BC’s surgery wait times are still rising, while a Victoria company says private facilities have a part to play

It has been more than two years since Alyse Frampton first went to the doctor complaining about pain in her hips.

It took a year—during which time she was misdiagnosed, then forced to find a new general practitioner after her previous one retired—for her to be correctly diagnosed with osteoarthritis in both joints, necessitating a double hip replacement.

Just this past June, nine months after the diagnosis, Frampton had her first hip replaced. Now she is facing another six- to nine-month wait for the second hip replacement.

Meanwhile, her condition continues to worsen and the pain continues to increase to the point that she’s now in pain “around the clock.” It prevents her from living the active lifestyle that brought her to Victoria in the first place.

Her inability to get around easily, meanwhile, has meant she spends most of her time alone.

“I can’t wait for it to be over,” she said.

Frampton is one of thousands of British Columbians currently waiting for hip replacement surgery, and one of hundreds in the Greater Victoria area alone. While her interactions with health-care workers have been positive, she and her husband, George Galt, say they are tired of having no control and very little understanding of the opaque system.

In the Island Health region, and across the whole province, elective surgery wait times have increased exponentially due to the pandemic. But COVID-19 has only exacerbated an issue that has afflicted the province for years

Island Health has been making moves to shorten wait times by contracting surgeries and pre- and post-op care to private and investor-owned clinics. And while these initiatives have shown success, researchers are concerned about the long-term effects this could have on the public health-care system.

Worsening wait times

More than 300,000 surgeries are performed in BC in a normal year, more than half of which are emergency or unscheduled procedures that do not appear on waiting lists. The Island Health region completed 56,496 surgeries last year. Of those, up to 30% were considered emergencies, and performed within 72 hours.

An elective surgery is different from an emergency surgery simply in that it is scheduled in advance. But that doesn’t mean they are unimportant: vital surgeries like joint repair and replacements, tumour removal, and hernia surgeries also fall within the same category.

However, wait lists and the time to complete these surgeries has grown steadily over the past two decades, to the point that a large percentage of patients are waiting well above what is considered an acceptable wait time.

A 2019 report by the BC Anesthesiologists’ Society shows that just before the pandemic, 85,468 people were waiting for surgery in the province. At that point, 40% of them had already waited longer than the federal government’s benchmark limit of 26 weeks. Some had been waiting for surgery for more than a year.

And the waiting list has grown over the past two decades. Between 2001 and 2018 the number of patients awaiting surgery jumped 54.4%—an increase three times faster than the province’s population growth.

There’s no easy solution to the problem, and any fix will require teamwork between the provincial government, regional health authorities, and other health-care providers, Dr. Roland Orfaly, CEO of the BC Anesthesiologists’ Society told CBC in 2019. “This isn't a problem that's developed overnight.”

But practically overnight, early last year, the problem grew exponentially worse.

‘A lot of inefficiencies’

The province has spent hundreds of millions of dollars hiring new staff and expanding hours to deal with the COVID-induced waiting list growth, and as of May, it has mostly succeeded: the vast majority of delayed surgeries have been completed. But wait times remain lengthier than ever.

Andrew Longhurst, a research associate with the Canadian Centre for Policy Alternatives (CCPA) and a PhD student at Simon Fraser University, is one of the authors of a 2016 CCPA report that looked at different ways the province could tackle the growing waitlist. While the report was released prior to the pandemic, Longhurst says the major findings have not significantly changed in BC or much of Canada in the intervening years.

Longhurst points to “inefficiencies” in how patients move through the system: for example, how patients in the public system are typically referred to a specific surgeon rather than a group of surgeons with the same specialty. Wait times can vary widely between surgeons, so offering a first-available option instead would get patients into surgery more quickly.

“A key part of this is when you equalize the workload, you reduce a lot of those long waits,” Longhurst said.

Even before a patient is added to a list, there needs to be a better process to determine whether they are actually a surgical candidate, he added; half the time a referral from a family doctor to an orthopedic surgeon doesn’t actually result in surgery. In a number of orthopedic areas especially, it would be more efficient to have patients see a physiotherapist with specialized training first to determine whether or not they are actually a surgical candidate.

These ideas are not new; they’ve been tried through pilot programs in various countries and with great success in Scotland, which is considered one of the leaders in developing long-term wait-time solutions.

This is also not new in BC. The Osteoarthritis Service Integration System (OASIS), an initiative started by Vancouver Coastal Health in 2006, for example, has sought to do basically what Longhurst’s research suggests.

The OASIS program was created as a central-intake system to assess whether hip and knee patients needed surgery, and direct others to non-surgical treatments. The result was that 1,955 patients—nearly half of all patients over three years—were diverted away from surgery, who would have otherwise contributed to creating longer waits for those with a greater need.

