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Achieving Patient-Centred Collaborative Care

https://policybase.cma.ca/en/permalink/policy9060

Last Reviewed
2019-03-03
Date
2007-12-01
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2007-12-01
Topics
Health systems, system funding and performance
Text
ACHIEVING PATIENT-CENTRED COLLABORATIVE CARE (2008) The Canadian Medical Association (CMA) recognizes that collaborative care is a desired and necessary part of health care delivery in Canada and an important element of quality, patient-centred care. The CMA considers patient-centred care to be the cornerstone of good medical practice. This is reflected in the first principle of the CMA Code of Ethics, which states that physicians have a fundamental responsibility to "Consider first the well-being of the patient." As patient advocates, physicians strive to ensure that their patients receive the best possible care. The CMA supports greater collaboration among providers in the interest of better patient care. In the context of clinical practice, the CMA defines collaborative care as follows: "Collaborative care entails physicians and other providers using complementary skills, knowledge and competencies and working together to provide care to a common group of patients based on trust, respect and an understanding of each others' skills and knowledge. This involves a mutually agreed upon division of roles and responsibilities that may vary according to the nature of the practice personalities and skill sets of the individuals. The relationship must be beneficial to the patient, and acceptable to the physician and other providers. If designed appropriately, collaborative care models have the potential to: * improve access to care; * enhance the quality and safety of care; * enhance the coordination and efficiency of care; and * enhance provider morale and reduce burnout within health professions. To realize this full potential, the profession acknowledges and accepts that it has a central role to play in the evolution of a team-based approach to care. These policy principles have been prepared by the Canadian Medical Association in order to ensure that the evolution of collaborative care in Canada is built around the needs of individual patients and groups of patients. This policy is founded on the CMA's document, Putting Patients' First: Patient-Centred Collaborative Care - A Discussion Paper. Principles for Collaborative Care The medical profession supports collaborative care, both in the hospital and in the community, as one of the essential elements of health care delivery in Canada. In the interests of enhancing the evolution of patient-centred collaborative care, the CMA proposes the following "critical success factors" and principles to address meaningfully the issues and barriers identified by physicians and bring clarity to the discussions. 1. PATIENT-CENTRED CARE First and foremost, medical care delivered by physicians and health care delivered by others should be aligned around the values and needs of patients. Collaborative care teams should foster and support patients, and their families, as active participants in their health care decision-making. New models should have the potential to empower patients to enhance their role in prevention and self-care. Models of collaborative care must be designed to meet the needs of patients. Collaborative models of practice must reduce fragmentation and enhance the quality and safety of care provided to patients. It is the patient who ultimately must make informed choices about the care he or she will receive. 2. RECOGNITION OF THE PATIENT-PHYSICIAN RELATIONSHIP The mutual respect and trust derived from the patient-physician relationship is the cornerstone of medical care. This trust is founded on the ethical principles that guide the medical profession as defined in the CMA Code of Ethics. The impact of collaborative models of practice on this relationship, and hence the patient's satisfaction and experience with their care, is unknown. Models of collaborative care must support the patient-physician relationship. Entry into and exit from a formal collaborative care arrangement must be voluntary for both the patient and the physician. A common Code of Ethics should guide the practice of collaborative care teams. Every resident of Canada has the right to access a personal family physician. † 3. PHYSICIAN AS THE CLINICAL LEADER Effective teams require effective leadership. A defined clinical leader is required to ensure proper functioning of the team and to facilitate decision-making, especially in complex or emergent situations. In collaborative care the clinical leader is responsible for maximizing the expertise and input of the entire team in order to provide the patient with comprehensive and definitive care. It is important to differentiate "clinical leadership" from "team coordination." The CMA defines a clinical leader as: "The individual who, based on his or her training, competencies and experience, is best able to synthesize and interpret the evidence and data provided by the patient and the team, make a differential diagnosis and deliver comprehensive care for the patient. The clinical leader is ultimately accountable to the patient for making definitive clinical decisions." Whereas, the team coordinator is defined as: "The individual, who, based on his or her training, competencies and experience, is best able to coordinate the services provided by the team so that they are integrated to provide the best care for the patient." The concept of "most responsible physician" has been and continues to be used to identify the individual who is ultimately responsible for the care of the patient. The "most responsible physician" is responsible for collecting, synthesizing and integrating the expert opinion of physician and non physician team members to determine the clinical management of the patient. Similarly, the presence of a defined clinical leader in a collaborative care setting creates clarity for patients, their families and the health care team by making lines of communication and responsibility clear, ultimately improving the quality and safety of care. In the CMA's opinion, the physician is best equipped to provide clinical leadership. This does not necessarily imply that a physician must be the team coordinator. Many teams will exist in which the physician will have a supporting role, including those focused on population health and patient education. We believe the most effective teams are ones in which the leadership roles have been clearly defined and earned. Some physicians may be prepared to play both roles; however, other members of the team may be best suited to serve as team coordinator. Currently, patients rely on, and expect, physicians to be clinical leaders in the assessment and delivery of the medical care they receive. In a collaborative care environment this expectation of physician leadership will not change. Team members will have specific knowledge and expertise in their respective disciplines. Physicians, by virtue of their broad and diverse knowledge, training and experience, have a unique appreciation of the full spectrum of health and health care delivery in their field of practice and are therefore best qualified to evaluate and synthesize diverse professional perspectives to ensure optimal patient care. The physician, by virtue of training, knowledge, background and patient relationship, is best positioned to assume the role of clinical leader in collaborative care teams. There may be some situations in which the physician may delegate clinical leadership to another health care professional. Other health care professionals may be best suited to act as team coordinator. 4. MUTUAL RESPECT AND TRUST Trust between individuals and provider groups evolves as knowledge and understanding of competencies, skills and scopes of practice are gained. Trust is also essential to ensuring that the team functions efficiently and maximizes the contributions of all members. Funders and providers should recognize the importance of team building in contributing to team effectiveness. Collaborative care funding models should support a more formalized and integrated approach to both change management and team building. As relationships are strengthened within the team, so too are trust and respect. Physicians and all team members have an opportunity to be positive role models to motivate and inspire their colleagues. All team members ought to make a commitment to respect and trust each other with the knowledge that it will lead to enhanced care for patients and a more productive work environment for all. To serve the health care needs of patients, there must be a collaborative and respectful interaction among health care professionals, with recognition and understanding of the contributions of each provider to the team. In order to build trust and respect within the team it is essential that members understand and respect the professional responsibility, knowledge and skills that come with their scope of practice within the context of the team. 5. CLEAR COMMUNICATION In collaborative care environments, it is essential that all members of the team communicate effectively to provide safe and optimal care. Effective communication is essential to ensure safe and coordinated care as the size of the team expands to meet patient needs. It is the responsibility of all team members to ensure that the patient is receiving timely, clear and consistent messaging. Physicians can take a leadership role in modeling effective communications throughout the team. In particular, there is an opportunity to enhance the consultation and referral process, in order to provide clear and concise instructions to colleagues and optimize care. Sufficient resources, including dedicated time and support, must be available to the team to maximize these communication requirements. Effective communication within collaborative care teams is critical for the provision of high quality patient care. Planning, funding and training for collaborative care teams must include measures to support communication within these teams. Mechanisms must be in place within a collaborative team to ensure that both the patients, and their caregiver(s) where appropriate, receive timely information from the most appropriate provider. Effective and efficient communications within the collaborative care team, both with the patient and among team members, should be supported by clear documentation that identifies the author. A common, accessible patient record in collaborative care settings is desirable to ensure appropriate communication between physicians and other health care professionals, to prevent duplication, coordinate care, share information and protect the safety of patients. An integrated electronic health record is highly desirable to facilitate communication and sharing among team members. 6. CLARIFICATION OF ROLES AND SCOPES OF PRACTICE In order for the team to function safely and efficiently, it is critically important that the scope of practice, roles and responsibilities of each health care professional on the team be clearly defined and understood. In turn, the patient, as a team member, should also have a clear understanding of the roles and scopes of practice of their providers. Collaborative care must first and foremost serve the needs of patients, with the goal of enhancing patient care; collaborative care is not contingent upon altering the scope of practice of any provider group and must not be used as a means to expand the scope of practice and/or independence of a health professional group. Changes in the scope of practice of all provider groups must be done with oversight from the appropriate regulatory authority. Where non-physicians have been provided with an opportunity to undertake activities related to patient care typically unique to the practice of medicine (e.g., ordering tests), they must not do so independently but undertake these activities within the context of the team and in a manner acceptable to the clinical leader. The role and scope of practice of each member of the collaborative care team should be clearly understood and delineated in job descriptions and employment contracts. A formal process for conflict resolution should be in place so that issues can be dealt with in a timely and appropriate manner. 7. CLARIFICATION OF ACCOUNTABILITY AND RESPONSIBILITY In the context of providing optimal care, providers must be accountable and responsible for the outcome of their individual practice, while sharing responsibility for the proper functioning of the collaborative care team. This individual responsibility is required so that regardless of the number and diversity of providers involved in the team, patients can be assured that their well-being is protected and that the team is working toward a common goal. In collaborative care teams, a physician should be identified as the person most responsible for the clinical care of individual patients, and as such must be accountable for the care rendered to patients. This is consistent with the commitment made by the physician in the doctor-patient relationship, mirrors the clinical training of the physician relative to other providers, is reflective of the current state of tort law as it applies to medical practice, and is compatible with the structure of care delivery in hospitals and in the community. Clearly, this type of arrangement does not eliminate the necessity for all providers to be accountable for the care that they provide. It is essential that all providers be responsible and accountable for the care that they provide and for the well-being of the patient. As clinical leader, the physician should be responsible for the clinical oversight of an individual patient's care. 8. LIABILITY PROTECTION FOR ALL MEMBERS OF THE TEAM As discussed earlier in this paper, the resolution of the multiplicity of liability issues that result from care delivered by teams requires clearly defined roles and responsibilities in the team setting and the absolute requirement for appropriate and sufficient liability coverage for each health professional. The August 2006 statement of the Canadian Medical Protective Association, Collaborative Care: A medical liability perspective, identifies issues of concern to physicians and proposes solutions to reduce those risks. All members of a collaborative care team must have adequate professional liability protection and/or insurance coverage to accommodate their scope of practice and their respective roles and responsibilities within the collaborative care team. Physicians, in their role as clinical leaders of collaborative care teams, must be satisfied with the ongoing existence of appropriate liability protection as a condition of employment of, or affiliation with, other members on collaborative care teams. Formalized procedures should be established to ensure evidence of this liability protection. 9. SUFFICIENT HUMAN RESOURCES AND INFRASTRUCTURE Collaborative models of health care delivery hold the promise of enhancing access to care for patients at a time of serious health human resource shortages. However, effective patient-centred collaborative care depends on an adequate supply of physicians, nurses and other providers. Governments and decision-makers must continue to enhance their efforts to increase the number of physicians and nurses available to provide health care services. Collaborative care should not be seen as an opportunity for governments to substitute one care provider for another simply because one is more plentiful or less costly than the other. In addition, governments must understand that co-location of individuals in a team is not a requirement for all collaborative care. Where team co-location does not exist, appropriate resources must be dedicated to ensure communication can be timely, effective and appropriate between providers. Governments, at all levels, must address the serious shortage of physicians to ensure quality patient care for Canadians. The effective functioning of a collaborative care team depends on the contribution of a physician. Governments must enhance access to medical care by increasing the number of physicians and providers, and not by encouraging or empowering physician substitution. 10. SUFFICIENT FUNDING & PAYMENT ARRANGEMENTS Funding must be present to support all aspects of the development of collaborative care teams. At the practice level, remuneration methods for physicians, irrespective of their specialty, must be available to facilitate collaborative care arrangements and environments in which physicians practice. All care delivery models, including collaborative care teams, must have access to adequate and appropriate resources. This includes, but should not be limited to, funding for health human resources, administration/management infrastructure, liability protection, clinical and team/administrative training, team building, and information technology. Remuneration models should be established in a manner that encourages providers to participate effectively in the delivery of care and team effectiveness. Reimbursement models must be configured to remunerate the communicator, coordinator, manager, and other roles and responsibilities of providers necessary for the success of collaborative care practice. The ability of a physician to work in a collaborative care team must not be based on the physician's choice of remuneration. Similarly, patients should not be denied access to the benefits of collaborative practice as a result of the physician's choice of payment model. Collaborative care relationships between physicians and other health care providers should continue to be encouraged and enhanced through appropriate resource allocation at all levels of the health care system. Physicians should be appropriately compensated for all aspects of their clinical care and leadership activities in collaborative care teams. Physicians should not be expected to incur the cost of adopting and maintaining health information technology capabilities that facilitate their ability to participate in collaborative practice teams. Governments must fund and support in an ongoing manner, both financially and technically, the development and integration of electronic health records. 11. SUPPORTIVE EDUCATION SYSTEM Canada is renowned for a quality medical education system and for the early efforts to enhance interprofessional training. The success of collaborative care requires a commitment towards interprofessional education and is contingent upon the positive attitudes and support of educators. To facilitate a sustainable shift toward collaborative practice, these efforts must be continued and enhanced in a meaningful way. However, governments and educators must ensure that the availability and quality of medical education is not compromised for medical trainees. Interprofessional education, at the undergraduate, postgraduate and continuing education levels, is necessary to facilitate a greater understanding of the potential roles, responsibilities and capabilities of health professions, with the overall goal of building better health care teams founded on mutual respect and trust. Governments must understand the importance of interprofessional education and fund educational institutions appropriately to meet these new training needs. Educational opportunities must exist at all levels of training to acquire both clinical knowledge and team effectiveness/leadership training. Interprofessional education opportunities must not come at the expense of core medical training. High quality medical education must be available to all medical trainees as a first priority. 12. RESEARCH AND EVALUATION More research and evaluations are necessary to demonstrate the benefits of collaborative care, to foster greater adoption by providers and to attract the necessary investment by governments. Quality management systems must be built into the team to ensure efficiencies can be recorded. Measures of the quality of care, cost effectiveness and patient and provider satisfaction should be evaluated. Research into the effectiveness of collaborative care models on health outcomes, patient and provider satisfaction and health care cost effectiveness should be ongoing, transparent and supported by governments. Quality assessment measures must be incorporated into the ongoing work of collaborative care teams. † Where the term "family physician" is used, it is also meant to include general practitioners.

