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Presentation to The Standing Committee on the Status of Women

https://policybase.cma.ca/en/permalink/policy10020

Date
2010-04-19
Topics
Health human resources
  1 document  
Policy Type
Parliamentary submission
Date
2010-04-19
Topics
Health human resources
Text
Good afternoon. As was said in my introduction, my name is Anne Doig and like the chair, I am a family physician. I practice as a "full service" family physician, which means that I provide care in hospital as well as in my office, including obstetrical services. I have practiced in Saskatoon for almost 32 years. It is my pleasure to be here today. As President of the Canadian Medical Association, I represent all physicians, but today, I am proud to represent women participating in what is now a traditional occupation for them, that is, medicine. Joining me today is Dr. Mamta Gautam, a specialist and champion of physician health and well-being. For 20 years, she worked as a psychiatrist treating physicians exclusively in her private practice in Ottawa, and has been hailed as "the Doctor's Doctor." The Association of Universities and Colleges of Canada has reported full-time university enrolment increased by more than 190,000, or 31%, between 2000 and 2006 and now stands at record levels. Full-time male enrolment has passed 350,000 students and full-time female enrolment has passed 460,000. Women account for two-thirds of full-time enrolment growth since 1971, a surge driven by the rapid increase in women's participation in the professions, including medicine. As it stands now, the males outnumber females among practicing physicians by 67%-33%. While there are still more men than women in practice, the percentage of female first-year residents in 2008 was 57%. This is a reversal of the percentage when I graduated, and an increase from 44% fifteen years ago. This means that a significant majority of physicians close to the beginning of their medical careers, are women. Not surprisingly, given those figures, there are many medical disciplines where the proportion of females is much higher than it was even just a few years ago. For instance, in general surgery - long held to be a bastion of male physicians - females comprised 18% of the 1993 first year residents compared to 40% in 2008. Just over half of first-year family medicine residents in 1993 were female compared to 64% today. However, women medical graduates still tend to choose to pursue residency training in family medicine, pediatrics, and obstetrics/gynecology in greater proportions than their male counterparts. As has always been the case, males continue to have a stronger preference for surgery - 23% compared to 11% of females - although that gap is narrowing. So, the overall numbers of women physicians are increasing as are the percentages of those going into what one might call non-traditional specialties, albeit at a slower rate. The so-called feminization of medicine brings with it several other issues and I will touch on two major ones. First, work-life balance. The rise in the number of women physicians is bringing a positive shift in the way physicians practice and the hours that they keep. Very few of today's young physicians - male or female - are willing to work the long hours that physicians of previous generations did. That said, data from the 2007 National Physician Survey, which included responses from over 18,000 physicians across the country, show that, on average, male doctors still work nearly 54 hours per week, while female doctors work 48 - although many work more than that. These figures do not include time on call, nor time spent on child care or other family responsibilities. Many members of the Committee can empathize with this level of commitment. In contrast, the European Union Work Time Directive has said that the maximum work week must be 48 hours. If Canada were to try to apply that directive to physicians our health care system would grind to a halt. The number of physicians opting to be paid by a means other than pure fee-for-service has dramatically increased. FFS rewards the doctor financially for seeing more patients. Female physicians typically spend more time in each patient encounter, a trait that is valued by patients but not rewarded by FFS remuneration. The second issue is stress. In spite of their increasing numbers, women in medicine still report higher rates of incidents of intimidation, sexual harassment and abuse than their male colleagues. As well, many female physicians continue to assume primary responsibility for home and family commitments in addition to their practice workload, thus compounding their stress levels. Female physicians are more likely to work flexible hours; flexibility in work schedules has been the method by which female physicians balance their professional and personal lives. Yet, as they take on more and strive to be more flexible that in itself creates more stress as they battle to be "all things to all people". The CMA identified the need to address and mitigate the unique demands on women physicians in its 1998 policy on Physician Health and Well-Being. I have brought copies to be shared with you today. As I mentioned at the start, I am joined today by Dr. Gautam who has considerable expertise in the stressors faced by physicians - and women physicians in particular - and in managing them. We will be happy to discuss the participation of women in medicine and to answer questions that you may have. Thank you.

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CMA's Presentation to the Senate Standing Committee on National Finance: Bill C-9, An Act to implement certain provisions of the budget tabled in Parliament on March 4, 2010 and other measures

https://policybase.cma.ca/en/permalink/policy9833

Date
2010-06-22
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2010-06-22
Topics
Health systems, system funding and performance
Text
Thank you Madame Chair and Committee members for the opportunity to speak to you today. As mentioned, I am Briane Scharfstein, Associate Secretary General at the Canadian Medical Association (CMA). I am a family physician by training and a member of the Ad Hoc Working Group on Medical Isotopes. The working group was created to advise the Minister of Health in 2008 when the first major sustained shutdown of the Chalk River occurred. When I agreed to join the group, I certainly didn't expect it to still be going over two years later. And, while I am a member of the working group, I want to be clear, that today I am speaking on behalf of the CMA and our more than 72,000 physician members across the country. My comments are a reflection of the Working Group's June 2008 Lessons Learned report and I regret to say that a good portion of our observations are still true today. I congratulate the Senate for looking specifically at the AECL proposals and for looking at implications for patients. While the CMA is not taking a specific position on the proposal in Bill C-9 for Atomic Energy Canada Ltd (AECL), in whole or in part, to be sold off to the private sector, we do believe that it is in the best interests of our patients that Canada remains a leader in the sector. As well, Canada's doctors strongly believe that the impact on individual patient care must be considered and factored into any decisions that might result in disruptions of the supply of medical isotopes. The CMA acknowledges that the federal budget did include $48 million over two years for research, development and application of medical isotopes and alternatives. Further, there was another allocation of $300 million on a cash basis for AECL's operations in 2010/11 to cover anticipated commercial losses and support the corporation's operations to ensuring a secure supply of medical isotopes and maintaining safe and reliable operations at the Chalk River Laboratory. However, the CMA remains preoccupied with Canada's ability to ensure a long-term, stable and predictable supply of medically necessary isotopes. That is why we are uneasy about the federal government's exit strategy from the isotope production sector. The report of the federal government's Expert Panel on the Production of Medical Isotopes, (December 2009) and the federal government's response to that report, (March 2010) appears to focus on the viability of this specific sector of the nuclear industry and has not alleviated our concerns. The government's response to the Panel Report was disappointing to the medical community. The government's decision to abandon Canada's long-standing international leadership in this sector is disheartening. Of particular concern is the absence of both immediate and medium-term solutions to address the current and impending challenges facing nuclear medicine. This is simply unacceptable. The CMA, along with our colleagues in the medical community, continues to assert that ensuring access to safe and reliable medical procedures and the provision of high-quality patient care must be the fundamental consideration of government decisions. While the production cost of isotopes cannot be ignored, particularly in times of global fiscal challenges, the medical application and benefits received are of paramount importance and must be neither discounted nor dismissed. Early diagnosis and treatment are key factors in successful outcomes in cardiac and cancer cases. Without early diagnosis and treatment, patients have an increased risk of needing greater medical intervention later on. With more intensive treatment comes a corresponding increase in costs to the health care system and, most importantly, poorer outcomes for patients. Specific concerns identified by the CMA and the medical community include, but are not limited to the following: * Canada's current dependence on international reactors, without a practical back-up plan should these reactors experience difficulties, or shutdown for routine maintenance. This is especially worrisome as the international agency, the Association of Imaging Producers & Equipment Suppliers (AIPES) warns of the unprecedented level of shortages, in a large part due to the Canada's Chalk River nuclear reactor remaining off line until August 2010 or beyond. In a recent Supply Crisis Update, AIPES points out that with a number of international reactors off-line for scheduled maintenance, the remaining reactors -the OPAL (Australia), Maria (Poland) and REZ (Czech Republic) reactors-are producing Mo99, but their combined output is limited to 15 - 20 % of the world requirements. * The abandonment of Canada's international responsibilities and world leadership in this sector is counter to the government's own innovation and productivity agenda. * A growing reliance on emerging technology, cyclotrons and liner accelerators that have yet to be proven as a suitable secure alternative source of radiopharmaceutical. * A projected future supply chain that is reliant on external sources, rather than domestic production, in times of domestic supply shortages. As well, we are concerned that the federal government is leaving it to the marketplace, solely relying on current distributors to identify external sources supply, rather than searching to identify alternative safe sources of supply. * Basing Canada's supply strategy on relicensing of the Chalk River reactor five years past its current license with no current guarantees that the plant will return and remain in production, let alone meet relicensing standards. * The apparent lack of a federal contingency plan if, in 2016, alternative sources of supply and alternative emerging technology does not meet clinical needs. * An analysis of the overall costs to the health care system as a result of the increased costs incurred during the prolonged period of shortages of isotopes supply and the rising costs as the demand for the alternative diagnostic and treatment models is not apparent. * Initiatives to help mitigate increased costs for governments and particularly for nuclear medicine facilities do not exist. The just released survey by the Canadian Institute for Health Information found that two-thirds of nuclear medicine facilities reported that they experienced an increase in the cost of isotopes and that they were managing but exceeding their budget due to vendor surcharges. Only 2% reported that the isotope supply disruptions had no economic impact. Canada's medical community therefore strongly urges that consideration be given to: * investing in a mixed-use reactor for research and isotope production, as per the recommendation of the Expert Panel on Isotopes Production report of December, 2009; * putting in place appropriate strategies and contingency plans to meet the health needs of Canadians; in particular consider a national deployment of PET technology for cancer detection and follow up. * enhancing transparency by the government that provides more information on the short and medium-tern detailed plans to address isotope shortages; * increasing the direct consultation with the official representatives of the nuclear medicine and medical community; * making a public commitment to keep the Chalk River NRU reactor operational beyond the arbitrary date of 2016, as long as necessary and until secure alternative supplies of isotopes or alternative radiopharmaceuticals are proven and are in place; and, * ensuring that the CNSC resurrects the external medical advisory council to facilitate communication between the medical community and the commission. Prior to 2001, members of the council provided CNSC staff with insight into how operational and policy decisions would affect patient care across the country. Canada's doctors believe that the federal government must maintain a leadership role in this sector and must not compromise the medical needs of Canadians.

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Healthy Canadians lead to a Productive Economy: Canadian Medical Association 2011 pre-budget consultation submission to the Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy10012

