ll read that “about four in ten” cancer cases are preventable. The Heart and Stroke Foundation notes that “almost 80 percent of premature heart disease and stroke can be prevented through healthy behaviours.” A similar number of Diabetes cases are also preventable. 

Many joint replacements and visits to ERs and walk-in clinics could also be avoided through healthy living. 

To be sure, not all health problems can be avoided through healthy living – everyday the system treats Canadians with genetic conditions, helps those injured in unavoidable accidents and more.  

But there is an opportunity to reduce pressure on the health care system through Canadians shifting to healthier lifestyles – better diets, more exercise, etc. 

To learn more, watch our Health Reform Now documentary (scroll up) or see this column. 

Partner with non-profits and for-profit clinics

European countries will partner with anyone who can help patients. 

It doesn’t matter if it’s a non-profit, a government entity or a private clinic. What matters is that patients receive quality treatment, in a timely manner and for a competitive price.  

In Canada, governments often delivery services using government-run hospitals instead of seeing if non-profit or private clinics could deliver the services more effectively. 

When governments have partnered with non-profit and private clinics, the results have often been quite good – Saskatchewan, Ontario and British Columbia are just a few examples of where partnerships have worked well. 

Canada should pursue more of these partnerships to reduce wait times and increase the volume of services provided to patients.  

To learn more, watch our Health Reform Now documentary (scroll up) or see the links above. 

Make cross border care more accessible

In Canada, citizens pay high taxes each year and we’re promised universal health care services in return. The problem is, wait times are often extremely long in our health system – sometimes patients have to wait years to see a specialist or receive surgery. 

If patients don’t want to wait long periods, they often have to reach into their own pocket and pay for treatment outside the province or country. 

Throughout the European Union, we also find universal health care systems. But a key difference is that EU patients have the right to go to other EU countries, pay for surgery and then be reimbursed by their home government. Reimbursements cover up to what the patient’s home government would have spent to provide the treatment locally. 

If Canada copied this approach, a patient waiting a year to get their hip operation could instead receive treatment next week in one of thousands of surgical clinics throughout the developed world. 

Governments benefit too as the patient is now back on their feet and avoiding complications that sometimes come with long wait times – meaning the government doesn’t have to treat those complications on top of the initial health problem. 

To learn more, watch our Health Reform Now documentary (scroll up) or this shorter video. 

Legalize access to non-government providers

Canada is the only country in the world that puts up barriers, or outright bans patients from paying for health services locally. 

For instance, a patient in Toronto cannot pay for a hip operation at a private clinic in Toronto. Their only option is to wait for the government to eventually provide treatment or leave the province and pay elsewhere. 

Countries with better-performing universal health care systems do not have such bans. They allow patients a choice – use the public system or pay privately for treatment. Sweden, France, Australia and more – they all allow choice. 

Why? One reason is that allowing choice means some patients will decide to pay privately. This takes pressure off the public system. For instance, in Sweden, 87% of patients use the public system, but 13% purchase private health insurance. 

Ultimately, more choice improves access for patients. 

To learn more, watch our Health Reform Now documentary (scroll up) or watch this short clip on this topic. 

Shift to funding services for patients, not bureaucracies

In Canada, most hospitals receive a cheque from the government each year and are then asked to do their best to help patients. This approach is known as “block funding”. 

Under this model, a patient walking in the door represents a drain on the hospital’s budget. Over the course of a year, hospital administrators have to make sure the budget stretches out so services are rationed. This is why you might have to wait until next year or the year after for a hip operation, knee operation, etc. 

In better-performing universal health systems, they take the opposite approach – hospitals receive money from the government each time they help a patient. If a hospital completes a knee operation, it might receive, say, $10,000. If it completes a knee operation on another patient, it receives another $10,000. 

This model incentivizes hospitals to help more patients – to help more patients with knee operations, cataract surgery, etc. This approach also incentivizes hospitals to spend money on expenses that help patients (e.g. more doctors, nurses, equipment, etc.) rather than using the money on expenses that don’t help patients (e.g. more admin staff). 

To learn more about this policy option, please watch our Health Reform Now documentary (scroll up) or see this post by MEI.