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The built environment and health

https://policybase.cma.ca/en/permalink/policy11063

Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Population health/ health equity/ public health
Text
The Built Environment is part of the overall ecosystem of our earth. It encompasses all the buildings, spaces and products that are created, or at least significantly modified by people. It includes our homes, schools and workplaces, parks, business areas and roads. It extends overhead in the form of electric transmission lines, underground in the form of waste disposal sites and subway trains and across the country in the form of highways (Health Canada, 1997)." The built environment affects every one of us every day, and mounting evidence suggests that it can play a significant role in our state of health and well-being. This policy statement provides the perspective of the Canadian Medical Association on how the built environment can influence health, and what all sectors in society might do to ensure that community design and development takes the health of residents into consideration. Background In the 19th century, the industrial revolution attracted hordes of people into cities. Congestion, squalid living conditions, and lack of clean water, clean air, and proper sewage systems led to outbreaks of diseases such as cholera and tuberculosis. These events, coupled with the development of the germ theory, served as a catalyst for public and professional awareness of how the built environment has direct health impacts; clean water, fresh air, uncongested living conditions, and proper housing were all recognized as constituents of good health. During the past three decades, the 'Healthy Cities' movement has brought a renewed interest to the health implications of the built environment by focusing on disease prevention through community design. Over the years this idea has proliferated, and a body of literature has grown revealing the large scope of health risk factors that may be influenced by the built environment. The literature indicates that the following connections between the built environment and public health are possible: o Decreased physical activity o Increased prevalence of obesity o Increased prevalence of asthma and other respiratory diseases o Injuries and unintended fatalities o Heat exposure. (Frank , Kavage S, & Devlin A, 2012) (Franks, Kavage & Devlin, 2012; Health Canada 2013) There is also mounting evidence that these factors may be compounded for vulnerable populations such as children, the elderly, and those living in poverty. Smart Growth is an urban planning and transportation theory that became popular almost two decades ago. Though different organizations may differ slightly in their view of what smart growth means, its general aims are to build compact accessible cities that avoid urban sprawl and mitigate auto-dependence. The 'Smart Growth' movement contains tenets that research supports in creating healthy built environments such as mixed land uses, providing transportation alternatives like walking and bicycle infrastructure and public transit, and creating walkable neighbourhoods. (Smart Growth BC, 2012)(See definitions) What the Research Is Telling Us Physical Activity Canada's physical activity guidelines recommend that children from 5 to 11 should be active for at least 60 minutes a day; those 18 and over should be active for at least 150 minutes per week. (Canadian Society of Exercise Physiology, 2011). Participation in regular physical activity bestows substantial health benefits; it can lengthen and improve quality of life and reduce the risk for many physical and mental health conditions. Physical activity can improve overall fitness, lower risk for heart disease, stroke, and high blood pressure, lower risk for non-insulin dependent diabetes and the risk of overweight. (Dannenberg, Frumkin, & Jackson, 2011) Physical activity includes more than exercise and leisure time activity, it also includes active transportation such as walking to school, work or errands as part of daily living. One of the most important determinants of physical activity is a person's neighbourhood. (Jackson & Kochtotzky) Research shows that urban sprawl, access to parks and recreation/fitness facilities, and neighbourhood walkability all may have an impact on physical activity levels (Cutts, Darby, Boone, & Brewis, 2009; Ewing, Schmid, Killingsworth, Zlot, & Raudenbush, 2003). Individuals living in walkable neighbourhood with a mix of land uses and interconnected street networks were found to be 2-4 times more likely to achieve 30 minutes moderate physical activity a day. Urban design characteristics associated with higher physical activity rates include pedestrian-oriented street and site design, parks, trails, playgrounds and other recreational facilities within walking distance and sidewalks. (Frank , Kavage S, & Devlin A, 2012) A barrier to physical activity can be the perception of the lack of a safe place to be active. Safety concerns keep 1 in 5 Canadians from walking or bicycling. Urban design that encourages walking and cycling can improve perceived neighbourhood safety. (Heart and Stroke Foundation of Canada, 2011) There are unique barriers to active modes of transportation in rural communities. Rural environments often lack pedestrian facilities and bike lanes; stores, schools, jobs, and services are sometimes located far apart from homes; and parks and recreation facilities are rare. Understanding these barriers is the first step towards finding opportunities to remove them. (Active Living Research and the Public Health Institute, 2013) CMA' policy on Active Transportation recommends that all sectors (government, business and the public) work together, as a matter of priority, to create a culture in their communities that supports and encourages active transportation and physical activity. Increased prevalence of obesity Obesity has almost doubled in the past 3 decades; in 1978 the measured obesity rate was 13.8% and in 2008 the measured obesity rate was 25.4% (PHAC/CIHI, 2011). Obesity is associated with high blood pressure, stroke, and heart disease, which are among the leading causes of disability and death (Statistics Canada, 2008). Mental health conditions, type II diabetes, several types of cancer, among many other diseases, are also linked to obesity (Guh, Zhang, Bansback, Amarsi, Birmingham, & Anis, 2009). The combined cost of obesity and these related conditions was estimated to be $4.3 billion dollars in 2005 (Public Health Agency of Canada, 2012). There are many factors involved in this increase, but a causal indicator is the decline in physical activity among Canadians: In 2005, 47% of Canadians were reported as being 'inactive' (Human Resource and Skills Development Canada, 2006). Urban design that encourages sedentary living habits such as work, home, school and shopping separated by distances that discourage walking, parking lots built as close as possible to final destinations not only discourage walking but encourage automobile usage. (Jackson, Kochtitzky, CDC) Less walkable, auto dependent built environments have been correlated with higher body weights and obesity. (Frank , Kavage S, & Devlin A, 2012) Furthermore, research indicates that the food environment that we live in, and the amount of healthy food choices we have access to, can affect the chance of becoming obese as well. For example, neighbourhoods with a high density of fast food restaurants or neighbourhoods with poor access to grocery stores (food deserts) have both been correlated with obesity (Larsen & Gilliland, 2008; Cummins & Macintyre, 2006; Frank L. D., 2009). Increased prevalence of asthma and other respiratory diseases In August 2008, the CMA released a report estimating that the effects of air pollution would result in 11,000 hospital admissions and 21,000 deaths Canada wide, totaling a financial cost of close to $8.1 billion dollar (Canadian Medical Association, 2008). Carbon monoxide, sulfur and nitrogen oxides, volatile organic compounds, ozone, and lead, among other toxins, are emitted into the air every day from industrial processes and car exhaust. These air-borne chemicals are associated with heart disease, cancer, acute respiratory illness, and the aggravation of other respiratory illnesses such as asthma (Frank L. D., 2009). While the built environment does not directly produce these chemicals, it has a role to play in where those chemicals are emitted, where they are concentrated, and, in the case of vehicles, how much of them are produced. Urban sprawl has been tied to longer commute times and higher total vehicle miles traveled per person. Neighbourhood design and walkability have been identified as factors that can affect number of vehicle trips taken and transportation mode choice, and increased mixed land use has been identified as a factor that could further decrease emission rates (Newman & Kenworthy, 1989; Frank, Sallis, Conway, Chapman, Saelens, & Bachman, 2006). Injuries and unintentional fatalities Transport-related injuries accounted for a total of $3.7 billion dollars in healthcare costs in Canada in 2009 (SmartRisk, 2009). The majority of this financial burden was related to motor vehicle, pedestrian, and cycling accidents. Death and injuries from these types of incidents typically happen at a younger age which both increases the years of life lost due to death or disability and the financial burden of continuing care (SmartRisk, 2009). The built environment perhaps has the most identifiable and direct correlation to this category of impacts. Designs of auto-oriented environments that promote high traffic volume, high traffic speed, and low accessibility for pedestrians and cyclists lead to increased incidence of injuries and fatalities (Surface Transportation Policy Partnership, 2002). Increased prevalence of illness and death related to heat exposure The 'urban heat island effect' is a phenomenon correlated with urban environments that are primarily asphalt and concrete and lack vegetation and green space. Such environments have been estimated to have anywhere from 1oC to 12oC higher surface level temperatures in comparison to rural areas (United States Environmental Protection Agency, 2012). This can be especially dangerous for elderly individuals in the summertime and studies have demonstrated increased mortality amongst these populations during hot summers (Centers for Disease Control and Prevention, 2009). This is not only an issue of building materials and the balance of green space but has to do with isolation as well: If elderly residents have poor access to public transportation they may not be able to reach air-conditioned facilities. Noise Exposure Noise - be it from transport, industry, neighbours, or construction - is a prominent feature of the urban environment. Prolonged exposure to environmental noise has been directly linked to physical and psychosocial health outcomes, including hypertension, high blood pressure and heart disease, hearing impairment, stress levels, and sleep. There is some evidence linking noise to reduced ability to concentrate and more aggressive behavior. (Stansfeld SA, 2003) In general, denser neighbourhoods have higher levels of ambient noise through the concentration of more people, traffic, and activities. However, as with air pollution, noise exposure is extremely site-specific and not necessarily exclusive to walkable or auto-oriented neighbourhoods. (Frank , Kavage S, & Devlin A, 2012) Canadian noise mapping data would assist researchers in assessing how environmental noise affects health and assist communities to proactively manage noise pollution. Vulnerable populations The research shows that certain built environment characteristics may affect specific populations such as children, the elderly, low-income populations. Children: Overweight and obesity is an issue for Canadians nationwide, but particularly so for children. Between 1978 to 2004 there was a 70% increase in overweight and obese children aged 12-17 (Statistics Canada, 2006). Obesity in children can lead to health issues such as hypertension, glucose intolerance, and orthopedic complications (Statistics Canada, 2006). Furthermore obesity in childhood has a high likelihood of carrying over into adulthood and may result in further health problems such as diabetes and heart disease (Statistics Canada, 2006). With this in mind, environments that promote physical activity are especially important for this segment of the population. Living in mixed use communities with walkable destinations, parks and recreational facilities is related to greater physical activity. (Dannenburg, Frumkin & Jackson, 2011) Elderly: The elderly population is generally less physically robust and more prone to chronic illnesses, which make them especially vulnerable to air pollution and heat exposure. Physical activity is an important aspect of daily life for this age group as it has been shown to reduce the negative health impacts of aging (Vogel, Brechat, Lepetre, Kaltenbach, Berthel, & Lonsdorfer, 2009). Being physically active however, requires accessible and safe streets that cater to the needs of individuals with mobility issues. Special consideration is required when constructing the built environment to ensure the needs of this growing population. CMA's policy on Health and Health Care Principles for an Aging Population recommends that communities take the needs and potential limitations of older Canadians into account when designing buildings, walkways, transportation systems or other aspects of the built environment. Low Income Populations: Low income populations are at higher risk for chronic illnesses such as high blood pressure and diabetes, and have a lower overall survivability for major heart attacks (Centre for Chronic Disease Prevention and Control. , 2002; Statistics Canada, 1996-97). They are also more likely to smoke, be overweight or obese, and are less likely to be