Date
2010-08-13
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2010-08-13
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association's (CMA) pre-budget submission is based on the premise that healthier Canadians are more productive Canadians. It also recognizes that the delivery of quality health care, in a timely manner, is paramount and is not mutually exclusive of any productivity agenda. With the recent release of its Health Care Transformation in Canada: Change That Works. Care That Lasts. policy document, the CMA declared its readiness to take a leadership position in confronting the hard choices required to make health care work better for Canadians. Physicians are reaching out to the Canadian public, opinion and business leaders, governments, interested parties and stakeholders to find ways to improve our health care system and to make sure that the upcoming reforms will focus on better serving patients. Canada's health care system cannot continue on its current path, especially as pressure grows from an aging population. The system needs to be massively transformed, a task that demands political courage and leadership, flexibility from within the health care professions and far-sightedness on the part of the public. It is a lot to demand, but one of Canada's most cherished national institutions is at stake. We must work together toward a common vision of what we aspire for our health care system. The CMA commends the federal government for publicly stating it will honour its previous commitment of a 6% annual increase to the Canada Health Transfer through to 2014. This sustained predictable funding has brought some long-term stability to the publicly financed health care sector. However, the CMA believes that the health care system must be capable of withstanding or accommodating demand surges and fiscal pressure. Capacity and innovation strategies need to be developed and implemented to meet emerging health necessities. In this brief, the CMA identifies a number of key issues related to health human resources and infrastructure that require immediate attention if the Canadian economy is to retain its competitive position in the global economy. Pressure is mounting on the system and there is a need to move beyond data collection to interdisciplinary collaboration. Including health care providers in the decision-making process would lead to better health public policy decisions, and result in much needed pan-Canadian health human resource planning. By making strategic direct investments in health human resources, public health and retirement savings, the federal government would retain its leadership role and contribute to the sustainability of a patient-centred health care system. Health care's contribution: A more productive and innovative economy The health care system in Canada employs over a million people, or 7.5% of the labour force. In 2009, Canada invested $183 billion in health care, representing 11.9% of our GDP. The benefits of health care investments not only contribute to a higher quality of life for all Canadians, but the economic multiplier effect of the initial investment is estimated to create an additional $92 billion in economic activity, such as in the high technology sector, financial services and R&D jobs.i Further federal investments in the health care system contribute to ensuring a more productive and innovative economy. Better Health, Improved Productivity The Conference Board of Canadaii, the Organization for Economic Co-operation and Development (OECD) iii, the World Health Organizationiv, the Commonwealth Fundv, and the Frontier Centre for Public Policyvi all rate Canada's health care system poorly in terms of "value for money" as well as efficiency. In both 2008 and 2009, the Euro-Canada Health Consumer Index ranked Canada 30th of 30 countries (the U.S. was not included in the sample) in terms of value for money spent on health care. Canadians deserve better. We know that investments in quality today will pay off in improved health that will reduce health care demand and expenditures down the road. The resultant improved productivity from the reduction of illness in the population will generate economic dividends for the country. Our proposals are informed by regular consultations with our 72,000 physician members and reflect what they believe are the most pressing gaps that exist in our health care system today. These recommendations will also start the process of fostering transformation of the health care system that not only serves the health needs of Canadians, but makes our health care system more effective, accountable and sustainable now and for generations to come. * Please note that the sum of the following recommendations would add less than 0.5% to the current $25 billion Canada Health Transfer that is committed to the provinces. Recommendations for the 2011 Federal Budget: A. Investing in Health Human Resources: $53.1 million over 4 years 1. The federal government should fulfill the balance of its 2008 election promisevii of investing $33.1 million over 4 years to fund 35 new residencies per year; and invest $20 million over 4 years in the repatriation of Canadian physicians working abroad. B. Investing in pandemic preparedness (post H1N1): $500 million over 5 years 2. The federal government should increase funding ($200 million over 5 years) to enhance disease surveillance by linking public health databases with real-time clinical information through patient Electronic Medical Records in order to facilitate data collection and analysis between local public health authorities and primary care practices. 3. The federal government should increase funding ($200 million over 5 years) for local health emergency preparedness planning to improve collaboration and coordination of clinical care and public health structures at the local level during public health crises and reduce the variation of capacity across the country. 4. The federal government should invest in the creation of a pan-Canadian strategy ($100 million over 5 years) to build a process for a harmonized national clinical response, including vaccine programs in times of potential health crises. C. Improving retirement savings options for the self-employed: federal taxes to be deferred over time 5. The federal government should increase RRSP limits and explore opportunities to provide pension vehicles for self-employed Canadians. D. Encourage Canadians to save for long-term care needs: federal taxes to be deferred over time 6. The federal government should study options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance. E. Support for informal caregivers 7. The federal government should undertake pilot studies that explore tax credit and/or direct compensation for informal caregivers for their work and expand relief programs for informal caregivers that provide guaranteed access to respite services for people dealing with emergency situations. A. Investing in Health Human Resources: $53.1 million over 4 years Every high-performing health system begins with a strong primary care system. Yet roughly 5 million Canadians do not have a regular family physician, and once Canadians do access primary care, they often face long waits to see consulting specialists and further waits for advanced diagnostics and treatment. Part of the reason for these delays is the shortage of health care professionals in Canada and the lack of long-term pan-Canadian planning to ensure needs are met. Canada ranks 26th of 30 OECD member countries in physician-to-population ratio. The lack of physicians in Canada puts the system under pressure and the impact of this is being felt by patients across the country. A Centre for Spatial Economics studyviiicommissioned by the CMA, found that the Canadian economy is expected to lose $4.7 billion in 2010, as a result of excessive wait times for just four procedures: joint replacements, MRIs, coronary artery bypass surgery and cataract surgery. When people wait too long for care businesses face increased human resource costs to replace lost or affected employees. There is a loss in output and especially productivity. The reduction in output would lower federal and provincial government revenues in 2010 by $1.8 billion. The econometric model in the report used to calculate these costs also estimates that to cut wait times to government recommended benchmarks would require a $586 million investment or just 2% of the current Canada Health Transfer. This investment would boost GDP by $6.2 billion. The global shortage of health professionals compounds the problem - while Canadian training programs still lack sufficient seats to produce enough new providers to meet current and future demands, Canadian-educated physicians, nurses, technicians, and other health professionals are being lured away by ample opportunities to train and work outside Canada. The CMA commends the federal government for recently announcing the Northern and Remote Family Medicine Residency Program in Manitoba, which constitutes an investment of just over $6.9 million. The program will provide extensive medical training for 15 additional family medicine residents over the next four years. We urge the government to build on this announcement and honour its full commitment. Thousands of health care professionals are currently working abroad, including approximately 9,000 Canadian-trained physicians. We know that many of the physicians who do come back to Canada are of relatively young age, meaning that they have significant practice life left. While a minority of these physicians return on their own, many more can be repatriated in the short term through a relatively small but focussed effort by the federal government, led by a secretariat within Health Canada. Recommendation 1: The federal government should fulfill its 2008 election promiseix of investing $33.1 million over 4 years to fund 35 new residencies per year; and invest $20 million over 4 years in the repatriation of Canadian physicians working abroad. B. Investing in pandemic preparedness (post H1N1): $500 million over 5 years The absence of a national communicable disease/immunization monitoring system is an ongoing problem. In 2003, the report of the National Advisory Committee on SARS and Public Health recommended that "the Public Health Agency of Canada should facilitate the long term development of a comprehensive and national public health surveillance system that will collect, analyze, and disseminate laboratory and health care facility data on infectious diseases... to relevant stakeholders." Seven years later, Canada still does not have a comprehensive national surveillance and epidemiological system. Clinicians' practices are highly influenced by illness patterns that develop regionally and locally within their practice populations; thus, surveillance data are useful in determining appropriate treatment. During the H1N1 outbreak, real-time data were not available to most physicians and when data did become available, they were already several weeks old. Greater adoption of electronic medical records (EMRs) in primary care and better public health electronic health records (EHRs), with the ability to link systems, will augment existing surveillance capacity and are essential to a pan-Canadian system. International strategy and technology consulting firm Booz Allen Hamilton found that the benefits of an interconnected Electronic Health Record (EHR) in Canada could provide annual system-wide savings of $6.1 billion. A pan-Canadian electronic health information system is urgently needed and must become a priority during the inter-pandemic phase, with adequate federal funding and provincial/territorial collaboration. Recommendation 2: The federal government should increase funding ($200 million over 5 years) to enhance disease surveillance by linking public health databases with real-time clinical information through patient Electronic Medical Records in order to facilitate data collection and analysis between local public health authorities and primary care practices. Recommendation 3: The federal government should increase funding ($200 million over 5 years) for local health emergency preparedness planning to improve collaboration and coordination of clinical care and public health structures at the local level during public health crises and reduce the variation of capacity across the country. A key measure to combat pandemic influenza is mass vaccination. On the whole, Canada mounted an effective campaign: 45% of Canadians were vaccinated, and the proportion was even higher in First Nations communities - a first in Canadian history. The outcome was positive, but many public health units were stretched as expectations exceeded their pre-existing constrained resources. Nationally promulgated clinical practice guidelines had great potential to create consistent clinical responses across the country. Instead, the variation and lack of coordination in providing important clinical information during this crises eroded the public's confidence in the federal, provincial and territorial response. Recommendation 4: The federal government should invest in the creation of a pan-Canadian strategy ($100 million over 5 years) to build a process for a harmonized national clinical response, including vaccine programs in times of potential health crisis. C. Improved retirement savings options for self-employed: federal taxes to be deferred over time With the aging Canadian population and the decline in the number of Canadians participating in employer-sponsored pension plans, now is the time to explore strengthening the third pillar of Canada's government-supported retirement income system: tax-assisted savings opportunities and vehicles available to help Canadians save to meet future continuing care needs. Of keen interest to the medical profession are measures to help self-employed Canadians save for their retirement. Physicians represent an aging demographic - 38% of Canada's physicians are 55 or older. Self-employed physicians, like many other self-employed professionals, are unable to participate in workplace registered pension plans (RPPs). This makes them more reliant on Registered Retirement Savings Plans (RRSPs) relative to other retirement savings vehiclesx. The recent economic downturn has shown that volatility of global financial markets can have an enormous impact on the value of RRSPs over the short-and medium-term. This variability is felt most acutely when RRSPs reach maturity during a time of declining market returns and RRSP holders are forced to sell at a low price. The possibility that higher-earning Canadians, such as physicians, may not be saving enough for retirement was raised by Jack Mintz, Research Director for the Research Working Group on Retirement Income Adequacy of Federal-Provincial-Territorial Ministers of Finance. In his Summary Report, Mr. Mintz wrote that income replacement rates in retirement fall below 60% of after-tax income for about 35% of Canadians in the top income quintile. This is due to the effect of the maximum RPP/RRSP dollar limits and the government should consider raising these limits. Recommendation 5: The federal government should increase RRSP limits and explore opportunities to provide pension vehicles for self-employed Canadians. D. Encourage Canadians to save for long-term care needs: federal taxes to be deferred over time According to Statistics Canada's most recent population projections, the proportion of seniors in the population (65+) is expected to almost double from its present level of 13% to between 23% and 25% by 2031xi. With Canadians living longer and continuing care falling outside the boundaries of Canada Health Act (CHA) first-dollar coverage, there is a growing need to help Canadians save for their home care and long-term care needs. These needs are an important part of the retirement picture as the federal government considers options for ensuring the ongoing strength of Canada's retirement income system. Additional information is contained in CMA's submission to the House of Commons Standing Committee on Finance during its study on Retirement Income Security of Canadians (May 13, 2010). Recommendation 6: The federal government should study options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance. E. Support for informal caregivers Much of the burden of continuing care falls on informal (unpaid) caregivers. More than a million employed people aged 45-64 provide informal care to seniors with long-term conditions or disabilities, and 80% of home care to seniors is provided by unpaid informal caregivers. Canada lags behind several countries, including the U.K., Australia, Germany, Japan, the Netherlands and the U.S. in terms of supporting informal caregivers. Recommendation 7: The federal government should undertake pilot studies that explore tax credit and/or direct compensation for informal caregivers for their work and expand relief programs for informal caregivers that provide guaranteed access to respite services for people dealing with emergency situations. The CMA encourages the federal government to consider the recommendation found in the report entitled; Raising the Bar:A Roadmap for the Future of Palliative Care in Canada supported by the Canadian Hospice Palliative Care Association. Conclusion The recommendations contained in the CMA's pre-budget submission represent our priority recommendations for federal investments that will contribute to a healthy, more productive and innovative economy. These recommendations will also start the process of fostering transformation of the health care system that not only serves the health needs of Canadians but makes our health care system more effective, accountable and sustainable now and for generations to come. As the federal government's commitment to the provinces through the 2004 Health Care Accord expires in 2014, it is imperative that investments are made that not only provide better care but are also sustainable for our country's economy. Appendix Table 1 References i The additional economic activity generated by the health care sector is based on a conservative 1.5 multiplier. The CMA is pursuing precise estimates of the benefits of health care investments in Canada. Please see: Economic Footprint of Health Care Services in Canada Prepared for: Canadian Medical Association by Carl Sonnen with Natalie Rylska Informetrica limited January 2007 In economics, the multiplier effect or spending multiplier is the idea that an initial amount of spending (usually by the government) leads to increased consumption spending and so results in an increase in national income greater than the initial amount of spending. The existence of a multiplier effect was initially proposed by Richard Kahn in 1930 and published in 1931. http://en.wikipedia.org/wiki/Fiscal_multiplier Snowdon, Brian and Howard R. Vane. Modern macroeconomics: its origins, development and current state. Edward Elgar Publishing, 2005. ISBNS 1845422082, 9781845422080. p. 61. ii How Canada Performs 2008: A Report Card on Canada, The Conference Board of Canada see: http://sso.conferenceboard.ca/HCP/overview/health-overview.aspx iii Organization for Economic Co-operation and Development [OECD] (2007). OECD Health Data 2007. Version 07/18/2007. CD-ROM. Paris: OECD. iv World Health Organization [WHO] (2007). World Health Statistics 2007. see: http://www.who. v Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care May 15, 2007 (updated May 16, 2007)
Volume 59 Authors: Davis, Schoen, Schoenbaum, Doty, Holmgren, Kriss, Shea see: www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678 vi Euro-Canada Health Consumer Index 2008, Health Consumer Powerhouse, Frontier Centre for Public Policy, FC Policy Series No. 38 see:www.fcpp.org/pdf/ECHCI2008finalJanuary202008.pdf vii Health Care Certainty for Canadian Families, the Conservative Party of Canada, backgrounder 10/08/08. See: http://www.conservative.ca/?section_id=1091&section_copy_id=107023&language_id=0 viii The economic cost of wait times in Canada, the Centre for Spatial Economics, July 2010. ix Health Care Certainty for Canadian Families, the Conservative Party of Canada, backgrounder 10/08/08. See: http://www.conservative.ca/?section_id=1091&section_copy_id=107023&language_id=0 x A more detailed outline of the issues surrounding pension reform can e found in CMA's Submission on Pension Reform Backgrounder for the Standing Committee on Finance, May 13, 2010. www.cma/submissions-to-government xi Statistics Canada. Populations projections. The Daily, Thursday, December 15, 2005.

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Study on Canada's pandemic preparedness: CMA's Presentation to the Senate Standing Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy10010

Date
2010-10-22
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Date
2010-10-22
Topics
Health care and patient safety
Text
We are very pleased to appear on behalf of the Canadian Medical Association before this Senate committee as part of your study of pandemic preparedness and the H1N1 experience in Canada. Earlier this year, the CMA collaborated with the College of Family Physicians of Canada and the National Specialty Society of Community Medicine to present a picture of lessons learned from the frontlines of the pandemic. Together we represent over 80,000 physicians engaged in all aspects of Canada's health care and public health systems. The report includes recommendations that, if acted upon, would help ensure that a strong foundation is in place to protect Canadians from future health threats. As President of the CMA and a practising physician, I am here to present my association's point of view. Physicians have a unique and critical role to play during public health emergencies. Many people turn to their physician first for information and counseling. Physicians are the first line of defence. This was certainly the case during the H1N1 pandemic. This role was intensified by the confusion created by the great variation in mass vaccination programs across the country. Many physicians felt that their urgent need for clinically relevant information was not well recognized by the Public Health Agency of Canada, the Public Health Network and, in some cases, provincial, territorial, regional or local levels. The lack of national leadership on clinical guidance led to delays and the proliferation of differing guidelines across the country. Standard clinical guidance, adaptable to local circumstances, is the norm in medical practice. Nationally disseminated clinical practice guidelines on vaccine sequencing, use of anti-virals and hospital treatment would have created consistent clinical responses across the country. We recommend that the Public Health Network seek advanced pan-Canadian commitment to a harmonized and singular national response to clinical practice guidelines, including mass vaccination programs, during times of potential public health crisis. The CMA also recommends that the Public Health Agency of Canada work closely with the medical specialty societies, as it did successfully with Society for Obstetrics and Gynecology in the development of clinical guidance for the care and treatment of pregnant women. Many physicians and public health workers have complained that multiple levels of government provided similar, but not identical, advice. The differences led to skepticism among both physicians and the public and the inundation of messages led to overload. In situations where scientific evidence is rapidly changing, as was the case during the H1N1 pandemic, we need a national communication strategy, targeted to physicians that can build on communication processes already in place. It is especially important during a health emergency to build on existing systems that work well and can minimize the chances of conflicting messages. It is also important that two-way lines of communication between public health and primary care are established. Embedding primary care expertise into public health planning at all levels would help us avoid problems and improve our response. We believe that the H1N1 immunization process did not adequately engage physicians in planning and delivery. A number of difficulties, such as the impact of bulk packaging, the sequencing of patients and the logistics of inventory management, led to friction between front-line public health practitioners and family physicians. These could have been avoided with strengthened consultation, interdependence and mutual understanding before the crisis. A number of witnesses have noted the importance of surveillance. There is no doubt that greater use of electronic medical records - or EMRs - in primary care could have facilitated surveillance and communications. Family practice clinics with EMRs were able to quickly identify high-risk patients, communicate with them to schedule vaccination appointments, and collect the required data for public health. Another aspect of pandemic planning that cannot be ignored is the possibility that physicians themselves might fall ill. Physicians have never hesitated to provide care to patients during times of crisis, but this obligation must be balanced by a reciprocal obligation of society to physicians. Following the SARS outbreak, the CMA prepared Caring in a Crisis, a policy paper that addresses the need to take into account and plan for what would happen when health care providers become part of the statistics of those infected. We urge the committee to consider this challenge in your deliberations. My last point addresses the lack of surge capacity in Canada's health system. To mount a response to H1N1, public health units pulled human resources from other programs and many critical services were delayed, suspended or cancelled altogether. The resources of our critical care infrastructure were stretched to their limits in many hospitals and frontline health care providers were inundated with telephone calls and visits from the worried well and an increase in visits from those with flu symptoms. If H1N1 had been the severe pandemic that was expected and for which Canada had been preparing, our health system would have been brought to its knees. The CMA has been warning of the lack of surge capacity in our health system for over a decade. Canada remains vulnerable to the risks presented by epidemics and pandemics. If we are to be prepared for the next emergency, a long-range plan to build our public health capacity and workforce and to address the lack of surge capacity in our health system must become a priority. We therefore very much appreciate the review to Canada's response to the H1N1 pandemic that has been undertaken by this Committee, and we look forward to your report. Thank you.

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Elder Abuse and Disability Hearing: CMA's Presentation to the Parliamentary Committee on Palliative and Compassionate Care

https://policybase.cma.ca/en/permalink/policy10060

Date
2010-10-25
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2010-10-25
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) wishes to commend the multi-party group of Members of Parliament who have come together to form the Parliamentary Committee on Palliative and Compassionate Care. The challenge we face today in caring for our aging population is only going to get greater. Statistics Canada has projected a rapid increase in the proportion of seniors in the population. The first wave of the baby boom generation turns 65 next year. By 2031, seniors will account for roughly one-quarter of the population, nearly double the 13.9% observed in 2009.1 Canadians are clearly concerned about their ability to cope with future health care expenses, either their own or those of their parents. Respondents to the CMA's 2010 Annual National Report Card on Health Care survey anticipate a range of implications associated with our aging population: * 29% reported that they will likely alter their retirement plans (e.g., work longer) to help pay for their own future costs or those of their parents; * Almost one in five (19%) anticipates moving their parents into their own home and supporting them financially; and * One in six (16%) anticipates paying for their parents to live in a nursing home.2 The CMA believes that the federal government could play a key role in allaying Canadians' concerns about the future by leading negotiations with the provinces and territories and taking direct action on extending access along the continuum of care. These actions should focus on three priority areas: * Increasing access by all Canadians to affordable prescription drugs; * Supporting informal caregivers; and * Increasing access to palliative care at the end of life. If nothing is done to extend Medicare to cover more of the continuum of care, it will erode over time as a national program. When the Canada Health Act (CHA) was passed in 1984, physician and hospital services represented 57% of total health spending; this had declined to 42% as of 2009.3 While there is significant public spending beyond CHA-covered services (more than 25% of total spending) for programs such as seniors' drug coverage and home care, these programs are not subject to the CHA principles and coverage across the provinces and territories varies significantly. Access to Prescription Drugs The federal government missed an excellent opportunity to modernize Medicare in July 2004 when Premiers called on it to upload responsibility for drug programs. The Premiers stated that "a national pharmaceutical program should immediately be established. The federal government should assume full financial responsibility for a comprehensive drug plan for all Canadians, and be accountable for the outcomes."4 The federal government did not give this offer even fleeting consideration. Instead, the September 2004 10-Year Plan to Strengthen Health Care contained a watered-down version of the First Ministers' 2003 commitment to ensure that all Canadians would have reasonable access to catastrophic drug coverage by the end of 2005/06. The 2004 Accord reduced this commitment to the development of costing options for pharmaceutical coverage, as part of a nine-point National Pharmaceuticals Strategy (NPS).5 Costing options were included in the 2006 progress report of the NPS but they included estimates of the cost of catastrophic coverage wildly exceeding those of Romanow and Kirby, ranging from $6.6 billion to $10.3 billion.6 Nothing further has been heard about the NPS since stakeholder consultations were held in fall 2007. As recently as September 2008, the provinces and territories (PTs) were still interested in federal participation in pharmaceuticals. In the communiqué from their annual meeting, the PT health Ministers called for a three-point funding formula to support a national standard of pharmacare coverage, including: * PT flexibility and autonomy in program design; * Prescription drug costs not to exceed 5% of net income; and * Federal and PT governments to cost share 50/50, estimated at $2.52 billion each in 2006.7 Again there was no reaction from the federal government. Since then the PT governments have appeared to be giving up hope of federal participation in access to pharmaceuticals. At their June 2009 meeting, the western Premiers announced they would develop a joint western purchasing plan for pharmaceuticals,8 and more recently at the August 2010 meeting of the Council of the Federation, Premiers agreed to establish a pan-Canadian purchasing alliance for common drugs, medical supplies and equipment.9 Health Ministers reaffirmed this commitment at their September 2010 meeting.10 One can speculate that had the federal government taken up the Premiers' offer in 2004, many aspects of the NPS would be in place by now. Meanwhile, access to prescription drugs presents a hardship for many Canadians. In the CMA's 2009 National Report Card survey, nearly one in six (14%) reported they had either delayed or stopped buying some prescription drugs. This ranged from more than one in five (22%) with annual incomes of less than $30,000 to just over one in 20 (7%) of those with incomes greater than $90,000.11 The wide geographic disparity in out-of-pocket drug expenditures is shown in the table below, which is compiled from Statistics Canada's 2009 Survey of Household Spending. Table 1 shows the percentage of households spending more than 3% and 5% of after-tax income on prescription drugs, by province, in the year prior to the survey. [Note - see PDF for correct display of table information] % of Households Spending Greater than 3% and 5% of After-tax Income on Prescription Drugs, Canada and Provinces, 2008 Geography >3% >5% Canada 7.6 3.0 Newfoundland and Labrador 11.6 5.4E Prince Edward Island 13.3 5.8E Nova Scotia 8.9 3.8 New Brunswick 9.1 4.1E Quebec 11.6 3.3 Ontario 4.7 2.2E Manitoba 12.0 5.2 Saskatchewan 11.5 5.9 Alberta 4.6E 2.2E British Columbia 7.5 3.6 E - Use with caution - high coefficient of variation Source: Statistics Canada, CANSIM Table 109-5012 Under both thresholds there is a more than two-fold variation across provinces in the incidence of catastrophic drug expenditures. At the 5% threshold the range is from 2.2% of households in Ontario and Alberta to 5.8% in PEI and 5.9% in Saskatchewan. With the growing availability of more expensive drugs, this variation is only likely to be exacerbated in the years ahead. Recommendation 1 The federal government should negotiate a cost-shared program of comprehensive prescription drug coverage with the provincial/territorial governments. This program should be administered through provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. Such a program should include the following elements: * A mandate for all Canadians to have either private or public coverage for prescription drugs; * Uniform income-based ceiling (between public and