The final report on the public inquiry into preferential access to health services in Alberta was released on August 21, 2013.[1] As described in the report, the inquiry, which began in December of 2012 and heard from 68 witnesses prior to its completion in the spring of 2013, uncovered some isolated incidents of improper preferential access to Alberta’s publicly-funded health care system.  There was no evidence that any individual had been medically harmed[2] as a result of these incidents or that improper preferential access is a widespread phenomenon in Alberta.  In fact, the Commissioner of the inquiry, the Honourable Justice John Vertes, ultimately concluded that “[i]mproper preferential access is a minor component of the public health care system.”[3] However, the inquiry demonstrated that “myriad” opportunities exist within the health care system for queue-jumping and preferential treatment.  In light of these findings, Justice Vertes made 12 recommendations for preventing future incidents of improper access.

Background

The multi-million dollar public inquiry was established by the Alberta Government pursuant to the Health Quality Council of Alberta Act[4] in February 2012 in order to investigate allegations that some individuals were receiving faster access to public health care services for reasons other than medical need.  At the centre of the inquiry were media reports that Dr. Stephen Duckett, the former CEO of Alberta Health Services, had claimed some of his predecessor CEOs had designated “go to guys” who would manipulate wait lists in response to requests from prominent Albertans for expedited care.  Further, as described in the report, Dr. Raj Sherman, an emergency room physician and current Liberal MP, reportedly claimed that it was common for prominent Albertans to jump the queue for medical care and that he had personally received requests from hospital executives for certain patients to get preferential treatment.[5]

The inquiry investigated other controversial allegations, such as the “Calgary Flames” incident, where during the 2009 H1N1 pandemic the Calgary Flames hockey players, staff and their families had allegedly by-passed five-hour line-ups and received vaccinations at a private clinic; and the “Helios” incident, where patients from the private Helios Wellness Centre were allegedly being bumped to the front of the line for colonoscopies at the public Colon Cancer Screening Centre in Calgary–sometimes receiving screenings within weeks or even days, while other patients often had to wait years.

In the early stages of the inquiry, the government faced criticism that the scope was too narrow.[6]  Similar criticism remains in the wake of the final report.  After its release, Wildrose Leader Danielle Smith praised the report’s recommendations, but was quoted as stating “[o]f course, this isn’t the inquiry most people were asking for.  We were asking for an inquiry that also looked into bullying and intimidation of health care professionals.”[7]  Dr. Sherman also weighed in with reproach, stating that the Alberta government “has wasted precious time and millions of taxpayers’ money to investigate a symptom of a disease instead of formulating a plan to cure it.”[8]

Important Factual Findings

Justice Vertes concluded that the allegations of preferential treatment made by Dr. Duckett and Dr. Sherman, which had initially prompted the inquiry, were in fact unfounded.  As he stated in the report, “[t]here was no evidence proving that any MLA had used influence or other means to enhance his or her own care or that of family or friends.”[9]

But Justice Vertes did find evidence that isolated incidents of queue-jumping had occurred.  Among these incidents were the Calgary Flames and Helios allegations.  According to Justice Vertes, the Calgary Flames episode was a “clear-cut” case of improper preferential access.[10]  Evidence presented at the inquiry by 15 witnesses over several days also satisfied Justice Vertes that Helios patients had received improper preferential access to screening colonoscopies.[11]  Despite these findings, Justice Vertes emphasized that such incidents were rare and were not representative of the Alberta health care system as a whole.

Defining “Improper Preferential Access”

Critical to the inquiry was an understanding of the concept of improper preferential access.  Whether a particular form of preferential access will be regarded as improper is contextual, and depends on how it is accepted by the public and within the general medical community.  For example, Justice Vertes noted that some people may consider it appropriate for front-line health care workers and their families to be given priority vaccinations during a pandemic, or for preferential access to be given to patients enrolled in research studies.[12]  Accordingly, developing a widely accepted definition of “improper preferential access” is no simple task.  Justice Vertes ultimately defined the term broadly as “any policy, decision or action that cannot be medically or ethically justified, resulting in someone obtaining priority access over others similarly situated.”[13]

Recommendations

Given the various factors that can impact whether something constitutes “improper” preferential access, Justice Vertes recommended that Alberta Health Services’ future policy on preferential access explicitly state which forms of preferential access are considered improper and will not be permitted. 