physically active (Creatore, Gozdyra, Booth, & Glazier, 2007). Many of these factors may be due to limited access to stable housing, housing location (normally close to highways or industrial zones with high pollution exposure), neighbourhood safety, and lack of access to or affordability of healthy food options. Recommendations Planning and public health combined efforts in the 19th century to improve living conditions. Today there is a need for health care practitioners, particularly those in the public health field, and community planners to work together, to share their expertise and efforts, to improve the health and well-being of Canadians. By designing communities that encourage and support healthy living - physical activity, healthy weights, access to healthy foods - we can address some of the risk factors for many chronic diseases and create supportive, active communities. Health Care Associations can: o Advocate for health supportive environments by increasing the public and policy makers' understanding of the impact of the built environment on health. o Advocate for the contribution that public health professionals can make to urban planning and development to ensure that population health impacts are recognized and mitigated. o Provide community planners with strong public health arguments and health data to support healthy communities. Health Care Professionals can: o Incorporate an awareness of a patient's built environment (such as housing, access to transportation and healthy foods) into treatment programs and health counseling. o Encourage your community to adopt policies and design principles that build healthy supportive environments. Federal, Provincial and Local Governments can: o Integrate concepts of population health into urban planning. o Promote multidisciplinary planning teams, including professionals in medicine, public health and community design to ensure that all stakeholders take health impacts into account. o Incorporate health impact assessments into community planning and development initiatives in the public sector. o Encourage the private sector to provide infrastructure and amenities in developments that promote healthy living. The Public can: o Learn more about the connection between the built environment and health and advocate for positive change. o Become involved in public consultations regarding local community planning and development. Further Research o Develop research projects at the Federal level on the impact of the built environment on health to inform and help coordinate programs and initiatives at the provincial and local levels. o Focus on creating a standardized set of health indicators that can be uniformly applied to assess the status of a community's built environment. o Research into the effectiveness of policy options on various communities (urban, suburban, rural). Conclusion It is important that we acknowledge how our surroundings can affect our lives and health, and work together to create positive change. The CMA is willing to work with other people and organizations to ensure that the influence of the built environment on health receives the attention that it warrants with the ultimate goal of building or re-inventing healthy communities for all Canadians. Definitions In order of appearance Inactive: "Respondents are classified as active, moderately active or inactive based on an index of average daily physical activity over the past 3 months. For each leisure time physical activity engaged in by the respondent, an average daily energy expenditure is calculated by multiplying the number of times the activity was performed by the average duration of the activity by the energy cost (kilocalories per kilogram of body weight per hour) of the activity. The index is calculated as the sum of the average daily energy expenditures of all activities. Respondents are classified as follows: 3.0 kcal/kg/day or more = physically active; 1.5 to 2.9 kcal/kg/day = moderately active; less than 1.5 kcal/kg/day = inactive". (Human Resource and Skills Development Canada, 2006). Urban Sprawl: "A particular type of suburban development characterized by very low-density settlements, both residential and non-residential; dominance of movement by use of private automobiles, unlimited outward expansion of new subdivisions and leap-frog developments of these subdivisions; and segregation of land uses by activity." (United States Department of Housing and Urban Development, 1999) Walkability: Walkability refers to the ease with which pedestrians can move within and between environments. The literature gives varied definitions but the main variable to consider are the following: mixed land use (defined below), proximity to destinations (accessibility and convenience), pedestrian facilities (sidewalks, urban furniture etc...), street connectivity (short block lengths, availability of multiple alternate routes etc...), aesthetics (landscape, vegetation, architecture), presences of public spaces (parks, plazas, etc...), presence of traffic calming measures (lower speed limits, street narrowing, speed bumps etc...), and access to transit. (Shay, Spoon, & Khattak, 2003) Transportation Mode Choice: Transportation mode choice refers to an individuals decision regarding how to get from one destination to another. The theory behind mode choice is complex and involves characteristics of the built environment, socio-demographic and socioeconomic variables, benefit-cost analysis, and personal preference. (Cervero, Built Environments and Mode Choice: Toward a Normative Framework, 2002) Mixed Land Use: "Land use mix is the composition of uses within a given geographic area." (Cervero, Land Use Mixing and Suburban Mobility, 1998) The uses referred to can be restaurants, offices, studios, shops, or any variety of business, institution, natural space, or recreation site. In the literature there are various indices and equations used to measure the degree of 'mixed land use' in an area. Urban Heat Island Effect: The urban heat island effect occurs when the sun significantly heats urban surfaces (concrete, asphalt, etc...) to significantly higher temperatures than the surroundings air (can be upwards of 27-50oC). Comparatively shaded or more moist regions (such as rural areas with lots of vegetation) stay much closer to the surrounding air temperature. This heat imbalance between urban surfaces and surrounding air causes heat to transfer from those surfaces to the air, elevated the temperature above what it normally would be. This happens both at a surface and an atmospheric level. (United States Environmental Protection Agency, 2012) Smart Growth: Smart Growth is an urban planning and transportation theory that became popular almost two decades ago. Though different organization's may differ slightly in their view of what smart growth means, it's general aims are to build compact accessible cities that avoid urban sprawl and mitigate auto-dependence. Some of the principles of this movement are as follows: 1). Incorporate mixed land uses into community designs 2). Build compact, accessible neighbourhoods close to jobs and amenities 3). Provide alternative modes of public transportation 4). Diversify housing to meet the needs of people from all socioeconomic classes 5). Maintain and protect natural open spaces 6). Build within existing communities instead of developing beyond community boundaries 7). Preserve agricultural land 8). Use new, sustainable technology in infrastructure and buildings 9). Develop community identity 10). Encourage active citizens to remain engaged in their communities (Smart Growth BC, 2012) Bibliography Human Resource and Skills Development Canada. (2006). Retrieved July 15, 2012, from Indicators of Well-Being in Canada: Physical Activity: http://www4.hrsdc.gc.ca/.3ndic.1t.4r@-eng.jsp?iid=8 Active Living Research and the Public Health Institute. (2013). Where the Rubber Meets the Road: Promoting Active Transportation in Rural Areas.. Retrieved September 2013, from Active Living Research : http://activelivingresearch.org/where-rubber-meets-road-promoting-active-transportation-rural-areas Canadian Medical Association. (2008). No Breathing Room: National Illness Cost of Air Pollution. Ottawa: CMA. Canadian Society of Exercise Physiology. (2011). Canadian Physical Activity Guidelines. Canadian Society of Exercise Physiology. Centers for Disease Control and Prevention. (2009, May 31). Extreme Heat: A Prevention Guide to Promote Your Personal Health and Safety. Retrieved July 15, 2012, from CDC: http://www.bt.cdc.gov/disasters/extremeheat/heat_guide.asp Centre for Chronic Disease Prevention and Control. . (2002). Diabetes in Canada, 2nd Edition. Ottawa: Health Canada. Cervero, R. (1998). Land Use Mixing and Suburban Mobility. Transportation Quarterly, 42(3). Cervero, R. (2002). Built Environments and Mode Choice: Toward a Normative Framework. Transportation Research Part D: Transport and Environment , 7(4), 265-284. Creatore, M., Gozdyra, P., Booth, G., & Glazier, R. (2007). Chapter 1: Setting the Context. In M. Creatore, P. Gozdyra, G. Booth, R. Glazier, & M. Tynan, Neighbourhood Environments and Resources for Healthy Living - A Focus on Diabetes in Toronto: ICES Atlas. Toronto: Institute for Clinical Evaluative Sciences. Cummins, S., & Macintyre, S. (2006). Food Environments and Obesity - Neighbourhood or Nation. International Journal of Epidemiology, 35(1), 100-104. Cutts, B., Darby, K., Boone, C., & Brewis, A. (2009). City Structure, Obesity, and Environmental Justice: An Integrated Analysis of Physical and Social Barriers to Walkable Streets and Park Access. Social Science and Medicine, 69(9), 1314-1322. Dennenberg, A. L., Howard, F., & J, J. R. (Eds.). (2011). Making Healthy Places Designing and Building for Health, Well-being and Sustainability . Washington: Island Press. Department of Health and Human Resources. (2004, August 20). National Institute of Health. Retrieved July 30, 2012, from Obesity and the Built Environment: http://grants.nih.gov/grants/guide/rfa-files/rfa-es-04-003.html Ewing, R., Schmid, T., Killingsworth, R., Zlot, A., & Raudenbush, S. (2003). Relationship Between Urban Sprawl and Physical Activity, Obesity, and Morbidity. The Science of Health Promotion, 18(1), 47-57. Frank , L., Kavage S, & Devlin A. (2012). Health and the Built Environment: A Review. World Medical Association. Frank, L. D. (2009, January). Final Report on Health Assessment Tool Development for Peel Region by Larry Frank. Retrieved July 15, 2012, from Peel Region: http://www.peelregion.ca/health/urban/pdf/Peel-Lit-Review-Final-11072008-submitted.pdf Frank, L., Sallis, J., Conway, T., Chapman, J., Saelens, B., & Bachman, W. (2006). Many Pathways from Land Use to Health: Associations Between Neighborhood Walkability and Active Tranportation, Body Mass Index, and Air Quality. Journal of the American Planning Association, 72(1), 75-87. Guh, D., Zhang, W., Bansback, N., Amarsi, Z., Birmingham, C., & Anis, A. (2009). The Incidence of Co-morbidities Related to Obesity and Overweight: A Systematic Review and Meta-Analysis. Public Health, 9(88), 1-20. Heart and Stroke Foundation of Canada. (2011). Position Statements: Community Design,Physical Activity, Heart Disease and Stroke. Retrieved June 2012, from Heart and Stroke Foundation of Canada: http://www.heartandstroke.com/site/c.iklQLcMWJtE/b.3820627/ Jackson, R. J., & Kochtotzky, C. (n.d.). Creating a Healthy Enviroment: The Impact of the Built Environment on Public Health. Retrieved April 2012, from Sprawl Watch Clearinghouse Monograph Series: http://www.sprawlwatch.org/health.pdf Larsen, K., & Gilliland, J. (2008). Mapping the Evolution of 'Food Deserts" in a Canadian City: Supermarket Accessibility in London, Ontario, 1961-2005. International Journal of Health Geographics, 7(16), 1-16. Newman, P., & Kenworthy, J. (1989). Gasoline Consumption and Cities. Journal of the American Planning Association , 55(1), 24-37. PHAC/CIHI. (2011). Obesity in Canada. Ottawa: Public Health Agency of Canada. Public Health Agency of Canada. (2012, July 18). Obestiy in Canada: Snapshot. Retrieved July 29, 2012, from Public Health Agency of Canada: http://www.phac-aspc.gc.ca/publicat/2009/oc/index-eng.php Shay, E., Spoon, S., & Khattak, A. (2003). Walkable Environments and Walking Activity. Carolina Transportation Program, Department of City and Regional Planning. North Carolina: Carolina Transportation Program. Smart Growth BC. (2012). 10 Smart Growth Principles. Retrieved 30 July, 2012, from Smart Growth BC: http://www.smartgrowth.bc.ca/Default.aspx?tabid=133 SmartRisk. (2009). The Economic Burden of Injury in Canada. Toronto: SmartRisk. Stansfeld SA, M. M. (2003). Noise pollution: non-auditory effects on health. . British Medical Bulletin,, 68, 243-257. Statistics Canada. (1996-97, May 29). National Population Health Survey, Cycle 2. Canada: The Daily. Statistics Canada. (2006, June 28). Childhood Obesity: A Troubling Situation. Retrieved July 15, 2012, from StatsCan: http://www41.statcan.ca/2006/2966/ceb2966_004-eng.htm Statistics Canada. (2008). Mortality, Summary List of Causes. Health Statistics Division . Ottawa: Statistics Canada. Surface Transportation Policy Partnership. (2002). Mean Streets 2002. Washington, DC: STPP. United States Department of Housing and Urban Development. (1999). The State of the cities 1999: Third Annual Report. Washington, DC: USHUD. United States Environmental Protection Agency. (2012, July 13). Heat Island Effect. Retrieved July 29, 2012, from United States Environmental Protection Agency: http://www.epa.gov/hiri/ United States Environmental Protection Agency. (2012, June 21). Heat Island Effect: Basic Information. Retrieved July 15, 2012, from United States Environmental Protection Agency: http://www.epa.gov/hiri/resources/pdf/BasicsCompendium.pdf Vogel, T., Brechat, P., Lepetre, P., Kaltenbach, G., Berthel, M., & Lonsdorfer, J. (2009). Health Benefits of Physical Activity in Older Patients: A Review. The International Journal of Clinical Practice, 63(2), 303-320.

