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MacKinnon also challenged two frequent criticisms of private clinics: that they’d cream off the easiest surgeries and steal the best staff. Instead, she says surgeries were assigned by health regions and clinics hired retired nurses and nurse practitioners who liked the better hours and low-hassle atmosphere. She noted that surgeries — which covered only an array of specialties, not a complete list of surgeries — came in 26 per cent cheaper than in hospitals. “I think it was extremely well done.” Only in Canada, she said, would there be any fuss over who owns the clinics providing service in a single-payer system, MacKinnon said.

La Presse published a follow-up story the next day with a response from the Government of Quebec’s health ministry, saying the minister does not agree with the numbers in the study. The health ministry pointed to their own statistics, which showed a much shorter average wait time for surgery – 8.5 weeks instead of 19.9.

“At the very least I think media reports should have explained the limitations,” Picard said.

“I don’t think the report has much value because it’s a survey with a small sample size and questionable methodology,” Picard wrote in an email.

The La Presse story didn’t mention that Quebec’s health ministry starts calculating wait times from the moment the doctor decides the patient needs surgery. The Fraser Institute’s 19.9 weeks of waiting is calculated from the time the patient gets a referral to a specialist from their GP – a vital piece of information that would have explained some of the discrepancy.

“When wait times are measured in a scientific fashion using a common definition – such as in the Health Council of Canada annual report – the data are valuable,” Picard said.

Legal precedent: Whatever way the case is decided at trial, it is likely to be appealed and eventually reviewed by the Supreme Court of Canada. A decision from this level will mean all provincial and territorial governments will have to revisit equivalent laws. The foundational pillars of Canadian medicare - equitable access and preventing twotier care - could well be vanquished in the process. Wait times: Day will likely argue that Canada performs poorly on wait times compared to other countries, and that other countries allow two-tier care; thus, if Canada is allowed two-tier care, our wait times would improve. But this approach is too simplistic. Comparisons to the British health system, fail to recall that, despite having two-tiers, it has in the past suffered horrendously long-wait times. Recent efforts to tackle wait times have come from within the public system, with initiatives like wait time guarantees and tying payment for public officials to wait times targets.

By looking to Britain, we are comparing apples to oranges. British doctors are generally full-time salaried employees while most Canadian physicians bill medicare on a fee-forservice basis. Consequently, the repercussions of permitting extra billing in Canada could eviscerate our publiclyfunded system, whereas this is not the case in Britain. Imagine if most doctors in Canada could bill, as those at the Cambie clinic have done, whatever they want in addition to what they are paid by governments?

Conflict-of-interest incentives: Evidence suggests there is a danger in providing a perverse incentive for physicians who are permitted to work in both public and private health systems at the same time. Wait times may grow for patients left in the public system as specialists drive traffic to their more lucrative private practice. Sound improbable? Academic studies have noted this trend in specific clinics that permit simultaneous private-public practice. And recent U.K. news reports have profiled a case where a surgeon bumped a public patient in need of a transplant for his private-pay patient.

Competition: Proponents of privatized health services often claim it would add a healthy dose of competition, jolting the "monopoly" of public health care from its apathy. But free markets don't work well in health care. Why? Because public providers and private providers won't truly compete if the laws Day challenges are struck down. Instead, those with means and/or private insurance will buy their way to the front of queues. Public coverage for the poor will likely suffer, as is clearly evident in the U.S., with doctors refusing to provide care to low-income patients in preference for those covered by higher-paying private insurance.

Of course, this is all based on an outcome that is not yet known. It may be that the charter challenge in B.C. will be unsuccessful, but clearly the stakes for ordinary Canadians are high. Sadly Dr. Day is not bringing a challenge for all Canadians. Isn't it past time our governments and doctors work to ensure all Canadians - and not just those who can afford to pay - receive timely care? Colleen Flood is Professor and University Research Chair in Health Law Policy at the University of Ottawa. Kathleen O'Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University and Managing Editor of EvidenceNetwork. ca

The Wildrose says it would establish waittime caps for five procedures that now face lengthy delays. Those include hip and knee replacements, cataract surgery, coronary artery bypass and radiation treatment. To make it happen, the system must be fixed from within so that all Albertans can benefit. Instead, the Wildrose wants to put in place an escape hatch that only the wealthy can use - if wait times are exceeded, the patient will be sent out of province, or to a private clinic, and the procedure paid for by the Alberta government for whatever it would cost to be done in Alberta. This plan does nothing for the vast majority of patients on wait lists. The reason is that it's not simply a matter of the procedure being done elsewhere. A patient having a hip replacement cannot travel for months. According to the government's own website, myhealth.alberta.ca: "You should not travel long distances in the first three months after (hip replacement) surgery because being seated for long periods while travelling increases the risk of blood clots."

