How NOT to shorten the queues for needed surgery

The only thing that keeps our eccentric and unsustainable health care system working is the incredible professional commitment of the individuals who work within it, battling against the perverse incentives of a crazy system. If you ever wanted proof of that statement, this is the story for you.

For financial reasons, including an unwillingness or inability to attract and retain anaesthetists, Nova Scotia’s health system managers wanted to reduce operating room capacity. Yes, you read that right. At a time when governments across the country are swearing on a stack of Bibles, Korans, Torahs and other multiculturally-correct sacred texts that they will move heaven and earth to shorten surgery waiting times,  management here are cutting access to the only facilities where these procedures can be performed. And since Halifax is a regional centre offering surgical services to, among other places, New Brunswick, this story matters to New Brunswickers as well as Nova Scotians.

Before these health managers could reduce operating room access, however, they had a problem to solve. Surgeons were paid essentially on a piecework basis, known as “fee for service”.

If you reduce the total amount of available time in the operating theatres in a fee for service system for doctors, and leave the fees per procedure unchanged, what happens? Surgeons’ incomes fall. What’s wrong with that? Surgeons are highly skilled medical professionals in big demand, and we cannot simply arbitrarily reduce their incomes or they get angry. And angry surgeons can either do a lot to embarrass the government, or they can simply up stakes and move to a place that treats them better and pays them better too, such as Alberta or the US.

So the clever managers of our health care system came up with a solution. They put the surgeons on salary. That way, if they perform 30 operations a week or 100, their income remains essentially the same.

Before, though, the economic interests of surgeons and the political interests of governments trying to shorten queues were aligned: the more the surgeons operated, the higher their incomes, while more operations meant shorter queues and therefore happier voters.

But when docs go on salary, the near-universal experience has been that productivity falls. After all, if your pay is no longer linked to what you actually produce, most people are tempted to kick back a little bit.

Those incentives to work less and enjoy a bit more leisure, however, take a while to make themselves felt. And anyway, surgeons, like most of us, don’t live by bread alone. Generally speaking they’re not in medicine to make money, but because they love operating. So while putting docs on salary may have bought their acquiescence, they are increasingly frustrated by the system’s clear signals that their surgical skills are not very highly valued. After all, they are now being paid in part not to operate. Their income is the same no matter how little they work, and the time they can work even if they want to is now restricted by the cuts to operating hours and facilities.

The perverse outcome is that surgeons who want nothing more than to be allowed to operate are being paid as before and told to do more administration, research and golf. Fortunately they still operate as much as they can, and certainly far more than a simple calculation of economic self-interest would justify. Only their professional commitment saves the system from disaster.

It will take as much as a generation before this new arrangement fatally wounds the high standards of honour and professionalism that have always characterized the surgical fraternity.

New surgeons will look more dispassionately at the real rewards that surround their profession, and understand that they are most valued when they don’t work too hard. They’ll wonder why their older colleagues chafe at “normal” access to operating facilities. They may even come to accept the rationalizations of managers in the system that less surgical time “saves money” when everyone who looks at the lengthening queues for health care understands that this represents an increasing accumulation of pain and suffering. Making people wait for care can only represent a “saving” if we place no value on people’s pain and anxiety.

The greatest irony of all is that no one can even demonstrate what effect these changes will have on waiting time.  No one bothers to capture regular information about who is waiting, or the amount of time operating rooms are in use.  When these changes were announced I offered my institute’s help in collecting and analysing the effects of moving surgeons to salary and reducing access to operating theatres. I was told that there was really no baseline information available so that we could usefully compare the new system with the old. Whatever the intentions of the health planners in making these changes, how will they ever know if they’ve got the results they wanted?  As usual in health care we are, quite literally, operating in the dark.


Brian Lee Crowley is president of the Atlantic Institute for Market Studies (, a public policy think tank in Halifax. E-mail: