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Brad Wall’s health-care promise is difficult – but smart

Saskatchewan Premier Brad Wall talks to media in October, 2012. Mr. Wall has called an alleged high-school hazing incident ‘disturbing.’

Liam Richards/The Canadian Press

Saskatchewan has pledged to eliminate emergency room wait times by 2017.

That is a pretty bold promise because waits – and seemingly interminable ER waits in particular – are the Achilles heel of medicare.

Premier Brad Wall first unveiled the initiative as part of Saskatchewan Plan For Growth: Vision 2020 and Beyond back in October 2012, but it didn't get a lot of attention because of the document's sweeping scope.

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But both the Premier and Health Minister Dustin Duncan have re-iterated the pledge recently, which is especially interesting given that emergency rooms in the province have struggled to stay open around-the-clock, let alone eliminate waits.

Making a political promise is one thing; making it a reality is quite another. One has to wonder if the Saskatchewan Party, which has overseen some pretty dynamic changes in the province in recent years – among them bolstering the health system to make it what is undoubtedly the country's best – have over-reached on this one.

Canadians are among the most frequent users of emergency rooms in the world. There are roughly 16.2 million ER visits a year in a country of 34 million.

We also have the dubious distinction of some of the longest waits in the Western world: The median wait is 2.4 hours, one in 10 patients waits more than 7.5 hours, and the stories of the epic 24– and 48-hour waits are legion, especially around this time of year, in flu season.

The problem with ER waits is they are rarely ER-based. Rather, they are the most visible manifestation of a larger systems problem.

And when you try to implement simplistic, one-off solutions in a complex system like healthcare, you are as likely as not to provoke a domino-like cascade of other problems.

Excessive ER waits are usually explained using the laws of supply and demand: There are too few doctors and too many patients.

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But, in the ER itself, sheer volume of patients is not as much a problem as patient flow.

Almost all the bottlenecks in emergency rooms are caused by so-called "access block" – meaning there are not enough beds for patients who need to be admitted to hospital.

That's because Canadian hospitals are routinely at 100 per cent capacity. This time of year, it is normal to see hospitals at 110 per cent or more. (In practical terms, that means a bunch of people are on stretchers in the hallways outside the ER, not an uncommon sight.) The hospitals are full not because there are too many sick people or too few beds, but because there is a lack of homecare and nursing home spots for those who no longer need acute care but cannot live independently. There are roughly 7,500 of these "alternate level of care" patients (also known as "bed-blockers") on any given day, the equivalent of about 20 hospitals worth.

It is estimated that each one of these warehoused patients results in care being delayed/denied to about four patients per hour, according to the Canadian Association of Emergency Physicians. They also note that when a hospital's occupancy is under 90 per cent, there are rarely significant waits in ER.

Saskatchewan, to its credit, seems to understand this complex dynamic, and has invested in a "patient flow initiative" to find solutions along the continuum rather than just pouring money into emergency rooms. (Though they have done that too, jacking up the salaries of the province's ER docs by about 13 per cent in a new contract.)

Another oft-cited problem is that too many patients show up in the emergency room with minor problems – the equivalent of a hangnail. There is a lot of tisk-tisking about this "inappropriate" use by "irresponsible" patients but the reality is that nobody goes and sits in the ER for hours for fun; they do it because of the lack of alternatives.

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Many Canadians don't have a regular family doctor – more than four million by some estimates – and same-day and after-hour appointments can be hard to come by, so many end up in the ER by default. Again, that doesn't necessarily mean there is a lack of doctors; but it does remind us our primary-care system is mired in the Stone Age. Reforms are desperately needed and, thankfully, underway in many provinces.

According to data compiled by the Canadian Institute for Health Information, 8.5 per cent of ER visits are non-urgent, 37 per cent are less urgent, 39 per cent are urgent, 14 per cent are emergent, and less than 1 per cent require resuscitation.

That means almost half of visits are unnecessary, and could be handled in a primary care setting by a doctor or nurse-practitioner. Saskatchewan has vowed to make getting these patients out of the ER.

But, we have to be careful with the assumption that the "inappropriate" users are responsible for longer waits or that waits will disappear if they are diverted elsewhere.

The non-emergency patients in ER don't occupy stretchers, they need little nursing care, and require brief treatment times. They don't actually cost more because most emergency docs are now salaried rather than on fee-for-service.

The other much-discussed ER clientele are the so-called frequent flyers. One per cent of patients account for 49 per cent of all hospital costs and those patients – who tend to have multiple chronic conditions, physical and mental – spend an inordinate amount of time in emergency rooms, some a jaw-dropping 150 days or more.

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That is a clientele that needs to be diverted, usually to other social services. But, again, their care doesn't often result in other people waiting. If anything, the frequent flyers tend to be ignored, as demonstrated by the tragic case of Murray Sinclair, a Winnipeg man found dead after a 34-hour wait in ER.

Resolving all those challenges before 2017 is a tall order. But setting an ambitious goal – no more ER waits – and answering to it publicly is a good start.

If other province's had Saskatchewan's chutzpah, then the needed transformation of the healthcare system might actually become a living, breathing initiative rather than merely the subject of memos and reports.

André Picard is The Globe's health columnist. Follow him on Twitter.

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