Wildrose Leader Brian Jean says "equal access to a waiting list is not equal access to health care." Access to private or out-of-province care is only for the wealthy, and does not translate to equal access to health care. Only a tiny number of people would be removed from the waiting list under this system; it would do nothing to shorten the wait for the less affluent. Health Minister Stephen Mandel said the Wildrose's plan is "stupid." It is indeed stupid. The system is crying out for a fix from within. That is where our politicians' efforts must be 100 per cent focused.

One of them, 55-year-old Julie Bennett, explains to CBC that she's relying on narcotic pain killers to get her through while she awaits her surgery. She is told it won't happen until 2016, even though she was referred for the procedure in 2013, and she worries she will end up in a wheelchair before then. The other patient, 85-year-old Chiara Borello, spent two weeks in hospital while doctors experimented with medication to try to control her pain, according to her daughter Renata Borello. "If I drop dead, that's fine," the elder Borello tells CBC. "But I won't take any more of that poison [the debilitating painkillers]. That's too much poison."

As the executive director of the Canadian Constitution Foundation, which is supporting the plaintiffs' challenge, I endorse the ideal of ensuring that quality health care is readily available to every Canadian. But the belief that a two-tier system undermines that ideal is wrong. It's as wrong as the assumption that "two-tier" equals "U.S.-style" (most of the rest of the world operates with mixed public and private health-care systems). And it's as wrong as pretending that we have a "onetier" system as it is. A couple of recent happenings, both as frustrating as they are telling, serve to underline the point rather nicely. On Monday, CBC News British Columbia published a story called "Patients' 'lives ruined' as hip surgery waits grow." The piece focuses on two B.C. osteoarthritis sufferers who are experiencing intolerable pain while they wait for the hip operations they need.

Rather, what we're seeing is that government is simply incapable of delivering timely health care through its centrally planned monopoly. It insists, though, on legally confining Julie Bennett and Chiara Borello to wait-lists by banning them from purchasing private health insurance that could cover the cost of their needed surgery, or allowing that aforementioned oversupply of orthopedic surgeons to spend some of their time in the private system, working through some of those 3,000 cases that are causing such a bottleneck. We're supposed to just keep hanging in there and waiting until the government can get its act together.

Interestingly enough, that's exactly the message being sent by the second recent happening I referenced at the start of the column. The trial in the constitutional challenge to B.C.'s health care monopoly was supposed to begin this week, on March 2. It has now been delayed because six days before trial, the government lawyers informed the plaintiffs that the B.C. Ministry of Health had suddenly discovered "thousands of documents" that could be relevant to the case and must be turned over for review. Why these thousands of documents did not turn up at any point in the previous six years of litigation is unclear. It's tempting to read impure motives into the last-minute disclosure - an attempt to exhaust the funds and patience of the plaintiffs who can't rely on unlimited taxpayer-funded coffers and staff, perhaps. But it's every bit as possible that this is simply more evidence of the government's general inability to handle something as challenging as the healthcare file, which requires the nimbleness and efficiency that a bureaucracy is inherently illequipped to provide.

Either way, the plaintiffs will be back in court in six to eight weeks, ready to fight for their rights to make their own health-care decisions.

Marni Soupcoff is executive director of the Canadian Constitution Foundation (theccf.ca).

The trial was set to begin on Monday but now has been postponed as both sides examine the newly found ministry files. NDP health critic Judy Darcy says she hopes the government will throw everything it can at Dr. Day, because if he wins, she believes, British Columbia will be opening the door to a new twotiered health-care system for the country. She isn't convinced the B.C. Liberals wanted to fight this battle. "I think the government is under tremendous pressure to defend the Canada Health Act," she said in an interview. But at least at the outset, the province needed some prodding to engage.

