Quebecers Should Not Have to Leave Emergency Rooms Untreated

Viewpoint showing that more patients are leaving ERs without being treated, and more of them are leaving with urgent health problems

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Number of patients leaving Quebec emergency departments before being seen on the rise (CTV News, June 20, 2024) De plus en plus de patients quittent l’urgence sans avoir été pris en charge (Le Devoir, June 20, 2024) Quebec health system in crisis as patients walk out of emergency rooms untreated (True North, June 24, 2024) Money alone won’t fix Quebec’s health-care crisis (Montreal Gazette, June 27, 2024) Des patients plus découragés que jamais (Le Soleil, June 27, 2024)	Interview (in French) with Emmanuelle B. Faubert (Midi actualité, 107,7 FM, June 20, 2024) Interview (in French) with Emmanuelle B. Faubert (Sans réserve, 98,5 FM, June 20, 2024) Interview (in French) with Emmanuelle B. Faubert (Jean-François Baril, QUB Radio, June 20, 2024)	Interview with Emmanuelle B. Faubert (Global News, June 20, 2024)

This Viewpoint was prepared by Emmanuelle B. Faubert, Economist at the MEI. The MEI’s Health Policy Series aims to examine the extent to which freedom of choice and entrepreneurship lead to improvements in the quality and efficiency of health care services for all patients.

As wait times in Quebec emergency rooms just get longer, it is no surprise that a substantial number of patients leave without having been seen by a doctor. This is evidence of some serious flaws in our healthcare system.

Quebec Healthcare System’s Twin Failures

In 2023-2024, over almost 11 months, 3,265,349 patients visited Quebec’s emergency rooms.(1) Of this number, 376,460, or 11.5%, left before having been attended to by a health professional.(2) That amounts to 1,140 Quebecers a day who were thus abandoned by the system.

In comparison, 378,438 Quebecers were in this situation five years earlier, in 2018-2019.(3) The situation in 2023-2024, after 11 months, was thus similar to the results for the entire 2018-2019 year. This shows that far from improving, the situation has gotten worse.

The most serious failure concerns the 103,715 patients in the P1, P2, and P3 categories that correspond to urgent cases (see Figure 1), especially the first two, which represent very urgent health problems.(4) In these life-threatening conditions, these patients need to be treated rapidly.

Moreover, the proportion of these patients in categories P1 to P3 has increased compared to the pre-pandemic situation. While it was already 21.9% in 2018-2019, it rose to 27.5% in 2023-2024. Therefore, not only are more patients leaving an ER without being treated today, but more of them are leaving with urgent health problems.

The second failure highlighted by the data concerns the lack of access to primary care, especially for patients in categories P4 and P5, representing 70% of those having left an ER without seeing a doctor. These cases are minor or do not require immediate care.(5)

This situation is hardly surprising since, in theory, a large proportion of these cases could be cared for by health professionals other than emergency physicians. This is notably the case for the 84,966 patients in the priority 5 category, who did not have an urgent health issue when they visited an emergency room. However, having left without being treated, a certain number of them risk returning with aggravated medical conditions.

Part of the problem stems from the fact that hundreds of thousands of Quebecers do not have access to a family doctor and have no other choice but to visit an emergency room, even for a minor health problem, when all other options have been exhausted. In January 2024, 642,047 Quebecers were on a waiting list to find a family doctor.(6) If unattached patients could be ensured access to primary care, many emergency room visits could be avoided.

Potential Solutions

This failure at the primary health care level requires solutions outside of the hospital system. For example, specialized nurse practitioner (SNP) clinics can play a big role in improving Quebecers’ access to care. The province already has 11 of them, and as of April 15, 2024, these clinics can treat patients signed up with the Québec Family Doctor Finder (GAMF). Their number should double by 2028,(7) but why not pick up the pace to help meet our pressing needs today?

As for the inability of emergency rooms to treat patients with urgent problems more rapidly, we need to rethink the way our hospitals are administered. The implementation of activity-based funding, already introduced in Quebec for certain procedures, should also be accelerated. In this way, each patient becomes a source of income rather than an extra cost, incentivizing hospital administrators to treat more patients.(8)

Emergency room capacity also needs to be increased, including by independent entities, as Sweden did with the Saint Göran hospital in Stockholm, a facility financed by the universal system but administered independently.(9) The success of Saint Göran rests, among other things, on decentralization, which gives administrators organizational flexibility centred on the needs of patients. To this are added frequent performance measurements to evaluate productivity and patient satisfaction.

Competition between health care access points is also a key element. Unlike a monopoly, competition encourages continual innovation and improvement. The possibility of making a profit in a competitive context gives entrepreneurs an incentive to increase their productivity in order to treat more patients with the resources at hand. This is also of benefit to patients, who spend less time in emergency rooms.

In order to have fewer patients leaving emergency rooms before being treated, it is essential that we change tack and open up to more entrepreneurship and innovation in the health care sector.