private plans across provinces/territories) on out-of-pocket expenditures on drug plan premiums and/or prescription drugs (e.g., 5% of after-tax income); * Federal/provincial/territorial cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal/provincial/territorial sharing of reimbursement or by scaling the household income ceiling or both; * Group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size; and * A continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs). In negotiating this plan, consideration should be given to the following: * Establishing a program for access to expensive drugs for rare diseases where those drugs have been demonstrated to be effective; * Assessing the options for risk pooling to cover the inclusion of expensive drugs in public and private drug plan formularies; * Provision of adequate financial compensation to the provincial and territorial governments that have developed, implemented and funded their own public prescription drug insurance plans; and * Provision of comprehensive coverage of prescription drugs and immunization for all children in Canada. Supporting Informal Caregivers As the population ages, the incidence of diseases associated with dementia is projected to increase dramatically. A 2010 study commissioned by the Alzheimer Society of Canada has reported that the 2008 level of an estimated 103,728 new dementia cases is expected to more than double to 257,811 per year by 2038. Over this period, the demand for informal caregiving will skyrocket. In 2008, the Alzheimer Society reports, the opportunity cost of unpaid care giving was estimated at almost $5 billion. By 2038 this cost is expected to increase by 11-fold, to reach $56 billion, as the overall prevalence of dementia will have risen to 1.1 million people, representing 2.8% of the Canadian population.12 The burden of informal care giving extends beyond the costs related to dementia. Statistics Canada's 2007 General Social Survey has documented the extent to which Canadians are providing unpaid assistance to family, friends or other persons with a long-term health condition or physical limitation. Nationwide, 1.4 million adults aged 45 or over living in the community were receiving care in 2007. Of this number almost one in two (46.9%) were receiving both paid and unpaid care, almost three in 10 (27.4%) were receiving unpaid care only, and just under one in five (18.8%) were receiving paid care only. This underscores the importance of the informal sector. In terms of who was providing this care, an estimated four million Canadians were providing care, of whom one million were aged 65 or over, while almost two million (1.8) were in the prime working age range of 45 to 54. The provision of unpaid care represents a significant time commitment. The caregivers who reported helping with at least one activity spent an average 11.6 hours in a typical week doing so. Those providing care reported significant personal consequences. One in three reported spending less time on social activities (33.7%) or incurring extra expenses (32.7%), almost one in five cancelled holiday plans (18.7%) or spent less time with their spouse (18.7%), and more than one in 10 (13.7%) reported that their health had suffered. The 2.5 million informal caregivers who were in the paid labour force were likely to report that caregiving had had a significant impact on their jobs. Almost one in four (24.3%) reported missing full days of work and one in six (15.5%) reported reducing hours of work. Compared to the total population, informal caregivers were more likely to report stress in their lives. Almost three in 10 (27.9%) reported their level of stress on most days to be either quite a bit or extremely stressful compared to fewer than one in four (23.2%) of the total population.13 As the demand for informal care grows, it seems unlikely that the burden of informal caregiving will be sustainable without additional support. The federal government took the positive step in 2004/05 of introducing Employment Insurance (EI) Compassionate Care Benefits for people who are away from work temporarily to provide care or support to a family member who is gravely ill and at risk of dying within 26 weeks.14 So far, however, this program has had limited uptake. In 2007/08, 5,706 new claims were paid.15 This pales in comparison to the 235,217 deaths that year (although not all of these would be candidates for this type of care).16 Recommendation 2 The federal government should implement measures within its jurisdiction, such as the use of tax credits, to support informal caregivers. Increasing Access to Palliative Care at the End of Life The Senate of Canada, and Senator Sharon Carstairs in particular, have provided exemplary leadership over the last 15 years in highlighting both the progress and the persistent variability across Canada in access to quality end-of-life care. The Senator's 2005 report Still Not There noted that only an estimated 15% of Canadians have access to hospice palliative care and that for children the figure drops even further to just over 3%.17 The 2005 report repeated the 1995 call for a national strategy for palliative and end-of-life care. To date, palliative care in Canada has primarily centred on services for those dying with cancer. However, cancer accounts for less than one-third (30%) of deaths in Canada. Diseases at the end of life, such as dementia and multiple chronic conditions, are expected to become much more prevalent in the years ahead. The demand for quality end-of-life care is certain to increase as the baby boom generation ages. There will be an estimated 40% more deaths a year by 2020. While the proportion of Canadians dying in hospital has been decreasing over the past decade, many more Canadians would undoubtedly prefer to have the option of hospice palliative care at the end of their lives than current capacity will permit. In the 2004 Health Accord, First Ministers built on their 2003 Accord by agreeing to provide first dollar coverage for certain home care services by 2006, including end-of-life care for case management, nursing, palliative-specific pharmaceuticals and personal care at the end of life. Seven years later we have no comprehensive picture of the availability of end-of-life care across Canada. The Health Council of Canada's last detailed reporting on the implementation of the 2003 Accord was in 2006. At that time, the only province to report comprehensive end-of-life care was British Columbia.18 For most other jurisdictions, end-of-life care was discussed under "next steps." Since then, the Health Council has ceased comprehensive reporting on the Accord. In the 2007 National Physician Survey, doctors across Canada were asked to rate the accessibility of the range of services for their patients. Just one in three (32%) rated access to palliative care services as either excellent or very good.19 In 2006, the Canadian Hospice Palliative Care Association and the Canadian Home Care Association jointly issued a 35-point "gold standard" for palliative home care, covering the areas of case management, nursing care, pharmaceuticals and personal care, which they commended to governments.20 In its April 2009 report, the Special Senate Committee on Aging recommended a federally funded national partnership with provinces, territories and community organizations to promote integrated, quality end-of-life care for all Canadians, the application of gold standards in palliative home care to veterans, First Nations and Inuit, and federal inmates, and renewed research funding for palliative care.21 In 2010, the Quality End-of-Life Care Coalition of Canada (QELCC), of which the CMA is a member, released its Blueprint for Action 2010 to 2020. The four priorities are: * Ensure all Canadians have access to high-quality hospice palliative end-of-life care; * Provide more support for family caregivers; * Improve the quality and consistency of hospice palliative end-of-life care in Canada; and * Encourage Canadians to discuss and plan for end-of-life.22 This blueprint embodies the sound ideas that have emerged over the past decade. In June 2010, Senator Carstairs released her latest report Raising the Bar, which, while acknowledging some of the achievements that have been made in palliative care, repeats her previous calls for a national role and active engagement of the federal government.23 A wide range of stakeholders either have, or should have, a significant stake in the issue of palliative care. They include patients and the organizations that advocate on their behalf, caregivers (both formal and informal), the institutional and community health sectors, and the employer/business community. Recommendation 3 The CMA urges the federal government to collaborate with the provincial and territorial governments to convene a national conference in 2011 to assess the state of palliative care in Canada. Notes 1 Statistics Canada. Population projections for Canada, provinces and territories 2009 to 2036. Catalogue no. 91-520-X. Ottawa. Minister of Industry, 2010. 2 Canadian Medical Association. 10th Annual National Report Card on Health Care, August, 2010. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2010/report_card/2010-National-Report-Card_en.pdf. Accessed 09/28/10. 3 Canadian Institute for Health Information. National health expenditure trends 1975 to 2009. Ottawa, 2009. 4 Canadian Intergovernmental Conference Secretariat. Premiers' action plan for better health care: resolving issues in the spirit of true federation. July 30, 2004. http://www.scics.gc.ca/cinfo04/850098004_e.html. Accessed 09/28/10. 5 Canadian Intergovernmental Conference Secretariat. A 10-year plan to strengthen health care. http://www.scics.gc.ca/cinfo04/800042005_e.pdf. Accessed 09/28/10. 6 Health Canada. National Pharmaceuticals Strategy Progress Report. June 2006. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 09/28/10. 7 Canadian Intergovernmental Conference Secretariat. Annual Conference of Provincial-Territorial Ministers of Health. September 4, 2008. http://www.scics.gc.ca/cinfo08/860556005_e.html. Accessed 09/28/10. 8 Canadian Intergovernmental Conference Secretariat. Premiers taking action on pharmaceuticals. June 18, 2009. http://www.scics.gc.ca/cinfo09/850114004_e.html. Accessed 09/28/10. 9 Council of the Federation. Premiers protecting Canada's health care systems. http://www.councilofthefederation.ca/pdfs/PremiersProtectingCanadasHealthCareSystem.pdf. Accessed 09/28/10. 10 Canadian Intergovernmental Conference Secretariat. P/T health Ministers work together to advance common issues. September 13, 2010. http://www.scics.gc.ca/cinfo10/860578004_e.html. Accessed 09/28/10. 11 Canadian Medical Association. 9th Annual National Report Card on Health Care. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2009/report_card/Report-Card_en.pdf. Accessed 09/28/10. 12Alzheimer Society of Canada. Rising tide: the impact of dementia on Canadian society. http://www.alzheimer.ca/docs/RisingTide/Rising%20Tide_Full%20Report_Eng_FINAL_Secured%20version.pdf. Accessed 09/28/10. 13 Statistics Canada. 2007 General Social Survey: Care tables. Catalogue no. 89-633-X. Ottawa, Minister of Industry, 2009. 14Human Resources and Skills Development Canada. Information for health care professionals: EI Compassionate Care. http://www.rhdcc-hrsdc.gc.ca/eng/publications_resources/health_care/ei_ccb.shtml. Accessed 09/28/10. 15 Human Resources and Skills Development Canada. Table 2.12 Compassionate care benefits. http://www.hrsdc.gc.ca/eng/employment/ei/reports/eimar_2009/annex/annex2_12.shtml. Accessed 09/28/10. 16 Statistics Canada. Deaths 2007. The Daily, Tuesday, February 23, 2010. 17 Carstairs S. Still not there. Quality end-of-life care: a status report. http://sen.parl.gc.ca/scarstairs/PalliativeCare/Still%20Not%20There%20June%202005.pdf. Accessed 09/24/09. 18 Health Council of Canada. Jursdictional tables on health care renewal. Companion document to Health care renewal in Canada Measuring up? Annual report to Canadians 2006. Toronto, ON, 2007 19 College of Family Physicians of Canada. Canadian Medical Association. Royal College of Physicians and Surgeons of Canada. National Physician Survey 2007. Q25a. Please rate the accessibility of the following for your patients. http://www.nationalphysiciansurvey.ca/nps/2007_Survey/Results/ENG/National/pdf/Q25/Q25aALL.only_NON.CORE.only.pdf. Accessed 09/28/10. 20 Canadian Hospice Palliative Care Association. Canadian Home Care Association. The pan-Canadian gold standard for palliative home care. http://www.chpca.net/resource_doc_library/pan-cdn_gold_standards/Gold_Standards_Palliative_Home_Care.pdf. Accessed 09/28/10. 21 Special Senate Committee on Aging. Final report: Canada's aging population: Seizing the opportunity. April 2009. http://www.parl.gc.ca/40/2/parlbus/commbus/senate/com-e/agei-e/rep-e/AgingFinalReport-e.pdf. Accessed 09/28/10. 22 Quality End -of-life Coalition of Canada. Blueprint for action 2010 to 2020. http://www.chpca.net/qelccc/information_and_resources/Blueprint_for_Action_2010_to_2020_April_2010.pdf. Accessed 09/28/10. 23Carstairs S. Raising the bar: a roadmap for the future of palliative care in Canada. June 2010. http://sen.parl.gc.ca/scarstairs/PalliativeCare/Raising%20the%20Bar%20June%202010%20(2).pdf. Accessed 09/29/10.