The B.C. Nurses' Union led the charge in 2003, challenging the provincial government to enforce the law and stop private clinics from treading on publichealth turf. It was 2008 when the province finally sought an audit of the books of Dr. Day's two clinics. The two sides then spent four years arguing about the scope of the audit. Finally, in 2012, the Medical Services Commission concluded the clinics were extra billing patients and threatened an injunction, which is still up in the air. The audit was limited to a small sampling of a few hundred cases. "The only thing we saw was a one spot-check audit and it showed $150,000 worth of extra billing in a single month," Ms. Darcy said.

"So we are talking about millions of dollars over the years, and nothing has been done about that." The B.C. Health Coalition is an intervenor in the case. While the province may have been slow to get started, Steven Shrybman, a member of the group's legal team, says he is impressed with B.C.'s case as it stands now. "The province has demonstrated a very serious commitment to this case," he said. "I can't fault them for the job they have done in defending the validity of our medicare model under the Charter." Dr. Day has been angling for this day in court for many years, and all the while he says his case has grown stronger as the province's surgical waiting lists have grown.

"This is a case about patients being able to care for their own health when the government won't provide it," he said. The B.C. Supreme Court will hear, possibly later this spring, his argument that Canadians have a right, under the Charter, to access necessary and appropriate health care within a reasonable time - something he says does not exist in B.C. "The only way the government can win, in my view, is if they can show that wait lists are not a problem." Health Minister Terry Lake told reporters last week that the reason some waiting lists are growing is because the healthcare system is doing more surgeries. "But I have asked our provincial surgical advisory committee to look at the situation, because I think we can do better ... One of my real desires is to reduce those wait times."

That's why those freshly discovered Health Ministry files may be revealing, and if nothing else, Dr. Day's battle may drive the provincial government to find not just the desire, but the means, to take aim at surgical waiting lists.

Today that statistic has fallen considerably, with the average wait at 208 days and the median wait time 81.

But the push to not build or expand any long-term care homes -- an expensive undertaking -- also comes from the belief by those holding the purse strings that they have a better formula for budgeting those coveted health-care dollars.

"We are no longer, to the extent possible, having people make the decision to go to a long-term care home from hospital," said LeClerc.

This not only has relieved a burden on the wait lists, but also a burden on the hospital.

Seniors were more and more frequently taking up hospital beds to a high in January 2011 when 51 seniors were waiting at the Cornwall Community Hospital to go into care elsewhere. Now, LeClerc said, there are 14.

"We actually found that if we were to provide a range of services in the community, that up to a third of the people on the waiting list could come off the waiting list and be cared for in the community," said LeClerc.

So the focus has become trying to keep seniors in their homes -- with the help of community programs -- for just a few months longer, shortening the average long-term care home stay to less than three years where possible.

e care has concerned Cornwall Coun. Andre Rivette, who has said that home care places too high of a burden on families providing care. "They're saying that 82% of residents in Glen-Stor-Dun (Lodge) have dementia or Alzheimer's," he said. "Home care is not going to be of any use for the (82%)."

Many within the system believe allowing private, for-profit options is a potential solution. Government has always relied on private facilities such as walk-in clinics, X-ray clinics and laboratories to provide insured services within the public system. Perhaps it’s time to allow Canadians to purchase medical services on the open market.

Although a province may have an oversupply of surgeons, it has a shortage of the other disciplines. The hours nurses and anesthesiologists work in the private system would come at the expense of the hours they can devote to the public system.This is a key caveat on the argument in favour of allowing more private, for-profit health care options: it is difficult to create a private tier that does not ultimately weaken the public tier. In fact, it is tough to find examples where increased private options relieve pressure on the public system and reduce wait times.

There is some evidence of this in Saskatchewan, where the government has been allowing private, for-profit MRIs for about 10 months. To date, Saskatchewan claims it has taken 2,200 patients off public wait lists for MRIs. And yet, its wait times in the public system have not gone down.

In fact, during the first six months Saskatchewan allowed residents to purchase their own MRI tests, the government’s own website shows wait times went up.

Manitobans should hope for cuts, in the right places. Patients in Manitoba suffer longer wait times trying to see a doctor in the ER than in almost all jurisdictions across Canada. The numbers have been repeatedly crunched by the Canadian Institute for Health Information, a national health-care analysis agency. Manitobans wait, on average, 5.7 hours in the ER, compared with the national average of just over three hours. Repeated interventions and promises to cut queues here have failed and the lines are growing longer.

