Dr. Robert Bell is professor emeritus in the Department of Surgery at the University of Toronto, former deputy minister of health for Ontario, and former chief executive officer of the University Health Network.
The Ontario government’s decision this week to move more surgeries out of hospitals in order to address the province’s huge surgical backlog is the right thing to do. However, Premier Doug Ford’s government is making a big mistake in moving these surgeries to for-profit providers instead of creating community surgery centres overseen by public administrators.
Community surgery centres, sometimes referred to as ambulatory surgery centres, are specifically designed to handle high volumes of low-complexity surgeries. While hospitals need to spread their resources across many different departments (emergency care, imaging services, intensive care, etc.), surgery centres are purpose-built to perform high volumes of operations such as cataract replacements or knee and hip surgeries. Studies show that community surgery centres can complete about 30 per cent more operations than a hospital in a given day, at a similar cost.
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We have many examples across the country of the safe and efficient care being provided in publicly funded community surgery centres, such as the Jim Pattison Outpatient Care and Surgery Centre in Surrey, B.C. Many hospitals, including in Ontario, have already established high-efficiency community surgery centres and most would be eager to expand community surgery services with incremental funding from the government. Other not-for-profit community organizations, such as the Kensington Health eye-surgery centre, would also readily increase their volumes if provided with adequate funding. There is no doubt that we can quickly reduce Ontario’s surgery backlog by investing in publicly funded community surgery centres.
This is why the Ontario government’s announcement on Monday that it would address the issue by moving more surgeries to for-profit providers is the wrong approach. The decision will cause even more strain in the province’s health care system, and will be less beneficial for both patients and taxpayers.
With an expanded mandate from the Ford government, for-profit surgery providers will almost certainly compete for staff, such as nurses, currently employed in hospital operating rooms. These nurses are required to be available on occasional nights and weekends, to look after patients needing emergency surgery. If these nurses are offered the opportunity to work only day shifts by for-profit providers, it is likely that we will see an exodus from our hospitals. Just as Ontario emergency rooms have closed this past year because of inadequate staffing, we may see ORs shuttering – especially at night and on weekends – even though there will still be a need for emergency surgeries.
The risk to OR staffing is especially worrisome since Ontario hospitals have previously been restricted by Bill 124 in limiting pay increases for nurses to 1 per cent annually. The Ford government is appealing a Superior Court decision to strike down the legislation in November. Were this appeal to succeed, for-profit surgery centres would have an unfair advantage in competing for staff.
Although certain elements of a surgical procedure may be paid for by OHIP, patients may still be forced to pay unregulated costs for uninsured services associated with their operation by for-profit providers. For example, patients undergoing cataract surgery have options for the types of artificial lenses they can select for their eyes, depending on their vision needs. In not-for-profit settings, the cost of these lenses is capped and regulated. But at for-profit centres, prices are set by the operator.
The taxpayer will also pay more with an expanded for-profit surgery model. In its earlier proposal to move cataract surgery to the private sector, the government offered operators $605 for each patient (in addition to surgeon fees), in contrast to offering hospitals about $500 for each patient.
Alberta and Saskatchewan have invested in for-profit surgery, supposedly to reduce surgical wait times. However, a Canadian Institute for Health Information analysis in 2021 showed that waits for cataract surgery in those two provinces were essentially the same as in Ontario, and that wait times for hip and knee replacement were substantially worse. The College of Physicians and Surgeons of Ontario (the organization responsible for inspecting new for-profit surgery centres) has advised the government against increasing funding going to for-profit surgical care.
Ontario has other options for increasing surgery volumes and reducing wait times resulting from the pandemic. Repealing Bill 124, for example, would be a first step in attracting nurses back to hospital ORs, and moving surgeries to dedicated community facilities could increase volumes by 30 per cent for roughly the same cost. But investing more broadly in for-profit surgery providers – which has enormous risks for hospital staffing, and will increase the costs passed on to patients and taxpayers – should not be on the table.