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CMA's Presentation to the House of Commons Standing Committee on Finance: Pre-budget Consultations 2010-2011

https://policybase.cma.ca/en/permalink/policy10018

Date
2010-10-27
Topics
Health systems, system funding and performance
Health human resources
  1 document  
Policy Type
Parliamentary submission
Date
2010-10-27
Topics
Health systems, system funding and performance
Health human resources
Text
The CMA brief contains seven recommendations to address pressing needs in the health care system. Before I get to those, I'd like to highlight why, from my perspective, our health care system is in need of the federal government's attention. Yesterday, at the Ottawa Hospital, where I am Chief of Staff: * Our occupancy was 100 per cent. * 30 patients who came to the emergency department were admitted to the hospital, but we had beds for only four of them. * 10 are still waiting on gurneys in examining rooms within the emergency department. * Six patients were admitted to wards and are receiving care in hallways. * Three surgeries were cancelled - bringing the number of cancellations this year to 480. * But while all this was happening, we had 158 patients waiting for a bed in a long-term-care facility. Equally, a few blocks from here and in communities across the country, the health status of our poorest and most vulnerable populations is comparable to countries that have a fraction of our GDP - despite very significant investments in their health. This is just my perspective. Health care providers of all types experience the failings of our system on a daily basis. We as a country can do better and Canadians deserve better value for their money. Canada's physicians are calling for transformative change to build a health care system based on the principles of accessibility, high quality, cost effectiveness, accountability and sustainability. Through new efficiencies, better integration and sound stewardship, governments can reposition health care as an economic driver, an agent of productivity and a competitive advantage for Canada in today's global marketplace. The Health Accord expires in March 2014, and we strongly urge that the federal government begin discussions now with the provinces and territories on how to transform our health care system so that it meets patients' needs and is sustainable into the future. Canadians themselves also need to be part of the conversation. To help position the system for this transformative change, the CMA brief identifies a number of issues that the federal government should address in the short term: First, our system needs investments in health human resources to retain and recruit more doctors and nurses. Although we welcome measures in the last budget to increase the number of residency positions, we urge the government to fulfill the balance of its election promise by further investing in residencies, and to invest in programs to repatriate Canadian-trained physicians living abroad. Second, we need to bolster our public health e-infrastructure so that it can provide efficient, quality care that responds more effectively to pandemics. We recommend increased investment: * to improve data collection and analysis between local public health authorities and primary care practices, * for local health emergency preparedness, and * for the creation of a pan-Canadian strategy for responding to potential health crises. Third, issues related to our aging population also call for action. As continuing care moves from hospitals into the home, the community, or long-term care facilities, the financial burden shifts from governments to individuals. We recommend that the federal government study options for pre-funding long-term care - including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance - to help Canadians prepare for their future home care and long-term care needs. And, as much of the burden of continuing care for seniors also falls on informal, unpaid caregivers, the CMA recommends that pilot studies be undertaken to explore tax credit and/or direct compensation for informal caregivers for their work, and to expand programs for informal caregivers that provide guaranteed access to respite services in emergency situations. Finally, the government should increase RRSP limits and explore opportunities to provide pension vehicles for self-employed Canadians. Mr. Chair, a fuller set of recommendations is contained in our report -- Health Care Transformation in Canada: Change that Works. Care that Lasts. These include universal access to prescription drugs; greater use of health information technology; and the immediate construction of long-term care facilities. We urge the Committee to consider both our short-term recommendations - and our longer term vision for transforming Canada's health care system. I look forward to your questions. Thank you.