But that might have been expected, since data also show that more patients who need admission onto medical wards are lying in wait in the ER, because (for example) there aren't enough nursing home beds for elderly people ready to be discharged. This may explain why the NDP government's strategy to open quick-care community clinics has not eased the pressure on emergency rooms.

And despite the addition of hundreds of millions of dollars more in the health budget, Manitobans are still waiting too long for services such as knee replacements, ultrasounds or MRIs that are key to getting in to see a specialist and then get surgery, months down the road.

There is room to cut costs in government and public services, to use money more efficiently in smarter ways -- Manitoba spends more per capita, and as a share of its GDP, on health than most provinces. Yet, Mr. Pallister, an MLA in the cost-cutting days of the Filmon era, has chosen to tiptoe around the idea of cutting government expenses in the areas of health and education. He has said no frontline workers will lose their jobs, but that still leaves a lot of room for change.

Manitoba hospitals are run and funded much the way they have been for decades, which suits the institutions' needs, not those of patients. Budgets, for example, are funded basically to match hospital spending in the previous year, with a bit more for inflation or for new programs. Other jurisdictions with as good or better systems (including those in Canada) have moved to tie budgets instead to the volume of services delivered. This helps spur innovation that puts patients at the centre of service. Further, European countries, outperforming Manitoba and Canada's medicare system for quality and cost, have universal systems that blend private and public funding.

The fear of private health care is almost palpable in Canada because Canadians can't see past the U.S. model, which sits next door like an elephant waiting to roll over. But Canada has more in common with, and more to learn from, the European experience, where social-welfare systems are equally strong and tied to national identity.

Mr. Selinger's sacred-cow analogy means he will milk the scare tactics to death. Manitobans need a better prescription for what ails our health system. It's up to opposition parties to start talking about that.

"Despite the added system capacity, wait lists continue to grow."

According to the report, there were approximately 1,284 people waiting for long-term care beds in April 2007. That increased to approximately 1,740 clients in April 2010 — an increase of 35.5 per cent. During the same period of time, bed capacity increased by about 13 per cent.

While the wait for hospital clients decreased from approximately 80 days in 2009-10 to 65 days in 2010-11, wait times for clients in the community increased from 110 days in 2009-10 to approximately 150 days in 2010-11.

Officials with the Department of Health and Wellness said they are working on programs that will help keep senior citizens in their homes and will take steps to improve and streamline admissions to long-term care facilities.

This year, Nova Scotia's NDP government cancelled the program creating new long-term care beds.

As a policy under the workers' compensation insurance system, expedited fees were effective in reducing wait time to surgery. While a difference of only two weeks may not improve longer-term clinical outcomes post-surgery, it represents a reduction in the total disability duration (i.e., pain, suffering, quality of life) for the injured worker and increases the worker's likelihood of successfully returning to work; the reduced disability duration also represents a cost saving to the workers' compensation system for time-loss benefits and to employers who pay compensation premiums based on the frequency and duration of their claims experience.

the provision of surgeries "after hours" or within private clinics may result in a redistribution of finite resources (e.g., surgeons, surgeon time, surgical staff) from one insurance provider to another, favouring those associated with higher fees, thus creating inequities. An evaluation of the effect of workers' compensation policies on inequity in the provincial healthcare system was not part of this study and warrants future investigation.

the time leading up to surgery may be confounded by co-morbidities and that individuals with complications may be directed to the public system

A difference of approximately two weeks in surgery wait time associated with the expedited fee policy may have meaningful clinical and quality-of-life implications for injured workers, in addition to being cost-effective policy for workers' compensation insurance systems, but did not affect the return-to-work time post-surgery as part of total disability duration. Minimal (and not statistically significant) differences in disability duration were observed for surgeries performed in private clinics versus public hospitals.