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Canadian Medical Association Submission on Bill C-462 Disability Tax Credit Promoters Restrictions Act

https://policybase.cma.ca/en/permalink/policy10812

Date
2013-05-22
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2013-05-22
Topics
Physician practice/ compensation/ forms
Text
The Canadian Medical Association (CMA) is pleased to present this brief to the House of Commons Standing Committee on Finance regarding Bill C-462 Disability Tax Credit Promoters Restrictions Act. The Canadian Medical Association represents 78,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. The CMA is pleased that the House of Commons has made Bill C-462 a priority. This bill is an important step toward addressing the unintended consequences that have emerged from the Disability Tax Credit since 2005. Part 2: Issues to be addressed In 2005, the Disability Tax Credit was expanded to allow individuals to back-file for up to 10 years. While this was a welcome tax measure for individuals with disabilities, the CMA has been urging the Canada Revenue Agency to address the numerous unintended consequences that have emerged. Central among these has been the emergence of a "cottage industry" of third-party companies engaged in a number of over-reaching tactics. The practices of these companies have included aggressive promotional activities to seek and encourage individuals to file the Disability Tax Credit. The primary driver behind these tactics is profit; some companies are charging fees of up to 40 per cent of an individual's refund when the tax credit is approved. Further to targeting a vulnerable population, these activities have yielded an increase in the quantity of Disability Tax Credit forms in physician offices and contributed to red tape in the health sector. In some cases, third parties have placed physicians in an adversarial position with their patients. We are pleased that this bill attempts to address the concerns we have raised. The CMA supports Bill C-462 as a necessary measure to address the issues that have emerged since the changes to the Disability Tax Credit in 2005. However, to avoid additional unintended consequences, the CMA recommends that the Finance Committee address three issues prior to advancing Bill C-462. First, as currently written, Bill C-462 proposes to apply the same requirements to physicians as to third-party companies if physicians apply a fee for form completion, a typical practice for uninsured physician services. Such fees are subject to guidelines and oversight by provincial and territorial medical regulatory colleges (see Appendix 1: CMA Policy on Third Party Forms: The Physician Role). The CMA recommends that the Finance Committee: * Amend the definition of "promoters" under section 2 to exclude "a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment." * If the committee imports the term "person" from the Income Tax Act, then the applicable section of Bill C-462 should be amended to specify that, for the purposes of the act, "Person does not include a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment." Second, the CMA is concerned that one of the reasons individuals may be engaging the services of third-party companies is a lack of awareness of the purpose and benefits of the Disability Tax Credit. Additional efforts are required to ensure that the Disability Tax Credit form (Form T2201) be more informative and user-friendly for patients. Form T2201 should explain more clearly to patients the reason behind the tax credit, and explicitly indicate there is no need to use third-party companies to submit the claim to the CRA. The CMA recommends that the Finance Committee: * Recommend that the Canada Revenue Agency undertake additional efforts to ensure that the Disability Tax Credit form is more informative, accessible and user-friendly for patients. Finally, the CMA recommends that a privacy assessment be undertaken before the bill moves forward in the legislative process. It appears that, as written, Bill C-462 would authorize the inter-departmental sharing of personal information. The CMA raises this issue for consideration because protecting the privacy of patient information is a key duty of a physician under the CMA Code of Ethics. Part 3: Closing The CMA encourages the Finance Committee to address these issues to ensure that Bill C-462 resolves existing problems with the Disability Tax Credit while not introducing new ones. The CMA appreciates the opportunity to provide input to the Finance Committee's study of this bill and, with the amendments outlined herein, supports its passage. Summary of Recommendations Recommendation 1 The definition of "promoters" under section 2 of Bill C-462 should be amended to exclude "a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment." Recommendation 2 If the Committee imports the definition of "persons" from the Income Tax Act, the applicable section of Bill C-462 should be amended to specify that, for the purposes of the act, "Person does not include a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment." Recommendation 3 The Canada Revenue Agency should undertake additional efforts to ensure that the Disability Tax Credit form is informative, accessible and user-friendly. Recommendation 4 Prior to advancing in the legislative process, Bill C-462 should undergo a privacy assessment.

