By Maurice McGregor

Three cheers for Health Minister Phillipe Couillard's announcement that the law proscribing illegal overcharges in return for rapid access to publicly funded health services is now going to be energetically enforced.

However, our relief should remain guarded. The underlying cause of the illegal overcharges is, of course, the prolonged wait times for many services delivered by the public-health system.

As long as excessive wait times continue, people will look for ways to jump the queue. So health services must again be made available to all, when they are needed, and not months later. This is not only urgent, it is largely attainable.

The origin of the crisis is to be found in the budgetary cutbacks of the mid-1990s. The shortages of plant, equipment and funds have since largely been made up, and excessive wait times for cataract surgery, heart surgery and cancer irradiation have now been almost eliminated.

But shortages of nurses, medical technologists and doctors - problems that take longer to fix - limit further corrections. Without these professionals, beds cannot be opened, surgery is limited, and diagnostic equipment cannot be used to capacity. Although Quebec is training more professionals, that takes time.

However, we don't have to wait until the massive manpower shortage has been corrected to start reducing wait times.

Wait times are largely confined to a few hospitals in Montreal and Quebec City. To get substantial improvement, we need to correct only a limited number of shortages in these hospitals.

Furthermore, even though the waiting lists in these hospitals might be substantial, their management does not require a substantial increase in personnel.

Imagine a hospital in which the maximum capacity to carry out some test or operation is 100 per week, and suppose that the demand for this procedure is on average 101 per week. At the end of the first year there will be a waiting list of 52, and by the end of the second year, 104. While a brief burst of increased activity is required to serve the backed- up patients, a mere one-per-cent increase in capacity will stop the wait list reaccumulating.

So the numbers needed are not very great. What can we do to find them? Unfortunately the income gap between Quebec and the rest of North America for all health manpower remains a barrier to both recruitment and retention. But there are quite minor interventions that could bring significant relief.

First, would be a minor modification of a current policy that aims to increase the number of specialists working outside the big cities by rationing the number who are allowed to work in city hospitals.

Rigorous application of this policy effectively prevents hospitals from responding to demand. Thus, a hospital might have to close an operating room for want of permission to recruit an anesthetist, or to exclude fracture patients because it can't recruit an orthopedic surgeon. Astonishingly, city hospitals are not even allowed to recruit specialists in excess of their designated number from outside Quebec.

So a modest increase should be allowed in the number of medical specialists permitted to work in hospitals in which wait times are excessive, while these hospitals should be encouraged and funded to recruit the needed medical personnel from outside Quebec.

Recruitment of nurses and technologists from outside Quebec could be facilitated in three ways.

First, until the crisis is over, their licensing organizations should consider issuing restricted licences. This practice, used for many years for physicians trained outside Quebec, allows people to work under supervision in teaching hospitals.

Second, the program under which nurses can be recruited from France with financial support from government, should be temporarily extended to all countries with comparable levels of training to our own.

Third, recruitment could be helped by allowing nurses and technologists a period of grace after their recruitment to pass their language tests, as is the case for physicians. Potential recruits who wish to come to Quebec and to learn French can find it daunting to remain unemployed until their French test is passed.

And, if we are serious about resolving the wait-times crisis, we could also offer them free French tuition in paid time. No one questions the need for French competence, but in a crisis it is surely better to be cared for in fractured French than not cared for at all.

The necessary measures to preserve our universal-access health-care system are not complex, but they are difficult to achieve because they require the collaboration of different authorities. But is this too much to ask for? Long wait times are not inevitable. They should not be tolerated, measured and managed. They should be eliminated.

Maurice McGregor is a professor emeritus and former dean of medicine of McGill University.