One form of preferential access the inquiry heard evidence about was professional courtesy, where physicians give priority to requests for care by other physicians, health care workers and their families.  As there is a lack of consensus within the medical community about what kinds of professional courtesy amount to improper preferential access, Justice Vertes recommended that entities representing the relevant health care workers, including the College of Physicians and Surgeons of Alberta, collaborate to define the appropriate scope and application of this practice.

Justice Vertes identified “systemic issues that could foster an environment conducive to improper preferential access.”[14] He noted a number of entry points (e.g. workers’ compensation, private diagnostic imaging) into Alberta’s health care system, “each with its own opportunities for preferential access”.[15]  Wait lists also received considerable attention on the basis that they can serve to motivate individuals to access treatment through improper means.  In addition to recommending that the province continue its ongoing efforts to reduce wait times and improve access to health care services, Justice Vertes proposed that Alberta Health Services develop wait list management strategies, standardized referral procedures, and centralized triage and booking systems.

Justice Vertes made a number of additional recommendations including that the province: strengthen the queue-jumping provisions of Alberta’s Health Care Protection Act;[16] expand the whistleblower protection under the Public Interest Disclosure (Whistleblower Protection) Act;[17] consider creating an independent office of Health Advocate to provide advocacy assistance to patients and to help resolve complaints; develop a policy on courtesy calls, where health care professionals are alerted to the presence of high-profile patients; strengthen access, triage and booking procedures; develop a policy on the so-called private patient path, where physicians direct their patients to the emergency department for the purpose of being treated by them or another specific physician; and develop rules on how to address requests for special accommodation during a pandemic.

Government Response

The provincial government appears to support the recommendations.  In response to the final report, Alberta’s Health Minister, the Honourable Fred Horne, announced in a public statement that the government had accepted “in principle” Justice Vertes’ recommendations that required legislative action, and accepted all other recommendations “in full”.[18]  With respect to government action, he reported that “[w]e have already made progress on recommendations to reduce wait times, implement wait list management strategies, standardize referral procedures and booking systems, and to create a Health Advocate.”[19]  He also noted in the statement that “[p]ublic confidence in Alberta’s health system is critical. The checks and balances Justice Vertes has recommended in his report will reassure Albertans that preferential access is not occurring so they can have the utmost confidence in their health system.”[20]

Administrative Challenges

Justice Vertes identified certain challenges faced by the inquiry which flowed from the manner in which it was established and organized by the government.[21]  For example, he implied that the inquiry was called too hastily given that the allegations which prompted it had not been subject to any meaningful prior investigation.  He was critical of the fact that, contrary to accepted practice, he was not given an opportunity to comment on the terms of reference before they were finalized, noting that such consultation is “important primarily because the commissioner’s principal task is to ensure that it is possible to carry out the work described in the terms of reference.”[22]  He also concluded that the “tripartite arrangement” through which the Health Quality Council of Alberta administered the funding for the inquiry on behalf of the government resulted in a duplication of effort in budget oversight without any corresponding improvement in financial accountability.

He made a variety of recommendations for future inquiries, including that the Alberta government develop policies and procedures to guide commissions of inquiry on organizational matters; that a senior official in the cabinet office be designated as a contact person for any provincial inquiry in order to make prompt decisions on administrative and financial matters; and that future inquiries called pursuant to section 17 of the Health Quality Council of Alberta Act have the option of using the “administrative apparatus” of the Council.[23]

Implications

In his conclusions, Justice Vertes stated that faith in the public health care system can be damaged by the public perception that some people receive faster access to treatment because of who they are or who they know, even when actual incidents of these occurrences are extremely rare.[24]  In a country whose health care system is premised on the principle that access to services should be based solely on medical need, as opposed to social status or personal connections, the report could be said to have significance for all provinces.  It remains to be seen, however, what kind of long-lasting impact the public inquiry and the ensuing recommendations will have on wait times and queue-jumping in Alberta’s health care system.