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Canadian Medical Association Submission on Bill S-209, An Act to Amend the Criminal Code (prize fights)

https://policybase.cma.ca/en/permalink/policy10708

Date
2013-04-15
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Date
2013-04-15
Topics
Health care and patient safety
Text
In 2010, physician delegates to the CMA's annual General Council voted in favour of a ban on mixed martial arts prize fighting matches in Canada. The CMA's complete policy on head injury and sport, the central concern of physicians with respect to mixed martial arts, is attached as an appendix to this brief. A key recommendation in this policy is that physicians discourage participation in sports in which intentional trauma to the head and body is the objective of the sport, as is the case with mixed martial arts (MMA). Background MMA prize fighting, like commercial boxing, is distinct from healthy sport because the basic tenet is to win by deliberately incapacitating one's opponent through violent bodily assault. Professional fighters train in different martial arts disciplines in order to develop the widest possible set of fighting techniques. Blows delivered by hands, feet, elbows and knees are entirely permissible.1 "Bouts" are won in a number of ways that include deliberate head injury such as knockout (KO) and technical knockout (TKO). Physician and referee stoppage are recognized as a necessary option for the declaration of a winner in order to prevent continued violence.4; 5 Despite the introduction of rules and regulations meant to ensure fighter safety, MMA is a violent sport with a high risk of injury. Publications seem to indicate that the overall injury rate in professional MMA competitions ranges approximately from 23 to 28 injuries per 100 fight participations, which is similar to that found in other combat sports involving striking, including boxing.1; 5; 7 Organizers support the rules because they realize that prize fighting can't be sustained as a business if the fighters are unable to return to the ring. The injuries vary in severity but include many types of head injury: ocular injuries, such as rupture of the bony orbit or of the eye itself; facial injuries including fractures; spine injuries; concussion; and tympanic membrane ruptures.2, 6, 7 Most sanctioned matches end in a submission, judge's decision or referee/physician stoppage, as opposed to KO or TKO. It is important to note that the overall risk of critical injury, defined as a persistent acquired brain injury, permanent blindness, permanent functional loss of limb or paralysis, appears to be low. The ability of referees to intercede and for fighters to voluntarily concede victory to their opponents, as well as the presence of physicians at the ringside, are all thought to play a role in minimizing the risk of critical injury.7 The risk of traumatic brain injury and concussion nevertheless remains one of the chief concerns with respect to MMA. KO rates are thought to be lower in professional MMA events than in similar boxing competitions, but it is not clear why. It is well known that knockouts are the result of brain injury4 and at least one study reported that blunt trauma to the head was a common reason for match stoppage. One study reported a severe concussion rate of 16.5 per 100 fighter participations (3.3% of all matches). 6 Regrettably, as in other combat sports, long-term follow-up of players is insufficient to measure how often head injury leads to permanent brain damage.1, 3 Issues Insufficient research Whether you defend or condemn MMA, the true nature and rate of severe brain injuries is speculative.6 Similarly, the absence of longitudinal studies means that the true long-term health implications of MMA fighting can only be surmised. Risk factors for injury Unsurprisingly, losing fighters are at a considerably greater risk for sustaining injury. It is notable that fighters losing by KO or TKO appear to have a higher overall incidence of injury.4 An increased duration of fighting is associated with an increased incidence of injury.3, 5 However, it remains unclear how age and fight experience contribute to the risk for sustaining injury.2, 3, 4 It appears that fighters with head injury continue to fight and sustain further injury, head injury being more clearly associated with injury than are either inexperience or age. Current situation Despite the sport's growing popularity, professional MMA competitions are currently illegal in Canada. Indeed, section 83(2) of the Criminal Code of Canada states that only boxing matches, where only fists are used, are legal. However, the governments of Nova Scotia, Quebec, Ontario, Manitoba and Northwest Territories have regulated/licensed MMA through athletic governing commissions, effectively circumventing the Criminal Code. The legality of the sport in New Brunswick, Alberta and British Columbia currently varies by municipality. CMA Recommendations The CMA recommends that Section 83(2) of the Criminal Code, the ban on mixed martial arts, be maintained in its current form. The CMA recommends that the federal government undertake further research on head injuries and concussion in Canada, including expanding current surveillance tools for the incidence of these injuries. References 1. Bledsoe, G. H. (2009). Mixed martial arts. In R. Kordi, N. Maffulli, R. R. Wroble, & W. A. Angus (Eds.), Combat Sports Medicine (1st ed., pp. 323-330). London: Springer. 2. Buse, G. J. (2006). No holds barred sport fighting: A 10 year review of mixed martial arts competition. British Journal of Sports Medicine, 40(2),169-172. 3. Bledsoe, G. H., Hsu, E. B., Grabowski, J. G., Brill, J. D., & Li, G. (2006). Incidence of injury in professional mixed martial arts competitions. Journal of Sports Science and Medicine, 5(Combat Sports Special Issue), 136-142. 4. Walrod, B. (2011). Current review of injuries sustained in mixed martial arts competition. Current Sports Medicine Reports, 10(5), 288-289. 5. Unified Fighting Championship. (n.d.). Unified rules and other important regulations of mixed martial arts. Retrieved May 28, 2012, from http://www.ufc.com/discover/sport/rules-and-regulations 6. Ngai, K. M., Levy, F., & Hsu, E. B. (2008). Injury trends in sanctioned mixed martial arts competition: A 5-year review from 2002 to 2007. British Journal of Sports Medicine, 42(8), 686-689. 7. Scoggin III, J. F., Brusovanik, G., Pi, M., Izuka, B., Pang, P., Tokomura, S. et al. (2010). Assessment of injuries sustained in mixed martial arts competition. American Journal of Orthopedics, 39(5), 247-251.

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Canadian Medical Association Submission on Motion 315 (Income Inequality)