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CMA’s Recommendations for Bill S-5 An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts

https://policybase.cma.ca/en/permalink/policy13918

Date
2018-02-15
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Date
2018-02-15
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health care and patient safety
Text
The Canadian Medical Association (CMA) is pleased to provide this submission to the House of Commons Standing Committee on Health for its study of Bill S-5, An Act to amend the Tobacco Act and the Non-Smokers Health Act and to make consequential amendments to other Acts. We support the government’s effort to implement a new legislative and regulatory framework to address vaping products and related matters. Vaping products, such as electronic cigarettes (or e-cigarettes) replicate the act and taste of smoking but do not contain tobacco. We also recognize that the federal government is attempting to find a balance between regulating vaping devices and making them available to adults. Canada’s physicians, who see the devastating effects of tobacco use every day in their practices, have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use. The CMA has always supported strong, comprehensive tobacco control legislation, enacted and enforced by all levels of government, and we continue to do so. Our most recent efforts centred on our participation in the 2016 Endgame Summit, held late last year in Kingston, Ontario. This brief will focus on three areas: supporting population health; the importance of protecting youth; and, the promotion of vaping products. Overview Tobacco is an addictive and hazardous product, and a leading cause of preventable disease and death in Canada. Smoking has been on the decline in Canada the most recent Canadian Community Health Survey reports that 17.7% of the population aged 12 and older were current daily or occasional smokers in 2015 (5.3 million smokers); that is down from 18.1% in 2014.1 Many strong laws and regulations have already been enacted but some areas remain to be addressed and strengthened especially as the 1 Statistics Canada. Smoking, 2015. Health Fact Sheets. Statistics Canada Cat. 82-625-X. Ottawa: Statistics Canada; 2016. Available: http://www.statcan.gc.ca/pub/82-625-x/2017001/article/14770-eng.htm (accessed 2018 Feb 1). 2 Czoli CD, Hammond D, White CM. Electronic cigarettes in Canada: Prevalence of use and perceptions among youth and young adults. Can J Public Health. 2014;105(2):e97-e102. 3 Filippos FT, Laverty AA, Gerovasili V, et al. Two-year trends and predictors of e-cigarette use in 27 European Union member states. Tob Control. 2017;26:98-104. 4 Malas M, van der Tempel J, Schwartz R, Minichiello A, Lightfoot C, Noormohamed A, et al. Electronic cigarettes for smoking cessation: A systematic review. Nicotine Tob Res. 2016;18(10):1926–36. 5 O’Leary R, MacDonald M, Stockwell T, Reist D. Clearing the air: A systematic review on the harms and benefits of e-cigarettes and vapour devices. Victoria, BC: Centre for Addictions Research of BC; 2017. Available: http://ectaofcanada.com/clearing-the-air-a-systematic-review-on-the-harms-and-benefits-of-e-cigarettes-and-vapour-devices/ (accessed 2018 Feb 1). 6 El Dib R, Suzumura EA, Akl EA, Gomaa H, Agarwal A, Chang Y, et al. Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco smoking cessation or reduction: a systematic review and meta-analysis. BMJ Open. 2017 23;7:e012680. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5337697/pdf/bmjopen-2016-012680.pdf (accessed 2018 Feb 1). 7 Shahab L, Goniewicz M, Blount B, et al. Nicotine, carcinogen, and toxin exposure in long-term e- cigarette and nicotine replacement therapy users: A cross sectional study. Annals of Internal Medicine. 2017;166(6):390-400. 8 Collier R. E-cigs have lower levels of harmful toxins. CMAJ. 2017 Feb 27;189:E331. 9 Sleiman M, Logue J, Montesinos VN, et al. Emissions from electronic cigarettes: Key parameters affecting the release of harmful chemicals. Environmental Science and Technology. 2016 Jul 27;50(17):9644-9651. 10 England LJ, Bunnell RE, Pechacek TF, Tong VT, McAfee TA. Nicotine and the developing human: A neglected element in the electronic cigarette debate. Am J Prev Med. 2015 Aug;49(2):286-93. 11 Foulds J. Use of Electronic Cigarettes by Adolescents. J Adolesc Health. 2015 Dec;57(6):569-70. 12 Khoury M, Manlhiot C, Fan CP, Gibson D, Stearne K, Chahal N, et al. Reported electronic cigarette use among adolescents in the Niagara region of Ontario. CMAJ. 2016 Aug 9;188(11):794-800. 13 U.S. National Cancer Institute and World Health Organization. The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA- 8029A. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; and Geneva, CH: World Health Organization; 2016. 14 Miech R, Patrick ME, O’Malley PM, Johnston LD. E-cigarette use as a predictor of cigarette smoking: results from a 1-year follow-up of a national sample of 12th grade students. Tob Control. 2017 Dec;26(e2):e106–11. 15 Primack BA, Soneji S, Stoolmiller M, Fine MJ, Sargent JD. Progression to traditional cigarette smoking after electronic cigarette use among US adolescents and young adults. JAMA Pediatr. 2015 Nov;169(11):1018–23. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800740/pdf/nihms768746.pdf (accessed 2018 Feb 1). 16 Hoe J, Thrul J, Ling P. Qualitative analysis of young adult ENDS users’ expectations and experiences. BMJ Open. 2017;7:e014990. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5353280/pdf/bmjopen-2016-014990.pdf (accessed 2018 Feb 1). 17 Fairchild AL, Bayer R, Colgrove J. The renormalization of smoking? E-cigarettes and the tobacco “endgame.” N Engl J Med. 2014 Jan 23;370:4 Available: http://www.nejm.org/doi/pdf/10.1056/NEJMp1313940 (accessed 2018 Feb 1). 18 Choi K, Grana R, Bernat D. Electronic nicotine delivery systems and acceptability of adult cigarette smoking among Florida youth: Renormalization of smoking? J Adolesc Health. 2017 May;60(5):592–8. tobacco industry continues to evolve. Electronic cigarettes and vaping represents the next step in that evolution. While Canada is to be congratulated on its success to date, it needs to maintain an environment that encourages Canadians to remain tobacco-free if smoking prevalence is to be reduced further in Canada. The CMA believes it is incumbent on all levels of government in Canada to keep working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve that goal. Supporting Population Health The arrival of vaping products in Canada placed them in a “grey zone” with respect to legislation and regulation. Clarification of their status is crucial from a public health perspective because of their growing popularity, particularly among youth.2 E-cigarettes have both defenders and opponents. Proponents say they are safer than tobacco cigarettes since they do not contain the tar and other toxic ingredients that are the cause of tobacco related disease. Indeed, some believe they serve a useful purpose as a harm reduction tool or cessation aid (though it is forbidden to market them as such since that claim has never been approved by Health Canada). Opponents are concerned that the nicotine delivered via e-cigarettes is addictive and that the cigarettes may contain other toxic ingredients such as nitrosamines. Also, they worry that acceptance of e-cigarettes will undermine efforts to de-normalize smoking, and that they may be a gateway to the use of tobacco by people who might otherwise have remained smoke-free. This issue will be addressed later in this brief. This difference of opinion certainly highlights the need for more research into the harms and benefits of vaping products and the factors that cause people to use them.3 Encouraging smokers to move from combustible tobacco products to a less harmful form of nicotine may be a positive step. However the current available evidence is not yet sufficient to establish them as a reliable cessation method. A systematic review published by M. Malas et al. (2016) concluded that while “a majority of studies demonstrate a positive relationship between e-cigarette use and smoking cessation, the evidence remains inconclusive due to the low quality of the research published to date.”4 Indeed, some are helped by these devices to quit smoking but “more carefully designed and scientifically sound studies are urgently needed to establish unequivocally the long-term cessation effects of e-cigarettes and to better understand how and when e-cigarettes may be helpful.”4 The authors found that the evidence examining e-cigarettes as an aid to quitting smoking was determined to be “very low to low.”4 A similar result was found for their use in reducing smoking; the quality of the evidence was revealed as being “very low to moderate.”4 This conclusion is supported by another review conducted by the University of Victoria (2017). It too indicates that there are not enough studies available to fully determine the efficacy of vaping devices as a tobacco cessation device.5 This review also noted that there is “encouraging evidence that vapour devices can be at least as effective as other nicotine replacements.”5 Another review by R. El Dib et al. (2017) reinforces these findings. Limited evidence was also found with respect to the impact of electronic devices to aide cessation. They also noted that the data available from randomized control trials are of “low certainty” and the “observational studies are of very low certainty.”6 The wide range of devices available makes it very difficult to test which are the most effective in helping cessation efforts. Many of the studies are on older devices so it is possible that as second-generation technology becomes available they will prove to be more successful. In view of this uncertainty, the CMA calls for more scientific research into the potential effectiveness and value of these devices as cessation aids. Physicians need to be confident that if they recommend such therapy to their patients it will have the desired outcome. To that end, we are pleased that Health Canada will continue to require manufacturers to apply for authorization under the Food and Drugs Act to sell products containing nicotine and make therapeutic claims. Risk and Safety In addition to the discussion concerning the usefulness of vaping devices as cessation devices, concerns from a public health standpoint involve the aerosol or vapour produced by heating the liquids used in these devices, and the nicotine some may contain. The tube of an e-cigarette contains heat-producing batteries and a chamber holding liquid. When heated, the liquid is turned into vapour which is drawn into the lungs. Ingredients vary by brand but many contain nicotine and/or flavourings that are intended to boost their appeal to young people. The CMA is concerned that not enough is known about the safety of the ingredients in the liquids being used in vaping devices. While it is the case that because e-cigarettes heat rather than burn the key constituent, they produce less harmful toxins and are much safer than conventional cigarettes. Research in the UK suggested that “long-term Nicotine Replacement Therapy (NRT)-only and e-cigarette-only use, but not dual-use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes.”7 However, this study has been criticized because “it only looked at a few toxins and didn’t test for any toxins that could be produced by e- cigarettes.”8 The variety of flavourings and delivery systems available make it imperative that the risks associated with these products be fully understood. As one study noted “analysis of e-liquids and vapours emitted by e-cigarettes led to the identification of several compounds of concern due to their potentially harmful effects on users and passively exposed non-users.”9 The study found that the emissions were associated with both cancer and non-cancer health impacts and required further study.9 There is another aspect of the public health question surrounding vaping devices. There is data to support the idea that “nicotine exposure during periods of developmental vulnerability (e.g., fetal through adolescent stages) has multiple adverse health consequences, including impaired fetal brain and lung development.”10 Therefore it is imperative that pregnant women and youth be protected. There is not enough known about the effects of long-term exposure to the nicotine inhaled through vaping devices at this time.11 Recommendations: 1) Given the scarcity of research on e-cigarettes the Canadian Medical Association calls for ongoing research into the potential harms of electronic cigarette use, including the use of flavourings and nicotine. 2) The CMA calls for more scientific research into the potential effectiveness and value of these devices as cessation aids. 3) The Canadian Medical Association supports efforts to expand smoke-free policies to include a ban on the use of electronic cigarettes in areas where smoking is prohibited. Protecting Youth The CMA is encouraged by the government’s desire to protect youth from developing nicotine addiction and inducements to use tobacco products. Young people are particularly vulnerable to peer pressure, and to tobacco industry marketing tactics. The CMA supports continued health promotion and social marketing programs aimed at addressing the reasons why young people use tobacco and have been drawn to vaping devices, discouraging them from starting to use them and persuading them to quit, and raising their awareness of tobacco industry marketing tactics so that they can recognize and counteract them. These programs should be available continuously in schools and should begin in the earliest grades. The “cool/fun/new” factor that seems to have developed around vaping devices among youth make such programs all the more imperative.12 The CMA recommends a ban on the sale of all electronic cigarettes to Canadians younger than the minimum age for tobacco consumption in their province or territory. We are pleased to see that Bill S-5 aims to restrict access to youth, including prohibiting the sale of both tobacco and vaping products in vending machines as well as prohibiting sales of quantities that do not comply with the regulations. In fact, the CMA recommends tightening the licensing system to limit the number of outlets where tobacco products, including vaping devices, can be purchased. The more restricted is availability, the easier it is to regulate. The CMA considers prohibiting the promotion of flavours in vaping products that may appeal to youth, such as soft drinks and cannabis, to be a positive step. A recent report published by the World Health Organization and the US National Cancer Institute indicated that websites dedicated to retailing e-cigarettes “contain themes that may appeal to young people, including images or claims of modernity, enhanced social status or social activity, romance, and the use of e-cigarettes by celebrities.”13 We are therefore pleased that sales of vaping products via the internet will be restricted through prohibiting the sending and delivering of such products to someone under the age of 18. This will be critical to limiting the tobacco industry’s reach with respect to youth. There have also been arguments around whether vaping products will serve as gateways to the use of combusted tobacco products. The University of Victoria (2017) paper suggests this isn’t the case; it notes that “there is no evidence of any gateway effect whereby youth who experiment with vapour devices are, as a result, more likely to take up tobacco use.”5) They base this on the decline in youth smoking while rates of the use of vaping devices rise.Error! Bookmark not defined. Others contend that vaping is indeed a gateway, saying it acts as a “one-way bridge to cigarette smoking among youth. Vaping as a risk factor for future smoking is a strong, scientifically-based rationale for restricting access to e-cigarettes.”14 Further, in a “national sample of US adolescents and young adults, use of e-cigarettes at baseline was associated with progression to traditional cigarette smoking. These findings support regulations to limit sales and decrease the appeal of e- cigarettes to adolescents and young adults.”15 However, there may be a role for vaping products in relation to young users. A New Zealand study conducted among young adults that examined how electronic nicotine delivery systems (ENDS) were used to recreate or replace smoking habits. It found that study participants “used ENDS to construct rituals that recreated or replaced smoking attributes, and that varied in the emphasis given to device appearance.”16 Further, it was suggested that ascertaining how “ENDS users create new rituals and the components they privilege within these could help promote full transition from smoking to ENDS and identify those at greatest risk of dual use or relapse to cigarette smoking.”16 The CMA believes that further research is needed on the question of the use of vaping products as a gateway for youth into combustible tobacco products. Recommendations: 4) The Canadian Medical Association recommends a ban on the sale of all electronic cigarettes to Canadians younger than the minimum age for tobacco consumption in their province or territory. 5) The Canadian Medical Association calls for ongoing research into the potential harms and benefits of electronic cigarette use among youth. 6) The Canadian Medical Association recommends tightening the licensing system to limit the number of outlets where tobacco products, including vaping devices, can be purchased. Promotion of Vaping Products The CMA has been a leader in advocating for plain and standardized packaging for tobacco products for many years. We established our position in 1986 when we passed a resolution at our General Council in Vancouver recommending to the federal government “that all tobacco products be sold in plain packages of standard size with the words “this product is injurious to your health” printed in the same size lettering as the brand name, and that no extraneous information be printed on the package.” The CMA would like to see the proposed plain packing provisions for tobacco be extended to vaping products as well. The inclusion of the health warning messages on vaping products is a good first step but efforts should be made to ensure that they are of similar size and type as those on tobacco as soon as possible. The restrictions being applied to the promotion of vaping products is a positive step, especially those that could be aimed at youth, but they do not go far enough. The CMA believes the restrictions on promotion should be the same as those for tobacco products. As the WHO/U.S. National Cancer Institute has already demonstrated, e- cigarette retailers are very good at using social media to promote their products, relying on appeals to lifestyle changes to encourage the use of their products. The CMA is also concerned that e-cigarette advertising could appear in locations and on mediums popular with children and youth if they are not prohibited explicitly in the regulations. This would include television and radio advertisements during times and programs popular with children and youth, billboards near schools, hockey arenas, and on promotional products such as t-shirts and ball caps. As efforts continue to reduce the use of combustible tobacco products there is growing concern that the rising popularity of vaping products will lead to a “renormalization” of smoking. In fact, worry has been expressed that the manner they have been promoted “threaten(s) to reverse the successful, decades-long public health campaign to de- normalize smoking.”17 A recent US study indicated that students that use vaping products themselves, exposure to advertising of these devices, and living with other users of vaping products is “associated with acceptability of cigarette smoking, particularly among never smokers.”18 Further research is needed to explore these findings. Recommendations: 7) The Canadian Medical Association recommends similar plain packaging provisions proposed for tobacco be extended to vaping products. 8) Health warning messages on vaping products should be of similar size and type as those on tobacco as soon as possible 9) The Canadian Medical Association believes the restrictions on promotion of vaping products and devices should be the same as those for tobacco products. Conclusion Tobacco is an addictive and hazardous product, and a leading cause of preventable disease and death in Canada. Our members see the devastating effects of tobacco use every day in their practices and to that end the CMA has been working for decades toward the goal of a smoke-free Canada. The tobacco industry continues to evolve and vaping represents the next step in that evolution. The CMA believes it is incumbent on all levels of government in Canada to keep working on comprehensive, coordinated and effective tobacco control strategies, including vaping products, to achieve that goal. Bill S-5 is another step in that journey. Researchers have identified potential benefits as well as harms associated with these products that require much more scrutiny. The association of the tobacco industry with these products means that strong regulations, enforcement, and oversight are needed. Recommendations: 1) Given the scarcity of research on e-cigarettes the Canadian Medical Association calls for ongoing research into the potential harms of electronic cigarette use, including the use of flavourings and nicotine. 2) The CMA calls for more scientific research into the potential effectiveness and value of these devices as cessation aids.. 3) The Canadian Medical Association supports efforts to expand smoke-free policies to include a ban on the use of electronic cigarettes in areas where smoking is prohibited. 4) The Canadian Medical Association recommends a ban on the sale of all electronic cigarettes to Canadians younger than the minimum age for tobacco consumption in their province or territory. 5) The Canadian Medical Association calls for ongoing research into the potential harms and benefits of electronic cigarette use among youth. 6) The Canadian Medical Association recommends tightening the licensing system to limit the number of outlets where tobacco products, including vaping devices, can be purchased. 7) The Canadian Medical Association recommends similar plain packaging provisions proposed for tobacco be extended to vaping products. 8) Health warning messages on vaping products should be of similar size and type as those on tobacco as soon as possible 9) The Canadian Medical Association believes the restrictions on promotion of vaping products and devices should be the same as those for tobacco products.

