The election campaign is an opportunity for our right-wing parties to bring out the promise to use the private sector more to support the congested health network. It is more worrying when this commitment comes from the CAQ which is currently in government and which risks being re-elected.
Posted yesterday at 12:00 p.m.
Although this solution is often put forward during bistro discussions or family evenings, its merit is not supported by evidence. Worse, the development of the private sector in a context of labor shortage risks reducing access to services, especially for the elderly and those with multiple chronic diseases.
Quebec and Canada already make extensive use of private enterprise for service delivery. Think of medical and dental clinics, pharmacies, physiotherapy clinics, psychologists’ offices. There are also private CHSLDs, residences for the elderly and employment agencies for nurses and other health and social services personnel. For hospital services, the use of the private sector is limited to imaging clinics and a few surgery clinics for cataracts or orthopedic operations.
The CAQ’s commitment is to develop a private network of hospitals offering minor emergency services and surgery to reduce waiting lists and promote access.
It is often claimed that the private sector would be much more efficient and less costly than the public sector. However, the evidence belies this claim. In an analysis of all the studies carried out on this question, Devereaux and his colleagues in 2002 instead demonstrated that private for-profit establishments have a low (2%) but significantly higher mortality rate than public or private non-profit hospitals.1. Private establishments entail significantly higher costs (19% on average) than public establishments, profit obliges2. The Clinique Rockland experience showed opposite results for costs, but the owners of the clinic did not consider that their patients were very different from those receiving care in the hospital: younger, fewer comorbidities and less complex conditions. In efficiency comparisons, it should also be noted that public establishments often have operating programs disrupted by the occurrence of urgent and unforeseen cases. They must also assume the care required in the event of any complications occurring in people operated on privately.
Waiting time
It is also claimed that using the private sector reduces waiting lists and improves access. The experience of Alberta and Manitoba for cataracts shows that the wait time does not decrease by the introduction of private3. The total capacity of the system has remained the same: it only transfers patients from public to private, without impacting waiting lists. In addition, costs have increased significantly. That was 40 years ago, but myths die hard.
On the other hand, the development of the private sector runs the risk of having significant adverse effects on our public network. In a context of labor shortage, doctors, nurses, respiratory therapists and other personnel hired by the private sector will be drained from the public network, amplifying the shortage all the more. These professionals will be attracted by more luxurious buildings, more modern equipment, more interesting working hours and higher salaries. But these advantages have a price and the bill passed on to the Régie de l’assurance maladie du Québec (RAMQ) is likely to be higher. The recent experience of fertility clinics has clearly demonstrated this.
Our taxes will thus subsidize the private sector in a competition where the public will have to deal with more budgetary restrictions.
This will actually lead to a decrease in the surgical capacity of the public network. The net effect will ultimately be a transfer from the public to the private sector, with no net reduction in waiting times. Then, the private sector will focus on simpler cases and younger patients, leaving the elderly or complex cases on the waiting lists of public hospitals. Finally, as there is an à la carte profit, some doctors could be tempted to favor their private clinic to the detriment of the public establishment, both for their availability and for the referral of patients. This phenomenon has already been observed for radiology.
To the ardent supporters of the private health sector, I would remind you in closing that during the pandemic, the private sector did not demonstrate its superiority, far from it. Let us remember the disasters in certain private CHLSDs, the impotence of seniors’ residences and their appeal to the rescue of the public network, or the contribution of the personnel of private employment agencies to the outbreaks. The private sector seeks profits and leaves the risks and additional costs to the public. We have seen it in public-private partnerships. The attitude of private residences which refuse to continue to accommodate people with a loss of autonomy is another example; as soon as it is no longer paying, we shamelessly transfer to the public. And in addition, the public network is accused of not supporting them adequately.
Due to lack of staff and funding, operating rooms in our public hospitals are closed or their use is reduced. Staff shortages are also cutting into hospitals’ capacity for intensive care beds, an essential element for providing post-operative care. Finally, access to hospital beds is limited by people waiting for admission to a CHSLD, given our inability to provide adequate home care.
To reduce waiting times for surgery, it is therefore better to tackle these factors: improve the supply of home care, develop a workforce plan to attract and above all retain staff, reopen beds intensive care units and use our operating theaters at full capacity. When you are thirsty in the middle of the desert, you are desperately looking for an oasis. Beware, however, of mirages. Consolidating our public network is the real solution.