https://policybase.cma.ca/en/permalink/policy10715

Date
2013-04-25
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2013-04-25
Topics
Physician practice/ compensation/ forms
Text
The Canadian Medical Association is pleased to present its views to the House of Commons Standing Committee on Finance regarding income inequality in Canada. The Canadian Medical Association represents 78,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. Income inequality is a growing problem in Canada. According to a Conference Board of Canada report, high income Canadians have seen their share of income increase since 1990 while the poorest and even the middle-income groups have lost income share. In 2010 the top quintile of earners accounted for 39.1% of Canadian income while the bottom quintile only accounted for 7.3%. These numbers led to a ranking for Canada of 12 out of 17 among other high income countries in terms of income inequality.1 Research by the Organization for Economic Co-operation and Development has largely confirmed these results.2 Part 2: Why Income Inequality Matters to Canadian Physicians The issue of income inequality is an important one for Canada's physicians. As physicians, we are not the experts in housing, in early childhood development, income equality and so on. But we are the experts in recognizing the impact of these factors on the health of our patients. Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.3 In 2001, people in the neighbourhoods with the highest 20% income lived about three years longer than those in the poorest 20% neighbourhoods.4 Mental health is affected as well. Suicide rates in the lowest income neighbourhoods are almost twice as high as in the wealthiest neighbourhoods.5 Studies suggest that adverse socio-economic conditions in childhood can be a greater predictor of cardiovascular disease and diabetes in adults than later life circumstances and behavioural choices.6 Finally, the countries reporting the highest population health status are those with the greatest income equality, not the greatest wealth.7 These differences in health outcomes have an impact on the health care system. Most major diseases including heart disease and mental illness follow a social gradient with those in lowest socio-economic groups having the greatest burden of illness.8 Those within the lowest socio-economic status groups are 1.4 times more likely to have a chronic disease, and 1.9 times more likely to be hospitalized for care of that disease.9 Income plays a role in access to appropriate health care as well. Individuals living in lower income neighbourhoods, younger adults and men are less likely to have primary care physicians than their counterparts.10 Women and men from low-income neighbourhoods are more likely to report difficulties making appointments with their family doctors for urgent non-emergent health problems. They were also more likely to report unmet health care needs.11 People with lower socio-economic status are more likely to be hospitalized for ambulatory care sensitive conditions and mental health12, admissions which could potentially be avoided with appropriate primary care.13 Those with higher socio-economic status are more likely to have access to and utilize specialist services.14 Utilization of diagnostic imaging services is greater among those in higher socio-economic groups.15 Access to preventive and screening programs such as pap smears and mammography are lower among disadvantaged groups.16 It is not just access to insured services that is a problem. Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.17 Services such as physiotherapy and occupational therapy to name two are often not covered unless they are provided in-hospital or to people on certain disability support programs.18 Access to psychologists is largely limited to people who can pay for them, through private insurance or out of their own pockets.19 Similar access challenges exist for long-term care, home care and end-of-life care. There is a financial cost to this disparity. According to a 2011 report, low-income residents in Saskatoon alone consume an additional $179 million in health care costs than middle income earners.20 A 2010 study by CIHI found increased costs for avoidable hospitalizations for ambulatory care sensitive conditions were $89 million for males and $71 million for females with an additional $248 million in extra costs related to excess hospitalizations for mental health reasons.21 The societal cost of poor health extends beyond the cost to the health care system: healthier people lose fewer days of work and contribute to overall economic productivity.22 According to data in the U.K., those living in the most disadvantaged neighbourhoods experience almost 20 years less disability-free life than those in the highest income neighbourhoods. These individuals will become disabled before they are eligible for old age services, striking two blows to the economy: they will no longer be able to contribute through productive work, and their disability will consume a great deal of health care services.23 The reasons for this inequitable access are multifaceted and include patient specific barriers as well as challenges within the health care system itself. CMA recognizes the need for physicians to work to address the system related barriers. However, one of the biggest challenges for patients themselves remains economic. Having a low-income can prevent access through lack of transportation options, an inability to get time off work, and the inability to pay for services that are not covered by government insurance. Health equity is increasingly recognized as a necessary means by which we will make gains in the health status of all Canadians and retain a sustainable publicly funded health care system. Addressing inequalities in health is a pillar of CMA's Health Care Transformation initiative. Part 3: Ensuring adequate income for all Canadians "The rates of family and child poverty are unacceptably high taking into account Canada's high quality of living standard." 2010 Report of the Committee on Human Resources, Skills and Social Development and the Status of Persons with Disability One reason income is so critical to individual health is that it is so closely linked to many of the other social determinants of health. These include but are not limited to: education, employment, early childhood development, housing, social exclusion, and physical environment. The CMA and its members are concerned that adequate consideration during the decision-making process is not being given to the social and economic determinants of health, factors such as income and housing that have a major impact on health outcomes. Recent decisions such as changes to the qualifying age for Old Age Security, and new rules for Employment Insurance, among others, will have far reaching consequences on the income of individuals, especially those in vulnerable populations. We remind the government that every action that has a negative effect on health will lead to more costs to society down the road. One method to ensure that these unintentional consequences do not occur is to consider the health impact of decisions as part of the policy development and decision-making process. A Health Impact Assessment (HIA) is a systematic process for making evidence-based judgments on the health impacts of any given policy and to identify and recommend strategies to protect and promote health. The HIA is used in several countries, including Australia, New Zealand, the United Kingdom, and increasingly the United States. The HIA can ensure that government departments consider the health impacts of their policies and programs by anticipating possible unintended consequences and taking appropriate corrective action. The use of HIA will allow the federal government to demonstrate leadership in health care in Canada and provide greater accountability to all Canadians. The CMA recommends that: 1. The federal government recognize the importance of the social and economic determinants of health to the health of Canadians and the demands on the health care system; and 2. The federal government requires a health impact assessment as part of Cabinet decision-making. We are hearing about the need to address the poverty and income security of Canadians from stakeholders across the country. We have conducted a series of town halls with Canadians asking them questions about how the social and economic conditions of their communities affect their health. From Winnipeg, to Hamilton to Charlottetown we have heard how poverty and a lack of income is undermining Canadians' health. This public response is not surprising. According to the Conference Board of Canada, more than one in seven children in Canada live in poverty.24 This poverty will severely limit the ability of these children to achieve good health in the future. There are systemic barriers that contribute to this poverty. The annual welfare income in Canada varies between $3,247 for a single person to $21,213 for a couple with two children. The 'best' of Canadian programs provides an income within only 80% of the poverty line. The lowest income is barely 30% of that needed to 'achieve' poverty.25 It is not just people on social assistance, however, that are facing poverty. Data from 2008 indicates that one in three (33%) of children living in poverty had a parent that was employed. Based a review conducted in 2010, one in 10 workers still earned less than $10 an hour in 2009, with 19% paid less than $12. The same study found that roughly 400,000 full-time adult workers, aged 25+, were making less than $10/hr. and therefore paid less than poverty line wages.26 Some physicians are working directly with patients to try and address the income inadequacy which is undermining their health. Physicians from Health Providers Against Poverty in Ontario have developed a tool for physicians to use in screening their patients for poverty and linking them with provincial/territorial and/or federal programs that might help mitigate the health effects of their poverty. This group is also involved in training health care providers to support this work. While this program and others like it are serving as a 'band aid' solution for some living in poverty, the CMA feels that physicians and their patients should not be placed in this position. As part of its study on income inequality, the CMA encourages the Finance Committee to review two recent reports from Parliamentary committees on the same topic. The first and most recent is the report of the House of Commons Committee on Human Resources, Skills and Social Development and the Status of Persons with Disability, Federal Poverty Reduction Plan: Working in Partnership Towards Reducing Poverty in Canada.27 The second is the report of the Senate Committee on Social Affairs, Science and Technology In From the Margins: A Call to Action on Poverty, Housing and Homelessness.28 The Committee on Human Resources, Skills and Social Development and the Status of Persons with Disability, noted that the federal government's efforts to address poverty among Canadian seniors "is generally recognized as one of Canada's most notable achievements of the past 30 years." The report of the Senate Committee made a number of significant observations, two bear repeating: * "[W]hen all the programs are working, when the individual gets all possible income and social supports, the resulting income too often still maintains people in poverty, rather than lifting them into a life of full participation in the economic and social life of their communities." * "[A]t their worst, the existing policies and programs entrap people in poverty, creating unintended perverse effects which make it virtually impossible for too many people to escape reliance on income security programs and even homeless shelters." The public policy debate on addressing income inequality in Canada