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Bill C-45: The Cannabis Act

https://policybase.cma.ca/en/permalink/policy13861

Date
2018-04-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2018-04-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The CMA is pleased to provide this submission to the Senate Standing Committee, Social Affairs, Science &Technology on Bill C-45, the Cannabis Act. The CMA has long-standing concerns about the health risks associated with consuming cannabis,i particularly in its smoked form.1,2 Children and youth are especially at risk for cannabis-related harms, given their brains are undergoing rapid and extensive development. The CMA's approach to cannabis is grounded in broad public health policy. It includes promotion of health and prevention of drug dependence and addiction; access to assessment, counselling and treatment services; and a harm reduction perspective. The CMA believes that harm reduction encompasses policies, goals, strategies and programs directed at decreasing adverse health, social and economic consequences of drug use for the individual, the community and the society while allowing the user to continue to use drugs, not precluding abstinence.3,4 Specifically, the CMA recommends a multi-faceted cannabis public health strategy that prioritizes impactful and realistic goals before, and certainly no later than, any legalization of cannabis.5 We propose that the first goal should be to develop educational interventions for children, teenagers and young adults. Other goals relate to data collection; monitoring and surveillance; ensuring a proportionate balance between enforcement harms and the direct and indirect harms caused by cannabis use; and research. There is an ongoing need for research into the medicinal and harmful effects of cannabis use. As noted by the Lower-Risk Cannabis Use Guidelines, 6 there is limited evidence on such subjects as synthetic cannabinoids; practices like "deep inhalation" to increase the psychoactive effects of cannabis; and the combination of risky behaviours, like early-onset and frequent use, associated with experiencing acute or chronic health problems.6 Since 2002, the CMA has taken a public health perspective regarding cannabis and other illegal drugs. More recently, the CMA endorsed the Lower-Risk Cannabis Use Guidelines, and we submitted 22 recommendations to the Task Force on Cannabis Legalization and Regulation ("the Task Force").7 Overview According to the recent Canadian Tobacco, Alcohol and Drugs Survey, cannabis is the most used illicit drug in Canada.8 In particular, 25%-30% of adolescents or youth report past-year cannabis use.9 This concerns the CMA. The increasing rate of high usage, despite the fact that non-medical use of cannabis is illegal, coupled with cannabis' increased potency (from 2% in 1980 to 20% in 2015 in the United States),10 the complexity and versatility of the cannabis plant,ii the variable quality of the end product, and variations in the frequency, age of initiation and method of use make it difficult to study the full health impacts and produce replicable, reliable scientific results. The CMA submits, therefore, that any legalization of cannabis for non-medical use must be guided by a comprehensive cannabis public health strategy and include a strong legal-regulatory framework emphasizing harm reduction principles. Given that the Task Force employed a minimizing of harms approach11 and given how the proposed legislation aligns with the Task Force's recommendations,12 the bill addresses several aspects of a legal-regulatory framework "to provide legal access to cannabis and to control and regulate its production, distribution and sale."13 This work provides the starting point for creating a national cannabis public health strategy. The CMA has long called for a comprehensive drug strategy that addresses addiction, prevention, treatment, enforcement and harm reduction.3 There are, however, key public health initiatives that the Canadian government has not adequately addressed and should be implemented before, or no later than, the implementation of legislation. One such initiative is education. Education is required to develop awareness among Canadians of the health, social and economic harms of cannabis use especially in young people. Supporting a Legal-Regulatory Framework that Advances Public Health and Protection of Children and Youth From a health perspective, allowing any use of cannabis by people under 25 years of age, and certainly those under 21 years of age, is challenging for physicians given the effects on the developing brain.1,3,14 The neurotoxic effect of cannabis, especially with persistent use, on the adolescent brain is more severe than on the adult brain.15,16 Further, neurological studies have shown that adolescent-onset cannabis use produces greater deficits in executive functioning and verbal IQ and greater impairment of learning and memory than adult-onset use.17,18 This underscores the importance of protecting the brain during development. Since current scientific evidence indicates that brain development is not completed until about 25 years of age,19 this would be the ideal minimum age for legal cannabis use. Youth and young adults are among the highest users of cannabis in Canada. Despite non-medical use of cannabis being illegal in Canada since 1923, usage has increased over the past few decades. The CMA recognizes that a blanket prohibition of possession for teenagers and young adults would not reflect current reality or a harm reduction approach.3 Harm reduction is not one of polarities rather it is about ensuring the quality and integrity of human life and acknowledging where the individual is at within his/her community and society at large.5 The possibility that a young person might incur a lifelong criminal record for periodic use or possession of small amounts of cannabis for personal use means that the long-term social and economic harms of cannabis use can be disproportionate to the drug's physiological harm. The Canadian government has recognized this disproportionality for over 15 years. Since 2001, there have been two parliamentary committee reportsiii and two billsiv introduced to decriminalize possession of small amounts of cannabis (30 g). It was recommended that small amounts of cannabis possession be a "ticketable" offence rather than a criminal one. Given all of the above, the CMA recommends that the age of legalization should be 21 years of age and that the quantities and the potency of cannabis be more restricted to those under age 25. Supporting a Comprehensive Cannabis Public Health Strategy with a Strong, Effective Education Component The CMA recognizes that Bill C-45 repeals the prohibition against simple possession while increasing penalties against the distribution and sale of cannabis to young people, but this is not enough to support a harm reduction approach. We note that the Federal Tobacco Control Strategy, with its $38 million budget, is intended to help reduce smoking rates and change Canadians' perceptions toward tobacco.20 Similarly, there are extensive education programs concerning the dangers of alcohol, particularly for young people.v The government of Canada has proposed a modest commitment of $9.6 million to a public awareness campaign to inform Canadians, especially youth, of the risks of cannabis consumption, and to surveillance activities.21 A harm reduction strategy should include a hierarchy of goals with an immediate focus on groups with pressing needs. The CMA submits that young people should be targeted first with education. The lifetime risk of dependence to cannabis is estimated at 9%, increasing to almost 17% in those who initiate use in adolescence.22 In 2012, about 1.3% of people aged 15 years and over met the criteria for cannabis abuse or dependence - double the rate for any other drug - because of the high prevalence of cannabis use.23 The strategy should include the development of educational interventions, including skills-based training programs, social marketing interventions and mass media campaigns. Education should focus not only on cannabis' general risks but also on its special risks for the young and its harmful effects on them. This is critical given that for many, the perception is that (i) legalization of possession for both adults and young people translates into normalization of use and (ii) government control over the source of cannabis for sale translates into safety of use. Complicating this has been the fear-mongering messaging associated with illegal drugs. The evidence shows that fewer adolescents today believe that cannabis use has any serious health risks24 and that enforcement policies have not been a deterrent.25 Having an appropriate education strategy rolled out before legalization of possession would reduce the numbers of uninformed young recreational users. It would also provide time to engage in meaningful research on the impact of the drug on youth. Such strategies have been successful in the past; for example, the long-termvi Federal Tobacco Control Strategy has been credited with helping reduce smoking rates to an all-time low in Canada.26 The Lower-Risk Cannabis Use Guidelines were developed as a "science-based information tool for cannabis users to modify their use toward reducing at least some of the health risks."6 The CMA urges the government to support the widespread dissemination of this tool and incorporation of its messages into educational efforts. Other strategies must include plain packaging and labelling with health information and health warnings. Supporting a One-System Approach. Alternatively, a Review of Legislation in Five Years The CMA believes that once the act is in force, there will be little need for two systems (i.e., one for medical and one for non-medical cannabis use). Cannabis will be available for those who wish to use it for medicinal purposes, either with or without medical authorization (some people may self-medicate with cannabis to alleviate symptoms but may be reluctant to raise the issue with their family physician for fear of being stigmatized), and for those who wish to use it for other purposes. The medical profession does not need to continue to be involved as a gatekeeper once cannabis is legal for all, especially given that cannabis has not undergone Health Canada's usual pharmaceutical regulatory approval process. The Task Force's discussion reflects the tension it heard between those who advocated for one system and those who did not. One concern raised by patients was about the stigma attached to entering retail outlets selling non-medical cannabis. The CMA submits that this concern would be alleviated if the federal government continued the online purchase and mail order system that is currently in place. Given that there is a lack of consensus and insufficient data to calculate how much of the demand for cannabis will be associated with medical authorization, the Task Force recommended that two systems be established, with an obligation to review - specifically, a program evaluation of the medical access framework in five years.11 If there are two systems, then in the alternative, the CMA recommends a review of the legislation within five years. This would allow time to ensure that the provisions of the act are meeting their intended purposes, as determined by research on the efficacy of educational efforts and other research. Five-year legislative reviews have been previously employed, especially where legislation must balance individual choice with protecting public health and public safety.vii For example, like Bill C-45, the purpose of the Controlled Drugs and Substances Act is to protect public health and public safety.27 Its review within five years is viewed as allowing for a thorough, evidence-based analysis to ensure that the provisions and operations of the act are meeting their intended purpose(s).viii Furthermore, a harm reduction approach lends itself to systematic evaluation of the approach's short- and long-term impact on the reduction of harms.5 The CMA, therefore, submits that if a two-system approach is implemented when the legislation is enacted, the legislation should be amended to include the requirement for evaluation within five years of enactment. Criteria for evaluation may include the number of users in the medical system and the number of physicians authorizing medical cannabis use. The CMA would expect to be involved in the determination of such criteria and evaluation process. Conclusion Support has risen steadily in Canada and internationally for the removal of criminal sanctions for simple cannabis possession, as well as for the legalization and regulation of cannabis' production, distribution and sale. The CMA has long-standing concerns about the health risks associated with consuming cannabis, especially by children and youth in its smoked form. Weighing societal trends against the health effects of cannabis, the CMA supports a broad legal-regulatory framework as part of a comprehensive and properly sequenced public health approach of harm reduction. Recommendations 1. The CMA recommends that the legalization age be amended to 21 years of age, to better protect the most vulnerable population, youth, from the developmental neurological harms associated with cannabis use. 2. The CMA recommends that a comprehensive cannabis public health strategy with a strong, effective health education component be implemented before, and no later than, the enactment of any legislation legalizing cannabis. 3a. The CMA recommends that there be only one regime for medical and non-medical use of cannabis, with provisions for the medical needs of those who would not be able to acquire cannabis in a legal manner (e.g., those below the minimum age). 3b. Alternatively, the CMA recommends that the legislation be amended to include a clause to review the legislation, including a review of having two regimes, within five years. i The term cannabis is used as in Bill C-45: that is, referring to the cannabis plant or any substance or mixture that contains any part of the plant. ii The plant contains at least 750 chemicals, of which there are over 100 different cannabinoids. Madras BK. Update of cannabis and its medical use. Agenda item 6.2. 37th Meeting of the Expert Committee on Drug Dependence, Department of Essential Medicines and Health Products, World Health Organization; 2015. Available: www.who.int/medicines/access/controlled-substances/6_2_cannabis_update.pdf (accessed 2017 Jul 27). iii House of Commons Special Committee on the Non-Medical Use of Drugs (2001) and the Senate Special Committee on Illegal Drugs (2002). iv An Act to amend the Contraventions Act and the Controlled Drugs and Substances Act (Bill C-38), which later was reintroduced as Bill C-10 in 2003. v For example, the Substance Use and Addictions Program (SUAP), a federal contributions program, is delivered by Health Canada to strengthen responses to drug and substance use issues in Canada. See Government of Canada. Substance Use and Addictions Program. Ottawa: Health Canada; 2017. Available: www.canada.ca/en/services/health/campaigns/canadian-drugs-substances-strategy/funding/substance-abuse-addictions-program.html (accessed 2017 Jul 27). vi The Federal Tobacco Control Strategy was initiated in 2001 for 10 years and renewed in 2012 for another five years. vii Several federal acts contain review provisions. Some examples include the Controlled Drugs and Substances Act, SC b1996, c 19, s 9 (five-year review); the Preclearance Act, SC 1999, c 20, s 39 (five-year review); the National Defence Act, RSC 1985, c N-5, s 273.601(1) (seven-year review); the Public Servants Disclosure Protection Act, SC 2005, c 46, s 54 (five-year review); and the Red Tape Reduction Act, SC 2015, c 12 (five-year review). viii The 2012 amendments to the Controlled Drugs and Substances Act were adopted from Bill S-10, which died on order papers in March 2011. The Senate Standing Committee on Legal and Constitutional Affairs reviewed Bill S-10 and recommended that the review period should be extended from two to five years as two years is not sufficient to allow for a comprehensive review. See Debates of the Senate, 40th Parliament, 3rd Session, No 147:66 (2010 Nov 17) at 1550; see also Senate Standing Committee on Legal and Constitutional Affairs, Eleventh Report: Bill S-10, An Act to Amend the Controlled Drugs and Substances Act and to Make Related and Consequential Amendments to Other Acts, with Amendments (2010 Nov 4). 1 Canadian Medical Association. Health risks and harms associated with the use of marijuana. CMA submission to the House of Commons Standing Committee on Health. Ottawa: The Association; 27 May 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/Brief-Marijuana-Health_Committee_May27-2014-FINAL.pdf (accessed 2017 Jul 27). 2 Canadian Medical Association. A public health perspective on cannabis and other illegal drugs. CMA submission to the Special Senate Committee on Illegal Drugs. Ottawa: The Association; 11 Mar 2002. Available: http://policybase.cma.ca/dbtw-wpd/BriefPDF/BR2002-08.pdf (accessed 2017 Jul 27). 3 Canadian Medical Association. Bill C-2 An Act to Amend the Controlled Drugs and Substances Act (Respect for Communities Act). CMA submission to the House of Commons Standing Committee on Public Safety and National Security. Ottawa: The Association; 28 Oct 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/CMA_Brief_C-2_Respect%C3%A9-for_Communities_Act-English.pdf (accessed 2017 Jul 27). 4 Harm Reduction International. What is harm reduction? A position statement from Harm Reduction International. London, UK: Harm Reduction International; 2017. Available: www.hri.global/what-is-harm-reduction (accessed 2017 Jul 27). 5 Riley D, O'Hare P. Harm reduction: history, definition and practice. In: Inciardi JA, Harrison LD, editors. Harm reduction: national and international perspectives. Thousand Oaks, CA: Sage Publications; 2000. 6 Fischer B, Russel C, Sabioni P, et al. Lower-risk cannabis use guidelines: a comprehensive update of evidence and recommendations. Am J Public Health 2017;107(8):e1-e12. 7 Canadian Medical Association. Legalization, regulation and restriction of access to marijuana. CMA submission to the Government of Canada - Task Force on Cannabis Legalization and Regulation. Ottawa: The Association; 2016 Aug 29. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/2016-aug-29-cma-submission-legalization-and-regulation-of-marijuana-e.pdf (accessed 2017 Jul 27). 8 Government of Canada. Canadian Tobacco, Alcohol and Drugs Survey (CTADS): 2015 summary. Ottawa: Government of Canada; 2017. Available: www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey/2015-summary.html (accessed 2017 Jul 27). 9 Health Canada. Canadian Alcohol and Drug Use Monitoring Survey (CADUMS): summary of results for 2012. Ottawa: Health Canada; 2014. Available: www.canada.ca/en/health-canada/services/health-concerns/drug-prevention-treatment/drug-alcohol-use-statistics/canadian-alcohol-drug-use-monitoring-survey-summary-results-2012.html (accessed 2017 Jul 27). 10 World Health Organization. The health and social effects of nonmedical cannabis use. Geneva: World Health Organization; 2016. Available: http://apps.who.int/iris/bitstream/10665/251056/1/9789241510240-eng.pdf?ua=1 (accessed 2017 Jul 27). 11 Task Force on Cannabis Legalization and Regulation. A framework for the legalization and regulation of cannabis in Canada: final report. Ottawa: Health Canada; 2016. 12 Government of Canada. Legislative background: an Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts (Bill C-45). Ottawa: Government of Canada; 2017. 13 An Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts, Bill C-45, First Reading 2017 Apr 13. 14 Crean RD, Crane NA, Mason BJ. An evidence based review of acute and long-term effects of cannabis use on executive cognitive functions. J Addict Med 2011;5(1):1-8. 15 Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci USA 2012;109(40):E2657-64 16 Crépault JF, Rehm J, Fischer B. The cannabis policy framework by the Centre for Addiction and Mental Health: a proposal for a public health approach to cannabis policy in Canada. Int J Drug Policy 2016;34:1-4. 17 Pope HG Jr, Gruber AJ, Hudson JI, et al. Early-onset cannabis use and cognitive deficits: What is the nature of the association? Drug Alcohol Depend 2003;69(3):303-310. 18 Gruber SA, Sagar KA, Dahlgren MK, et al. Age of onset of marijuana use and executive function. Psychol Addict Behav 2011;26(3):496-506. 19 National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington (DC): The National Academies Press; 2017. 20 Canadian Cancer Society. 2017 federal pre-budget submission. Canadian Cancer Society submission to the Standing Committee on Finance. 2014 Aug. Available: www.ourcommons.ca/Content/Committee/421/FINA/Brief/BR8398102/br-external/CanadianCancerSociety-e.pdf (accessed 2017 Jul 27). 21 Health Canada. Backgrounder: legalizing and strictly regulating cannabis: the facts. Ottawa: Health Canada; 2017. Available: www.canada.ca/en/health-canada/news/2017/04/backgrounder_legalizingandstrictlyregulatingcannabisthefacts.html (accessed 2017 Jul 27) 22 Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet 2009;374(9698):1383-91. 23 Statistics Canada. Canadian Community Health Survey: Mental Health, 2012. The Daily. 2013 Sep 18. Statistics Canada cat. No. 11-001-X. Available: www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.htm (accessed 2017 Jul 27). 24 Miech RA, Johnston LD, O'Malley PM, Bachman JG, Schulenberg, JE. Monitoring the future national survey results on drug use, 1975-2010. Vol 1: Secondary students. Ann Arbor: Institute for Social Research, University of Michigan; 2011. 25 Spithoff S, Kahan M. Cannabis and Canadian youth: evidence, not ideology. Can Fam Physician 2014;60(9):785-7. 26 Health Canada. Strong foundation, renewed focus: an overview of Canada's Federal Tobacco Control Strategy 2012-2017. Ottawa: Health Canada; 2012. Available: www.canada.ca/content/dam/canada/health-canada/migration/healthy-canadians/publications/healthy-living-vie-saine/tobacco-strategy-2012-2017-strategie-tabagisme/alt/tobacco-strategy-2012-2017-strategie-tabagisme-eng.pdf (accessed 2017 Jul 27). 27 Controlled Drugs and Substances Act, SC 1996, c 19, s 9.

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Meeting the demographic challenge: Investments in seniors care