In the South Island, a private clinic has been operating with a similar model to OASIS since it opened in 2013. And while the clinic says they have proven private organizations have a place in public health care, some experts aren’t so sure.

Private clinics in a public system

The idea for RebalanceMD was born nearly a decade ago after a conversation on the side of a soccer field.

While watching their kids play, physiotherapist Stefan Fletcher and orthopedic surgeon Pat McAllister began chatting about how they could improve the chaotic system their patients faced while trying to get treatment. Rather than having patients zigzag across the city to attend various appointments with various specialists, the pair discussed how the whole process could be streamlined by creating a central-intake clinic and pooling waiting lists for surgeons and operating rooms.

Fletcher, the former head physiotherapist for Rugby Canada and current RebalanceMD CEO, started his career in New Zealand, a country where public and private health care co-exist. And while there is much less room for private organizations in Canada’s public system, Fletcher and co-founder McAllister saw a gap that a new purpose-built clinic could fill.

In 2013, with funding from the Specialist Services Committee and a partnership with Doctors of BC and the BC Ministry of Health, RebalanceMD launched in Uptown Mall, bringing specialists, non-operative surgeons, physiotherapists, and all South Island orthopedic surgeons together under one roof.

Their numbers showed promise right away: with the organization’s efforts, Greater Victoria’s wait times for orthopedic surgery procedures (like knee and hip replacements or ligament repair) dropped to some of the lowest in the country. Prior to the pandemic, Fletcher says wait times for a consultation were on average about six to 10 weeks, and the wait time from consultation to surgery was between 12 and 20 weeks, compared to the combined national average of 34.1 weeks.

These low wait times, Fletcher said, are due largely to Rebalance’s approach to prioritizing patients. Similar to OASIS, when patients are referred to Rebalance by their general practitioners, specialists assess them to first determine the urgency of the issue and then whether or not the patient will need surgery at all.

It’s like loading an airplane, Fletcher adds. “If you’re gonna load an A380 airplane through one door, it’s a very, very long line to get into that airplane. But if you open up four doors, you get basically everybody onto the airplane a lot quicker.

“So, basically, it’s just being very smart with making sure there’s multiple ways to access the system, at multiple different levels.”

RebalanceMD is contracted by Island Health to prepare patients for joint repair or replacement surgeries, and deliver post-op physiotherapy, so every patient in the Capital Regional District who needs a joint replacement goes through the clinic.

RebalanceMD's office in Victoria. Photo: Jolene Rudisuela / Capital Daily

In September 2020, private equity firm CAI Capital Partners acquired a majority stake in the company. According to supplier statements produced by Island Health, in the 2019/20 fiscal year, RebalanceMD received $1.23 million from the Health Authority as part of the contract, a 78% increase from the contracted amount in 2015/16. Fletcher says this money only goes towards the contracted services; the surgeons that work with RebalanceMD bill the province as they normally would.

RebalanceMD is not a surgical facility, but there are currently two private surgical facilities on the Island: View Royal Surgical Centre and Seafield Surgical Centre in Nanaimo, both owned by Surgical Centres Inc. According to the College of Physicians and Surgeons of BC, these facilities are both properly accredited and have been contracted by Island Health to perform surgeries that would otherwise be done in hospitals, specifically to reduce wait times.

The View Royal facility opened in 2017 and is working under a five-year, $30 million contract with Island Health to provide up to 2,750 publicly funded day surgeries and 3,000 colonoscopies each year.

When the contract was announced, BC Nurses’ Union president Gayle Duteil criticized the deal in a Times Colonist op-ed. “Paying for the use of privately owned operating rooms does nothing to address this crisis,” she wrote. “In fact, it will likely serve to increase surgical wait times overall as those specialty-educated nurses working in public operating rooms migrate to private facilities and flee an inadequately resourced public system.”

Longhurst agrees that private facilities are not a long-term solution to wait times.

“I don’t think profit has a place in health care,” he said. “We can see from every jurisdiction that experiments with it, the problems that it creates. I think it is entirely possible to bring a lot of these services back into not-for-profit and public sectors. And that’s where the focus ought to be.”

The CCPA report shows that private, for-profit care can cost significantly more than the same tests and procedures in a public hospital. In 2016, Island Health entered into an agreement to pay two Island MRI clinics in Comox and Nanaimo a total of $990,000 to perform 1,800 MRI scans. This works out to about $550 per scan, nearly double the $300 cost in a public facility—though Island Health acknowledged at the time the estimate did not include its overhead costs. This agreement came five years after the health authority abandoned its plans for private MRI delivery because completing the scans in the public sector was about four times less expensive.

A 2011 Health Policy report also found that WorkSafeBC paid about 375% more for expedited knee surgery in a private clinic than non-expedited surgery in a public hospital.