Medical buildings often have standard benchmarks — basing the number of examination rooms, for example, on the expected volume of patients. Ms. Brandenberg and her team instead used C.P.I. to map out common paths that patients, staff members, supplies and information would flow through. They worked in an empty office building, using cardboard mock-ups of surgical sites, recovery rooms, anesthesia areas and waiting rooms. Fifty staff members then play-acted various scenarios to test the design’s effectiveness. The final design reduces walking distances and waiting times for patients by grouping related facilities together and creating rooms that can be used for more than one purpose. The hospital was able to shave 30,000 square feet and $20 million off of the new building

Last year, amid rising health care expenses nationally, C.P.I. helped cut Seattle Children’s costs per patient by 3.7 percent, for a total savings of $23 million, Mr. Hagan says. And as patient demand has grown in the last six years, he estimates that the hospital avoided spending $180 million on capital projects by using its facilities more efficiently. It served 38,000 patients last year, up from 27,000 in 2004, without expansion or adding beds.

checklists, standardization and nonstop brainstorming with front-line staff

The program, called “continuous performance improvement,” or C.P.I., examines every aspect of patients’ stays at the hospital

The system is just one example of how Seattle Children’s Hospital says it has improved patient care, and its bottom line, by using practices made famous by Toyota and others. The main goals of the approach, known as kaizen, are to reduce waste and to increase value for customers through continuous small improvements.

Similar methods are now in place at other hospitals and health systems, including Beth Israel Deaconess Medical Center in Boston, Park Nicollet Health Services in Minneapolis and Virginia Mason Medical Center, also in Seattle.

All medical centers, especially larger ones, would have significant return on investment by using operations management techniques like C.P.I., says Eugene Litvak, president and chief executive of the Institute for Healthcare Optimization and an adjunct professor of operations management at the Harvard School of Public Health.

“The health care industry could be on the verge of an efficiency revolution, because it is currently so far behind in applying operations management methodologies,” says Professor Litvak.

TO be sure, not everyone believes that factory-floor methods belong in a hospital ward. Nellie Munn, a registered nurse at the Minneapolis campus of Children’s Hospitals and Clinics of Minnesota, thinks that many of the changes instituted by her hospital are inappropriate. She says that in an effort to reduce waste, consultants observed her and her colleagues and tried to determine the amount of time each of their tasks should take. But procedure times can’t always be standardized, she says. For example, some children need to be calmed before IV’s are inserted into their arms, or parents may need more information. “The essence of nursing,” she says, “is much more than a sum of the parts you can observe and write down on a wall full of sticky notes.”

one-day strike by the Minnesota Nurses Association against six local health care corporations, including her employer, partly in protest of lower staffing levels her union thinks have resulted from hospitals’ “lean” methods

the Lean Enterprise Institute

George Labovitz, a management professor at Boston University, says there are limits to performance-improvement methods in hospitals. “Human health is much more variable and complex than making a car,” he said, “so even if you do everything ‘right,’ you can still have a bad outcome.”

Joan Wellman & Associates, a process improvement consulting firm in Seattle

examine the “flow” of medicines, patients and information in the same way that plant managers study the flow of parts through a factory

In a typical workshop at Seattle Children’s, a group of doctors, nurses, administrators and representatives of patients’ families set aside a 40-hour week to work through C.P.I. methods. They plot each “event” a patient might encounter — like filling out forms, interacting with certain staff members, having to walk various distances or having to wait for assistance — and brainstorm about how each could be improved, or even eliminated.

it never ends

Standardization is also a C.P.I. cornerstone. Last year, 10 surgeons at Seattle Children’s performed appendectomies, and each doctor wanted the instrument cart set up differently. The surgeons and other medical staff members used C.P.I. to come up with a cart they all could use, reducing instrument preparation errors as well as inventory costs.

"Unlike the past several years, the 2012 results show a worsening of performance

the alliance sees a strong role for the federal government to play in setting national strategies and facilitating their implementation, as was done in the past for heart disease

Some provinces are slipping backwards, the alliance said, because so many hospital beds are filled with elderly patients with dementia.

The group called for a national strategy to deal with illnesses such as Alzheimer's disease and to factor dementia into the management of other chronic diseases such as heart disease and diabetes.

When seniors do go to hospital, they should be screened for delirium and dementia as early as possible to trigger services such as geriatric medicine and psychiatry while they're still waiting for a hospital bed

One solution is building up frontline community care

The findings are consistent with a report in March from the Canadian Institute for Health Information that said wait times are about the same as in 2009 with some provinces struggling more than others.