https://policybase.cma.ca/en/permalink/policy13924

Date
2018-08-03
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2018-08-03
Topics
Population health/ health equity/ public health
Text
Recommendation: That the federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer. The Canadian Medical Association unites physicians on national health and medical matters. Formed in Quebec City in 1867, the CMA’s rich history of advocacy led to some of Canada’s most important health policy changes. As we look to the future, the CMA will focus on advocating for a healthy population and a vibrant profession. Introduction The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission, focused on the major challenges confronting seniors care in Canada. As Canada’s demographic shift advances, the challenge of ensuring quality seniors care will only become more daunting unless governments make critical investments in our health care system today. This is a national issue that will affect all provinces and territories (PTs). However, not all PTs will bear the costs equally. The current federal health transfer system does not take demographics into account. The CMA proposes the federal government fund a share of the health care costs associated with our aging population by means of a new “demographic top-up” to the Canada Health Transfer (CHT). Recommendation: That the federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer. Seniors Care: Challenges and Opportunities Canada, like most OECD economies, is grappling with the realities of a rapidly aging population. The population of seniors over the age of 65 in Canada has increased by 20% since 2011 and it has been projected that the proportion of Canada’s total population over 65 will exceed one-third by 2056 with some provinces like Newfoundland and Labrador reaching that point as soon as the mid-2030s.1 Census figures also show that the fastest growing demographic in Canada between 2011 and 2016 was individuals over 90, growing four times the rate of the overall population during this period.2 These demographic changes have a number of major implications for the future of Canadian society. Chief among them is the new pressure they add to our health care system. As the population ages, it is expected that health care costs will grow at a significantly faster rate than in previous years. As demonstrated in Chart 1 below, population aging will be a top contributor to rising health care costs over the decade ahead. By 2026–27, these increases will amount to $19 billion in additional annual health care costs associated with population aging, as shown in Chart 2. Many seniors experience varying degrees of frailty, which the Canadian Frailty Network (CFN) defines as “a state of increased vulnerability, with reduced physical reserve and loss of function across multiple body systems” that “reduces ability to cope with normal or minor stresses, which can cause rapid and dramatic changes in health.”3 About 75% to 80% of seniors report having one or more chronic conditions.4 It is primarily the care associated with management of these conditions as well as increased residential care needs that drive the higher costs associated with seniors care. The average annual per capita provincial/territorial health spending for individuals age 15 to 64 is $2,700 compared with $12,000 for seniors age 65 and over.5 Our medicare system, which was established over half a century ago, is not designed or resourced to deal with this new challenge. The median age of Canadians at the time of the Medical Care Act’s enactment in 1966 was 25.5 years. It is now 40.6 years and is expected to rise to 42.4 years in the next decade.5 While past governments have placed significant focus on hospital care (acute and sub-acute), transitional care, community supports such as home care and long-term care (LTC) have been largely underfunded. Demographic changes have already begun to place pressure on our health care system, and the situation will only become worse unless funding levels are dramatically raised. Chart 1: Major contributors to rising health care costs (forecast average annual percentage increase, 2017–26)5 Chart 2: Provincial/terrioritial health care costs attributable to population aging ($ billions, all PTs relative to 2016–17 demographics)5 Individuals in Ontario wait a median of 150 days for placement in a LTC home.6 In many communities across the country acute shortages in residential care infrastructure mean that seniors can spend as long as three years on a wait list for LTC.7 Seniors from northern communities are often forced to accept placements hundreds of kilometres from their families.8 The human and social costs of this are self-evident but insufficient spending on LTC also has important consequences for the efficiency of the system as a whole. When the health of seniors stabilizes after they are admitted to hospital for acute care, health care professionals are often confronted with the challenge of finding better living options for their patients. These patients are typically assigned Alternate Level of Care (ALC) beds as they wait in hospital for appropriate levels of home care or access to a residential care home/facility. In April 2016, ALC patients occupied 14% of inpatient beds in Ontario while in New Brunswick, 33% of the beds surveyed in two hospitals were occupied by ALC patients.9 The average length of hospital stay of all ALC patients in Canada is an unacceptable 380 days. Not only does ALC care lead to generally worse health outcomes and patient satisfaction than both LTC and home care, but it is also significantly more expensive. The estimated daily cost of a hospital bed used by a patient is $842, compared with $126 for a LTC bed and $42 per day for care at home.10 Moreover, high rates of ALC patients can contribute to hospital overcrowding, lengthy emergency wait times and cancelled elective surgeries.11 Committing more funding to LTC infrastructure would lead to system-wide improvements in wait times and quality of care by helping to alleviate the ALC problem. A recent poll found that only 49% of Canadians are confident that the health care system will be able to meet senior care needs and that 88% of Canadians support new federal funding measures.12 Fortunately, there have been some signs at both the provincial and federal levels that seniors care has become an issue of increasing importance. New Brunswick recently introduced a caregiver’s benefit while the Ontario government has recently committed to building 15,000 LTC beds over the next decade. The federal government highlighted home care as a key investment area in the most recent Health Accord bilateral agreements and has made important changes to both the Canada Pension Plan (CPP) and Old Age Security (OAS) programs. The Demographic Top-Up: Modernizing the CHT Despite these recent and important initiatives by governments in Canada, additional policy and fiscal measures will be needed to address the challenges of an aging population. Many provincial governments have shown a clear commitment to the issue, but the reality is that their visions for better seniors care will not come to fruition unless they are backed up by appropriate investments. This will not be possible unless the federal government ensures transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Projections in a recent report by the Conference Board of Canada, commissioned by the CMA, indicate that health transfers are expected to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.3 Over the next decade, unless changes are made, provinces/territories will need to assume an increasingly larger share of health care costs. If federal health transfers do not account for population aging, the federal share of health care spending will fall below 20% by 2026.5 Aging will affect some provinces more than others, as demonstrated in Figure 1 below. The overall cost of population aging to all of the provinces and territories is projected to be $93 billion over the next decade.5 The absence of demographic considerations in transfer calculations therefore indirectly contributes to regional health inequality as provinces will not receive the support they need to ensure that seniors can count on quality care across Canada. Figure 1: Increases in health care costs associated with population aging, 2017 to 2026 ($ billions)5 The CMA recommends that the federal government address the health costs of population aging by introducing a “demographic top-up” to the Canada Health Transfer. One model for this would require the federal government to cover a share of the costs projected to be added by population aging in each province/territory (see above) equal to the federal share of total health costs covered now (22%). The Conference Board of Canada estimates that the overall cost of such a change would be $21.1 billion over the next decade (see Table 1). This funding would greatly enhance the ability of the provinces and territories to make much-needed investments in seniors care and the health care system as a whole. It could be used to support the provinces’ and territories’ efforts to address shortages in LTC, to expand palliative care and home care supports and to support further innovation in the realm of seniors care. Table 1: Cost of demographic top-Up by province in $ millions5 Conclusion The evidence that our health care systems are not prepared or adequately funded to ensure appropriate and timely access to seniors care, across the continuum of care, is overwhelming. Wait times for LTC and home care are unacceptably high and complaints about lack of availability in Northern and rural communities are becoming increasingly common. Health care providers in the LTC sector regularly raise concern about overstretched resources and a lack of integration with the rest of the health care system. By introducing a new demographic top-up to the Canada Health Transfer, the federal government would demonstrate real leadership by ensuring that all provinces/territories are able to adapt to an aging population without eroding quality of care. Furthermore, improvements in how we care for our seniors will lead to improvements for patients and caregivers of all ages through greater system efficiencies (e.g., shorter wait times for emergency care and elective surgeries) and more coordinated care. The CMA has been, and will continue to be, a tireless advocate for improving seniors care in Canada. The CMA would welcome opportunities to provide further information on the recommendation outlined in this brief. References 1Statistics Canada. Age and sex, and type of dwelling data: key results from the 2016 Census. Ottawa: Statistics Canada; 2017. Available: https://www150.statcan.gc.ca/n1/daily-quotidien/170503/dq170503a-eng.htm 2Ministry of Finance Ontario. 2016 Census highlights, fact sheet 3. Toronto: Office of Economic Policy, Labour Economics Branch; 2017. Available: www.fin.gov.on.ca/en/economy/demographics/census/cenhi16-3.html. 3Canadian Frailty Network. What is frailty? Kingston: The Network; 2018. Available: www.cfn-nce.ca/frailty-in-canada/ 4Canadian Institute for Health Information (CIHI). Health care in Canada, 2011: a focus on seniors and aging. Available: https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf 5The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018. Available: www.cma.ca/En/Lists/Medias/Conference%20Board%20of%20Canada%20-%20Meeting%20the%20Care%20Needs%20of%20Canada%27s%20Aging%20Population.PDF 6Health Quality Ontario. Wait times for long-term care homes. Available: www.hqontario.ca/System-Performance/Long-Term-Care-Home-Performance/Wait-Times 7Crawford B. Ontario’s long-term care problem: seniors staying at home longer isn’t a cure for waiting lists. Ottawa Citizen 2017 Dec 22. Available: https://ottawacitizen.com/news/local-news/ontarios-long-term-care-problem-seniors-staying-at-home-longer-isnt-a-cure-for-waiting-lists 8Sponagle J. Nunavut struggles to care for elders closer to home. CBC News 2017 Jun 5. Available: www.cbc.ca/news/canada/north/nunavut-seniors-plan-1.4145757 9McCloskey R, Jarrett P, Stewart C, et al. Alternate level of care patients in hospitals: What does dementia have to do with this? Can Geriatr J. 2014;17(3):88–94. 10Home Care Ontario. Facts and figures – publicly funded home care. Hamilton: Home Care Ontario; n.d. Available: www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare 11Simpson C. Code gridlock: why Canada needs a national seniors strategy. Ottawa: Canadian Medical Association; 2014. Available: www.cma.ca/En/Lists/Medias/Code_Gridlock_final.pdf 12Ipsos Public Affairs. Just half of Canadians confident the healthcare system can meet the needs of seniors. Toronto: Ipsos; 2018. Available: www.ipsos.com/en-ca/news-polls/Canadian-Medical-Association-Seniors-July-17-2018

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Maintaining Ontario’s leadership on prohibiting the use of sick notes for short medical leaves

https://policybase.cma.ca/en/permalink/policy13934

Date
2018-11-15
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2018-11-15
Topics
Physician practice/ compensation/ forms
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) submits this brief to the Standing Committee on Finance and Economic Affairs for consideration as part of its study on Bill 47, Making Ontario Open for Business Act, 2018. The CMA unites physicians on national, pan-Canadian health and medical matters. As the national advocacy organization representing physicians and the medical profession, the CMA engages with provincial/territorial governments on pan-Canadian health and health care priorities. As outlined in this submission, the CMA supports the position of the Ontario Medical Association (OMA) in recommending that Schedule 1 of Bill 47 be amended to strike down the proposed new Section 50(6) of the Employment Standards Act, 2000. This section proposes to reinstate an employer’s ability to require an employee to provide a sick note for short leaves of absence because of personal illness, injury or medical emergency. Ontario is currently a national leader on sick notes In 2018, Ontario became the first jurisdiction in Canada to withdraw the ability of employers to require employees to provide sick notes for short medical leaves because of illnesses such as a cold or flu. This legislative change aligned with the CMA’s policy position1 and was strongly supported by the medical and health policy community. An emerging pan-Canadian concern about the use of sick notes As health systems across Canada continue to grapple with the need to be more efficient, the use of sick notes for short leaves as a human resources tool to manage employee absenteeism has drawn increasing criticism in recent years. In addition to Ontario’s leadership, here are a few recent cases that demonstrate the emerging concern about the use of sick notes for short leaves:
In 2016, proposed legislation to end the practice was tabled in the Manitoba legislature.2
The Newfoundland and Labrador Medical Association and Doctors Nova Scotia have been vocal opponents of sick notes for short leaves, characterizing them as a strain on the health care system.3,4
The University of Alberta and Queen’s University have both formally adopted “no sick note” policies for exams.5,6
The report of Ontario’s Changing Workplaces Review summarized stakeholder comments about sick notes, describing them as “costly, very often result from a telephone consultation and repeat what the physician is told by the patient, and which are of very little value to the employer.”7 Ontario’s action in 2018 to remove the ability of employers to require sick notes, in response to the real challenges posed by this practice, was meaningful and demonstrated leadership in the national context. The requirement to obtain sick notes negatively affects patients and the public By walking back this advancement, Ontario risks reintroducing a needless inefficiency and strain on the health system, health care providers, their patients and families. For patients, having to produce a sick note for an 4 employer following a short illness-related leave could represent an unfair economic impact. Individuals who do not receive paid sick days may face the added burden of covering the cost of obtaining a sick note as well as related transportation fees in addition to losing their daily wage. This scenario illustrates an unfair socioeconomic impact of the proposal to reinstate employers’ ability to require sick notes. In representing the voice of Canada’s doctors, the CMA would be remiss not to mention the need for individuals who are ill to stay home, rest and recover. In addition to adding a physical strain on patients who are ill, the requirement for employees who are ill to get a sick note, may also contribute to the spread of viruses and infection. Allowing employers to require sick notes may also contribute to the spread of illness as employees may choose to forego the personal financial impact, and difficulty to secure an appointment, and simply go to work sick. Reinstating sick notes contradicts the government’s commitment to end hallway medicine It is important to consider these potential negative consequences in the context of the government’s commitment to “end hallway medicine.” If the proposal to reintroduce the ability of employers to require sick notes for short medical leaves is adopted, the government will be introducing an impediment to meeting its core health care commitment. Reinstating sick notes would increase the administrative burden on physicians Finally, as the national organization representing the medical profession in Canada, the CMA is concerned about how this proposal, if implemented, may negatively affect physician health and wellness. The CMA recently released a new baseline survey, CMA National Physician Health Survey: A National Snapshot, that reveals physician health is a growing concern.8 While the survey found that 82% of physicians and residents reported high resilience, a concerning one in four respondents reported experiencing high levels of burnout. How are these findings relevant to the proposed new Section 50(6) of the Employment Standards Act, 2000? Paperwork and administrative burden are routinely found to rank as a key contributor to physician burnout.9 While a certain level of paperwork and administrative responsibility is to be expected, health system and policy decision-makers must avoid introducing an unnecessary burden in our health care system. Conclusion: Remove Section 50(6) from Schedule 1 of Bill 47 The CMA appreciates the opportunity to provide this submission for consideration by the committee in its study of Bill 47. The committee has an important opportunity to respond to the real challenges associated with sick notes for short medical leaves by ensuring that Section 50(6) in Schedule 1 is not implemented as part of Bill 47. 5 1 Canadian Medical Association (CMA). Third-Party Forms (Update 2017). Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD17-02.pdf (accessed 2019 Nov 13). 2 Bill 202. The Employment Standards Code Amendment Act (Sick Notes). Winnipeg: Queen’s Printer for the Province of Manitoba; 2016. Available: https://web2.gov.mb.ca/bills/40-5/pdf/b202.pdf (accessed 2019 Nov 13). 3 CBC News. Sick notes required by employers a strain on system, says NLMA. 2018 May 30. Available: www.cbc.ca/news/canada/newfoundland-labrador/employer-required-sick-notes-unnecessary-says-nlma-1.4682899 4 CBC News. No more sick notes from workers, pleads Doctors Nova Scotia. 2014 Jan 10. Available: www.cbc.ca/news/canada/nova-scotia/no-more-sick-notes-from-workers-pleads-doctors-nova-scotia-1.2491526 (accessed 2019 Nov 13). 5 University of Alberta University Health Centre. Exam deferrals. Edmonton: University of Alberta; 2018. Available: www.ualberta.ca/services/health-centre/exam-deferrals (accessed 2019 Nov 13). 6 Queen’s University Student Wellness Services. Sick notes. Kingston: Queen’s University; 2018. Available: www.queensu.ca/studentwellness/health-services/services-offered/sick-notes (accessed 2019 Nov 13). 7 Ministry of Labour. The Changing Workplaces Review: An Agenda for Workplace Rights. Final Report. Toronto: Ministry of Labour; 2017 May. Available: https://files.ontario.ca/books/mol_changing_workplace_report_eng_2_0.pdf (accessed 2019 Nov 13). 8 Canadian Medical Association (CMA). One in four Canadian physicians report burnout [media release]. Ottawa: The Association; 2018 Oct 10. Available: www.cma.ca/En/Pages/One-in-four-Canadian-physicians-report-burnout-.aspx (accessed 2019 Nov 13). 9 Leslie C. The burden of paperwork. Med Post 2018 Apr.

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