At the end of August, Island Health ended four contracts with private companies for housekeeping, mixed services, and patient food services. The province said that doing so will provide more stability and increase wages, benefits, and working conditions up to the public-sector standard for more than 4,000 workers who were brought back into the public system.

Longhurst also noted that private delivery can sometimes result in upselling services at a cost to the patients and delivery of publicly-funded surgeries that are not necessarily needed.

“So it’s not to say that appropriateness and the decision for intervention isn’t an issue in public hospitals. It certainly is,” he says. “But we know very clearly that when you have an organization that is focused around deriving a profit from its activities, and some things are more lucrative than others, it can really create conflicts of interest.”

Online Google reviews for RebalanceMD describe many positive experiences at the clinic, but multiple people also reported upselling and being pushed to buy products or attend physiotherapy sessions they didn’t feel they needed. Frampton, for her part, says she has not had to pay for any of the RebalanceMD services and has never experience any upselling pressure. Throughout her treatment journey, she has only purchased a better quality walker and cane from a downtown medical supply store.

Fletcher says RebalanceMD does not upsell products and services.

“We are 100% in the public system. We’re not driving private services. We’re driving delivery of public services in private facilities,” he said. “We work with very strong collaboration with the Health Authority and the Ministry of Health, and we’re showing that there’s a responsible role that can be played by a private organization to deliver public services.”

Innovation and prevention

In April of this year, 12 non-urgent surgeries were cancelled in Island Health due to the stress on the health-care system. At the time, Health Minister Adrian Dix said these cancellations were not related to COVID-19 patients being transferred from other jurisdictions to the Island, as had happened earlier in the pandemic. Rather, they were due to staffing and capacity issues.

The province as a whole is facing a nursing shortage, which has been amplified by the global pandemic. The BC Nurses’ Union has repeatedly said that the pressures on the health-care system are not new, but COVID-19 has increased the stresses nurses face.

Just at the end of August, a lack of nurses led to the temporary closure of the Saanich Peninsula Hospital emergency room. Island Health told Black Press the closure—which lasted from 7pm Aug. 21 to 7am Aug. 22—was because the hospital was short two of the four required registered nurses.

“The piece to recognize in this is that it doesn’t really matter what we do on our end; it’s a complete circle,” Fletcher said. “Health-care workers are all under the gun. So we need to sort of also have a model which is sustainable and respectful to all the moving pieces in the equation.”

Fletcher says the answer is innovation.

Island Health, in collaboration with Rebalance, is testing out a new approach to hip and knee surgeries that would see patients released from hospital in 24 hours. About 70 cases have been successfully completed to date at the Royal Jubilee Hospital, Fletcher said, and the average length of stay in hospital has been reduced from 3.7 days to 1.2.

“One of the biggest restrictions is not the amount of surgeries that can be done. It’s the amount of beds available for a patient to recover in the hospital,” Fletcher said.

But in the long term, Rebalance is working on getting more same-day orthopedic surgeries out of hospitals entirely, with the help of private clinics working in the public system, like View Royal Surgical Centre.

Usman Mushtaq, coordinator with the BC Health Coalition, says RebalanceMD and other private clinics are innovating new ways of completing surgeries, but the concern is that public funds are being diverted into a for-profit enterprise. “And while they’re doing good work, none of that investment is coming back into the public system to help the public system in the long run,” he said.

Vancouver Coastal’s OASIS, which is similar to RebalanceMD, is still in existence, but other pilot programs initiated by health authorities have not fared so well. Longhurst says in 2021 some promising public programs have been terminated or are languishing, and haven’t received the attention and leadership needed to realize their full potential.

“And this is not just a BC phenomenon. It’s often been said that Canada is a land of perpetual pilot projects,” he said.

Longhurst agrees that no part of the system functions in a vacuum, and coming up with ways to reduce pressure on any one part is important. But the focus should be more on strengthening the entire public system and preventative-focused care as well. That includes ensuring that older adults have the support they need to avoid unnecessary trips to the hospital for preventable injuries.

As Frampton’s hip continues to deteriorate and her mobility declines, she has become more worried about falling and injuring herself.  But she still has months to wait until she’s pain free.

Three months after her first hip surgery, Frampton still doesn’t have a date for her second. The time between now and her next procedure will be spent pretty much immobile at home, where she has been stuck for the past two years. And for her pain, the Tylenol 3s aren’t cutting it anymore.

“You don’t have any control as a patient,” she says. “You know, you’re fed into the line and you just have to accept that and wait your turn.”

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Correction at 8pm on Sept. 17: An earlier version of this story said that Alyse Frampton had purchased her cane and walker from RebalanceMD, when in fact she had bought them from a medical supply store in downtown Victoria.