is not new. For instance, the 1971 report of the Special Senate Committee on Poverty recommended that a guaranteed annual income financed and administered by the federal government be established. In consideration of this concept, from 1974 to 1979, the Governments of Canada and Manitoba funded the Manitoba Basic Guarantee Annual Income Experiment (referred to as "Mincome"). While this was initially designed to be a labour market study, the results were also relevant from a health perspective. A recent study of this data concluded that hospitalizations declined by 8.5 per cent for the Mincome subjects.29 The CMA recommends that: 3. The federal government gives top priority to the development of strategies to minimize poverty in Canada. Part 4: Addressing access barriers in the health sector Access to services not covered by provincial health plans remain a large barrier for Canadians. Those with low incomes are less likely to be able to access needed pharmaceuticals and services due to this barrier. One in 10 Canadians can not afford the medications that they are prescribed.30 This further exacerbates the income inequality that exists. While we urge the federal government to take action on reducing poverty among Canadians, at the minimum action needs to be taken to ensure universal access to needed medical care. The CMA recommends that: 4. Governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies; 5. Governments examine methods to ensure that low-income Canadians have greater access to needed medical interventions such as rehabilitation services, mental health, home care, and end-of-life care; and 6. Governments explore options to provide funding for long-term care services for all Canadians. This could include public insurance schemes or registered savings plans allowing Canadians to save for their future long-term care needs. Finally, there is a need to recognize the effect on income related to providing care to family members who are ill. Many Canadians take time off work to care for their children or parents. Without adequate long-term care resources and supports for home care, Canadians may be forced to take a leave from the workforce to provide this unpaid care. Research suggests that more than one third of parents (38.4%) who care for children with a disability are required to work fewer hours to care for their children.31 While the 2011 federal budget provided some relief in the form of a Family Caregiver Tax Credit of up to $300, it is not enough. A 2004 Canadian study placed the value of a caregiver's time at market rates from $5,221 to $13,374 depending on the community of residence.32 This is a significant amount of unpaid work and may further add to income inequalities. Expanding the tax credit available to these individuals would help but there is a need to provide further supports to family caregivers. The CMA recommends that: 7. The federal government expands the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates. Part 5: Conclusion Once again, we commend the Standing Committee on Finance for agreeing to study this important issue. Canada's physicians see the examples of income inequality in their practices on a daily basis. Tackling this important social issue will contribute to not only reducing the burden of disease in Canada but to providing Canadians with the necessary financial resources to achieve good health. Summary of Recommendations Recommendation 1 The federal government recognizes the importance of the social and economic determinants of health to the health of Canadians and the demands on the health care system Recommendation 2 The federal government requires a health impact assessment as part of Cabinet decision-making. Recommendation 3 The federal government gives top priority to the development of strategies to minimize poverty in Canada. Recommendation 4 Governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. Recommendation 5 Governments examine methods to ensure that low-income Canadians have greater access to needed medical interventions such as rehabilitation services, mental health, home care, and end-of-life care; and Recommendation 6 Governments explore options to provide funding for long-term care services for all Canadians. This could include public insurance schemes or registered savings plans allowing Canadians to save for their future long-term care needs. Recommendation 7 The federal government expand the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates. References 1 Conference Board of Canada. How Canada Performs: Income Inequality. Ottawa (ON); 2013. Available: http://www.conferenceboard.ca/hcp/details/society/income-inequality.aspx (accessed 2013 Apr 11). 2 Organisation for Economic Co-operation and Development. Divided We Stand: Why Inequality Keeps Rising: An Overview of Growing Income Inequalities in OECD Countries: Main Findings. Paris (FR); 2011. Available: http://www.oecd.org/els/soc/49499779.pdf (accessed 2013 Apr 11). 3 Dunn JR. The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Toronto (ON); 2002. Available: http://www.opha.on.ca/our_voice/collaborations/makeconnxn/HDP-proj-full.pdf (accessed 2011 March 15) 4 Wilkins R, Berthelot JM and Ng E. Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996. Statistics Canada, Ottawa (ON); 2002. Health Reports 13 [Supplement]: pp. 45-71 5 Marmot, M. Fair Society Healthy Lives: The Marmot Review: Executive Summary. London (UK): 2010. Available: http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLivesExecSummary.pdf (accessed 2011 Jan 25); Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2011 Jan 14) 6 Raphael D. Addressing The Social Determinants of Health In Canada: Bridging The Gap Between Research Findings and Public Policy. Policy Options. March 2003 pp.35-40. 7 Hofrichter R ed. Tackling Health Inequities Through Public Health Practice: A Handbook for Action. The National Association of County and City Health Officials & The Ingham County Health Department. Lansing (USA); 2006. Available: http://www.acphd.org/axbycz/admin/datareports/ood_naccho_handbook.pdf accessed (2012 Mar 16). 8 Dunn, James R. (2002) The Health Determinants Partnership... 9 Canadian Population Health Initiative. Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions. Canadian Institute for Health Information, Ottawa (ON); 2012. Available: http://secure.cihi.ca/cihiweb/products/PHC_Experiences_AiB2012_E.pdf(accessed 2012 Jan 25). 10 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter7-AccesstoHealthCareServices.pdf (accessed 2012 Dec 10). 11 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter12-SDOHandPopsatRisk.pdf (accessed 2012 Dec 10...; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences with health-related services: Implications for health care reform. Health Policy 2006; 76:106-121. 12 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status for Males and Females. Ottawa(ON); 2010. Available: https://secure.cihi.ca/free_products/disparities_in_hospitalization_by_sex2010_e.pdf (accessed 2013 Feb 6) 13 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status...;Roos LL, Walld R, Uhanova J, et al. Physician Visits, Hospitalizations, and Socioeconomic Status: Ambulatory Care Sensitive Conditions in a Canadian Setting. HSR 2005; 40(4): 1167-1185. 14 Allin S. Does Equity in Healthcare Use Vary across Canadian Provinces? Healthc Policy 2008; 3(4): 83-99.;Frolich N, Fransoo R, Roos N. Health Service Use in the Winnipeg Regional Health Authority: Variations Across Areas in Relation to Health and Socioeconomic status. Winnipeg (MB) Manitoba Centre for Health Policy. Available: http://mchp-appserv.cpe.umanitoba.ca/teaching/pdfs/hcm_forum_nf.pdf (accessed 2013 Feb 6); McGrail K. Income-related inequities: Cross-sectional analyses of the use of medicare services in British Columbia in 1992 and 2002. Open Medicine 2008; 2(4): E3-10; Van Doorslaer E, Masseria C. Income-Related Inequality in the Use of Medical Care in 21 OECD Countries. Paris(FR) OECD; 2004. Available: http://www.oecd.org/els/health-systems/31743034.pdf (accessed 2013 Feb 6).;Veugelers PJ, Yip AM. Socioeconomic disparities in health care use: Does universal coverage reduce inequalities in health? J Epidemiol Community Health 2003; 57:424-428. 15 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services...Demeter S, Reed M, Lix L, et al. Socioeconomic status and the utilization of diagnostic imaging in an urban setting. CMAJ 2005; 173(10): 1173-1177. 16 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12...); Frolich N, Fransoo R, Roos N. Health Service Use in the Winnipeg... Wang L, Nie JX, Ross EG. Determining use of preventive health care in Ontario. Can Fam Physician 2009; 55: 178-179.e1-5; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences with health-related services... 17 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts.... 18 Barnes S, Dolan LA, Gardner B, et al. Equitable Access to Rehabilitation : Realizing Potential, Promising Practices, and Policy Directions. Toronto (ON) Wellesley Institute; 2012. Available : http://www.wellesleyinstitute.com/wp-content/uploads/2012/06/Equitable-Access-to-Rehabilitation-Discussion-Paper1.pdf (accessed 2013 Feb 6). 19 Kirby M, Goldbloom D, Bradley L. Changing Directions, Changing Lives: The Mental Health Strategy for Canada.Ottawa (ON): Mental Health Commission of Canada; 2012. Available: http://strategy.mentalhealthcommission.ca/pdf/strategy-text-en.pdf (accessed 2013 Mar 12). 20 Saskatoon Poverty Reduction Partnership. From poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Saskatoon (SK): Saskatoon Poverty Reduction Partnership; 2011.Available: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf (accessed 2012 Mar 13) 21 Canadian Institute for Health Information. Hospitalization Disparities by Socio-economic status... 22 Munro D. Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health. The Conference Board of Canada, Ottawa (ON); 2008. Available: http://www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb (accessed 2012 Mar 26). 23 Marmot Sir M. Achieving Improvements in Health in a Changing Environment. Presentation to the World Medical Association, Vancouver (BC); 2010. 24 Conference Board of Canada. How Canada Performs: Child Poverty. Ottawa (ON); 2013. Available: http://www.conferenceboard.ca/hcp/details/society/child-poverty.aspx (accessed 2013 Apr 11). 25 National Council of Welfare. Poverty Trends in Canada: Solving Poverty Information Kit. Her Majesty the Queen in the Right of Canada. Ottawa (ON); 2007. Available: http://www.ncw.gc.ca/l.3bd.2t.1ils@-eng.jsp?lid=140 (accessed 2012 Jan 25). 26 Campaign 2000. 2010 Report Card on Child and Family Poverty in Canada: 1989 - 2010. Toronto (ON); 2010. Available: http://www.campaign2000.ca/reportCards/national/2010EnglishC2000NationalReportCard.pdf (accessed 2013 Apr 11). 27 Hoeppner C, Chair. Federal Poverty Reduction Plan: Working in Partnership Towards Reducing Poverty in Canada. House of Commons Canada. Ottawa (ON); 2010. Available: http://www.parl.gc.ca/content/hoc/Committee/403/HUMA/Reports/RP4770921/humarp07/humarp07-e.pdf (accessed 2013 Apr 17). 28 Eggleton A, Segal H. In From the Margins: A Call TO Action On Poverty, Housing and Homelessness. The Standing Senate Committee on Social Affairs, Science and Technology. Ottawa(ON);2009. Available: http://www.parl.gc.ca/Content/SEN/Committee/402/citi/rep/rep02dec09-e.pdf (accessed 2013 Apr 17). 29 Forget, Evelyn L. The town with no poverty: the health effects of a Canadian Guaranteed Annual Income Field Experiment. University of Toronto Press. Canadian Public Policy 37(3), 283-305. 30 Law MR, Cheng L, Dhala IA et al. The effect of cost adherence to prescription medications in Canada. CMAJ February 21, 2012 vol. 184 no.3. 31 Campaign 2000. 2010 Report Card on Child and Family Poverty... 32 Chappell NL, Dlitt BH, Hollander JA et al. Comparative Costs of Home Care and Residential Care. The Gerontologist 44(3): 389-400.

