I recently testified at the Cambie Surgery Centre trial in B.C. Supreme Court. This legal action was against the government of B.C. to determine whether the citizens of the province have the right to pay privately for insured medical services. At issue is the unacceptably long wait lists for many orthopedic procedures. Individuals who require joint-replacement surgery often suffer excessive wait times for surgical treatment while struggling with severe, unrelenting pain and the resulting disability.
Until now, patients who are able to pay could elect to go through a private surgical clinic to have their surgery, which offers rapid pain relief, gets them moving again, and reduces their risk of other serious illness associated with inactivity. The provincial government is wanting to deny citizens access to privately funded services such as orthopedic surgery and magnetic resonance imaging. If waiting lists were reasonable, individuals would not pay thousands of dollars for a service that would be free in the public sector.
Certain groups, including the RCMP and WorkSafeBC patients are exempted from the prohibition of privately paid medical treatment and have guaranteed access to privately funded services on an expedited basis.
I am fully supportive of publicly funded healthcare, having provided psychiatric care for 35 years as part of the Canadian Medicare system. However, it has become nearly impossible for general practitioners to access timely psychiatric care for their patients. Patients who suffer from serious mental illnesses such as schizophrenia, bipolar disorder or depression and remain symptomatic for an extended period, do much worse than patients diagnosed, treated early and completely. Lengthy periods of untreated illness are associated with a greater likelihood that treatment will not be effective, increased functional impairment and heightened risk of suicide.
Access to psychiatry is limited by a number of factors. To see a psychiatrist, a family practitioner must determine if a referral is appropriate and necessary. They then send a referral to the psychiatrist, asking them to accept the patient for assessment. A large percentage of patients in B.C. do not have a family doctor and rely on walk-in clinics, where they see a doctor who has no long-term knowledge of their health. GPs working at walk-in clinics may not have a well-established referral network.
In 2006, the Canadian Psychiatric Association set ideal maximum wait times for patients with serious psychiatric illnesses. The guidelines stipulate that the most seriously depressed patients should be assessed within 24 hours. In B.C., patients in a psychiatric crisis can be assessed in a hospital emergency room, although waiting times in emergency rooms are excessive and for many, intolerable.
The association recommended that patients who are in an “urgent state” should be assessed by a psychiatrist within two weeks. Patients with depression who are in a “scheduled state” with “tolerable symptoms or disability,” should be assessed and treated within four weeks. It is my clinical experience that the current waiting list for patients to be referred to psychiatrists for major depression is frequently four to six months or even longer.
In 2011, prominent psychiatrist Dr. Elliott Goldner published his research on access to psychiatric care in Vancouver. Goldner created a fictional case of an adult male patient presenting with depression seeking a referral to a psychiatrist from their family doctor. The researchers called all 297 psychiatrists practicing within the Vancouver area. Of the 230 who were successfully contacted, 70 per cent said they were unable to accept the referral, 30 per cent indicated they might be able to consider accepting a referral after they had reviewed a detailed written referral note. Furthermore, they would not provide an estimate of the wait time, even if the patient was to be accepted. Only seven of the 230 psychiatrists offered an appointment time. Their wait times ranged from four to 55 days.
This research documents the real-life challenge that GPs and their patients face when trying to access timely psychiatric care. Family doctors do not have the time or resources to contact every practicing psychiatrist in their community to determine who will accept their patients. Typically, they try one psychiatrist, and if the referral is rejected, and it may take days or weeks to receive a response, then they move on to a second psychiatrist. There is no central registry for psychiatric referrals. Likewise, there are little or no private psychiatric services available, so patients with depression must waiting inordinate amounts of time for appropriate assessment and treatment.
British Columbia should establish a central registry of psychiatrists who are accepting patients, as well as a central intake number where GPs can refer their patients, who would then be matched to a psychiatrist who can see them in a timely fashion.
This centralized system would also allow the health authorities and the public to have access to real-time statistics related to psychiatric care. If the maximum ideal waiting time for a patient with depression is consistently exceeded additional psychiatric resources should be funded. Alternately, patients should be allowed to access private services.
I primarily discuss psychiatric services in this article. Readers should know that our government wants to eliminate any access to private health care using prohibitive fines for doctors who provide private services. This is in spite of the fact that 80,000 adult patients in B.C. are currently waiting for non-emergency surgery. This draconian measure is both unethical and constitutes a threat to our collective health.
If our publicly funded healthcare system cannot provide timely medical services, using well established guidelines for maximum waiting times, then individual citizens should be allowed to use their own funds to access appropriate healthcare. This is the case in almost every other healthcare system in the world.
We need to urgently discuss these issues with our elected representatives.
Dr. Derryck Smith is a clinical professor emeritus in the Department of Psychiatry at the University of B.C.
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