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CMA letter to the House of Commons Standing Committee on Justice and Human Rights. Bill C-32 (An Act to amend the Criminal Code (Impaired driving) and to make consequential amendments to other Acts)

https://policybase.cma.ca/en/permalink/policy8789

Last Reviewed
2019-03-03
Date
2007-06-11
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-06-11
Topics
Health care and patient safety
Text
The Canadian Medical Association (CMA) welcomes the opportunity to provide comments to the Standing Committee on Justice and Human Rights of the House of Commons concerning the study of Bill C-32 (An Act to amend the Criminal Code (impaired driving) and to make consequential amendments to other Acts). The CMA supports measures aimed at reducing the incidence of drug-impaired driving. We believe impaired driving, whether by alcohol or another drug, to be an important public health issue for Canadians that requires action by all governments and other concerned groups. The CMA has, on several occasions, provided detailed recommendations on legislative changes concerning impaired driving. In 1999, the CMA presented a brief to the House of Commons Standing Committee on Justice and Human Rights during its review of the impaired driving provisions of the Criminal Code (attached). While our 1999 brief focuses primarily on driving under the influence of alcohol, many of the recommendations are also relevant to the issue of driving under the influence of drugs. Recently, the CMA has published the 7th edition of its guide, Determining Medical Fitness to Operate Motor Vehicles (attached). It includes chapters on the importance of screening for alcohol or drug dependency and states that the abuse of such substances is incompatible with the safe operation of a vehicle. This publication is widely viewed by clinical and medical-legal practitioners as the authoritative Canadian source on the topic of driver competence. While changing the Criminal Code is an important step, the CMA believes further actions are also warranted. In our 2002 presentation to the Special Senate Committee on Illegal Drugs (attached), the CMA put forth our long standing position regarding the need for a comprehensive long-term effort that incorporates both deterrent legislation and public awareness and education campaigns. We believe such an approach, together with comprehensive treatment and cessation programs, constitutes the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. Drug-impaired drivers may be occasional users of drugs or they may also suffer from substance dependence, a well-recognized form of disease. Physicians should be assisted to screen for drug dependency, when indicated, using validated instruments. Government must create and fund appropriate assessment and treatment interventions. Physicians can assist in establishing programs in the community aimed at the recognition of the early signs of dependency. These programs should recognize the chronic, relapsing nature of drug addiction as a disease, as opposed to simply viewing it as criminal behaviour. While supporting the intent of the proposed legislation, the CMA urges caution on several significant issues. With regard to Clause 4 that amends the act as follows: 254.1 (1) The Governor in Council may make regulations (a) respecting the qualifications and training of evaluating officers; (b) prescribing the physical coordination tests to be conducted under paragraph 254(2)(a); and (c) prescribing the tests to be conducted and procedures to be followed during an evaluation under subsection 254(3.1). CMA contends that it is important that medical professionals and addiction medicine specialists in particular, should be consulted regarding the training offered to officers to conduct roadside assessment and sample collection. Provisions in the Act conferring upon police the power to compel roadside examination raises the important issue of security of the person and health information privacy. As well, information obtained at the roadside is personal medical information and regulations must ensure that it be treated with the same degree of confidentiality as any other element of an individual's medical record. Thus, the CMA would respectfully submit that Clause 9 of Bill-32 on the issue of unauthorized use or disclosure of the results needs to be strengthened because the wording is too broad, unduly infringes privacy and shows insufficient respect for the health information privacy interests at stake. For instance, clause 9(2) would permit the use, or allow the disclosure of the results "for the purpose of the administration or enforcement of the law of a province". This latter phrase needs to be narrowed in its scope so that it would not, on its face, encompass such a broad category of laws. Moreover, clause 9(4) would allow the disclosure of the results "to any other person, if the results are made anonymous and the disclosure is made for statistical or other research purposes" CMA would expect the federal government to exercise great caution in this instance, particularly since the results could be of individuals who are not actually convicted of an offence. One should query whether the Clause 9(4) should even exist in a Criminal Code as it would not appear to be a matter required to be addressed. If it is, then CMA would ask the government to conduct a rigorous privacy impact assessment on these components of the Bill, studying in particular, such matters as sample size, degree of anonymity, and other issues, especially given the highly sensitive nature of the material. CMA would ask whether clause 9(5) should specify that the offence for improper use or disclosure should be more serious than a summary conviction. Finally, it is important to base any roadside testing methods and threshold decisions on robust biological and clinical research. CMA also notes with interest Clause 5, specifically the creation of a new offence of being "over 80" (referring to 80mg of alcohol in 100ml of blood, or a .08 blood alcohol concentration level or BAC) and causing an accident that results in bodily harm which will carry a maximum sentence of 10 years and life imprisonment for causing an accident resulting in death. (Clause 5) We would also urge the Committee to take the opportunity that the review of this proposed legislation provides to recommend to Parliament a lower BAC level. Since 1988 the CMA has supported 50 mg% as the general legal limit. Studies suggest that a BAC limit of 50 mg% could translate into a 6% to 18% reduction in total motor vehicle fatalities or 185 to 555 fewer fatalities per year in Canada.1 A lower limit would recognize the significant detrimental effects on driving-related skills that occur below the current legal BAC.2 In our 1999 response to this Committee's issue paper on impaired driving3 and again in 2002 when we joined forces with Mothers Against Drunk Driving (MADD), CMA has consistently called for the federal government to reduce Canada's legal BAC to .05. Canada continues to lag behind countries such as Austria, Australia, Belgium, Denmark, France and Germany, which have set a lower legal limit. 4 CMA expressed the opinion that injuries and deaths resulting from impaired driving must be recognized as a major public health concern. Therefore we once again recommend lowering the legal BAC limit to 50 mg%. or .05%. Finally, CMA believes that comprehensive long-term efforts that incorporate deterrent legislation, such as Bill C-32, must be accompanied by public awareness and education strategy. This constitutes the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports this multidimensional approach to the issue of the operation of a motor vehicle regardless of whether impairment is cause by alcohol or drugs. Again, the CMA appreciates the opportunity to provide input into the legislative proposal on drug-impaired driving. We stress that these legislative changes alone would not adequately address the issue of reducing injuries and fatalities due to drug-impaired driving, but support their intent as a partial, but important measure. Yours sincerely, Colin J. McMillan, MD, CM, FRCPC, FACP President Attachments (3) 1 Mann, Robert E., Scott Macdonald, Gina Stoduto, Abdul Shaikh and Susan Bondy (1998) Assessing the Potential Impact of Lowering the Blood Alcohol Limit to 50 MG % in Canada. Ottawa: Transport Canada, TP 13321 E. 2 Moskowitz, H. and Robinson, C.D. (1988). Effects of Low Doses of Alcohol on Driving Skills: A Review of the Evidence. Washington, DC: National Highway Traffic Safety Administration, DOT-HS-800-599 as cited in Mann, et al., note 8 at page 12-13 3 Proposed Amendments to the Criminal Code of Canada (Impaired Driving): Response to Issue Paper of the Standing Committee on Justice and Human Rights. March 5, 1999 4 Mann et al

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CMA Letter to the Legislative Committee on Bill C-30: Clean Air Act

https://policybase.cma.ca/en/permalink/policy8714

Last Reviewed
2019-03-03
Date
2007-02-28
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2007-02-28
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to participate in the review of the Clean Air Act, Bill C- 30. The CMA, first founded in 1867, currently represents more than 64,000 physicians across the country. Our mission includes advocating for the highest standard of health and health care for all Canadians and we are committed to activities that will result in healthy public policy. The Environment: A Key Determinant of Health The physical environment is a key determinant of a population's health and the medical profession is concerned about environmental conditions that contribute to declining health in individuals and the population as a whole. Physicians have been part of an early warning system of scientists and other health professionals calling attention to the effects on human health of poor air quality because we see the impact in our practice and in our communities. There is strong evidence that air pollution is the most harmful environmental problem in Canada in terms of human health effects. We know from the smog health studies undertaken by the Ontario Medical Association (OMA), Health Canada and others, about the public health crisis created by polluted air in many parts of Canada. And it is a crisis. A study by the federal government estimated that 5,900 premature deaths occur annually in eight large Canadian cities. This is a conservative estimate as the study focused on the short-term impact of smog pollutants using time-series studies. This study was never extrapolated to the whole Canadian population, but we know that only approximately one third of the Canadian population, mainly residents of large, urban areas, were included in the analysis.1 The OMA Illness Costs of Air Pollution study estimated that there were 5,800 premature deaths due to air pollution in Ontario alone in 2005, and examined both short-term and long-term health impacts. The OMA projected that the annual figure will grow to 10,000 premature deaths by 2026 unless effective steps are taken to reduce smog.2 In addition to premature deaths, the OMA estimated that there were 16,000 hospital admissions and 60,000 emergency room visits in Ontario in 2005 because of respiratory and cardiovascular illnesses associated with air pollution exposure. During that same year, the OMA also estimated that there were 29 million minor illness days, defined as days where individuals either suffered from asthma symptoms or had to restrict their activities. Most of the people affected by these so-called minor illness days are children. In British Columbia, the Provincial Officer for Health published a conservative estimate in 2004 that air pollution in B.C. is causing between 140 and 400 premature deaths, 700 to 2,100 hospital stays, and between 900 and 2,750 emergency room visits each year.3 The direct and indirect costs of air pollution on the health of Canadians are estimated to be in the billions of dollars. According to the Ontario Medical Association, in 2005, air pollution costs in Ontario were estimated at: - $374 million in lost productivity and work time; - $507 million in direct health care costs; - $537 million in pain and suffering due to non-fatal illness; and - $6.4 billion in loss due to premature death.4 In Canada the environment is currently considered to be the most important issue facing society. In a recent poll by the Strategic Counsel for the Globe & Mail/CTV5 a majority of respondents ranked the impact of toxic chemicals, air and water pollution and global warming as life threatening. The environment, while a major concern today for the general public, has been of concern to physicians for some time. CMA, Health and the Environment In 1991 the CMA, released a policy paper Health, the Environment and Sustainable Development6 that clearly linked health and the environment. Building on the 1987 Brundtland Report (World Commission on Environment and Development, Our Common Future) that tied sustainable development to the environment and the economy, the CMA inserted health into this pair of interactions and stated that "continued environmental degradation will increase hazard to human health." The paper concluded with a number of recommendations for governments, the health sector, and physicians in support of environmentally sustainable development. The CMA has continued to give attention to environmental issues urging the government, prior to Canada's ratification of the Kyoto Protocol, to commit to choosing a climate change strategy that satisfies Canada's international commitments while maximizing the clean air co-benefits and smog-reduction potential of any greenhouse gas reduction initiatives. In 2002, the CMA also recommended that the federal Environment and Health Ministers commit their departments to improved health-based reporting by regularly updating the health effects information for pollutants of concern. Clean Air Act: A Physicians Perspective Doctors understand the concept that success from an intervention can be nuanced. In the case of disease, physicians know and accept that there are benefits of treatment even if a patient cannot be cured. Sometimes we just reduce their symptoms, or slow their rate of decline. But when treating the natural environment, so critical to human health, we suggest that you cannot accept a palliative solution. We must aim for cure. We must commit to measures of success in terms of real improvement in health. It is through this lens that the CMA urges that you view the Clean Air Act to ensure that it is health-relevant. The CMA would like to commend this government for acknowledging the impact of the physical environment on human health and we are encouraged that the Act recognizes the intimate connection between greenhouse gas reductions and improved air quality. Air pollution does not respect provincial borders therefore it is very important to establish national objectives and Canada wide standards that are strong and consistent across the country. To be health relevant national air quality objectives must result in air quality improvements. To this end, regardless of whether they are called objectives or standards, national air quality targets must protect the health of all Canadians and must be binding. Voluntary air quality guidelines guarantee no health benefit. The federal government must ensure that there is a regulatory framework in place to ensure that the standards are mandatory across the country. The annual reporting to Parliament on the attainment of the national air quality objectives and the effectiveness of measures to attain the objectives, as outlined in the Act, is very important. Transparency in reporting is essential to the integrity of any program, but is integral to the determination of health benefit. The International Panel on Climate Change's Fourth Assessment report released on February 2, 2007, concluded that global warming is unequivocal and that human activity is the main driver, asserting with near certainty - more than 90 percent confidence - that carbon dioxide and other heat-trapping greenhouse gases from human activities have been the main causes of warming since 1950. Its Third Assessment report: Climate Change 2001: Working Group II: Impacts, Adaptation and Vulnerability noted that global climate change will have a wide range of impacts on human health. "Overall, negative health impacts are expected to outweigh positive health impacts. Some health impacts would result from changes in the frequencies and intensities of extremes of heat and cold and of floods and droughts. Other health impacts would result from the impacts of climate change on ecological and social systems and would include changes in infectious disease occurrence, local food production and nutritional adequacy, and concentrations of local air pollutants and aeroallergens, as well as various health consequences of population displacement and economic disruption."7 Given the indisputable impact of greenhouse gas increases on climate change and its connection to human health, it is critical to ensure that Canada is moving quickly to reduce greenhouse gas emissions. The Clean Air Act and the subsequent notice of intent sets out short, medium and long term targets and timelines for the reduction of greenhouse gas emissions in Canada. The target setting approach proposed in the Act, based on emission intensity in the short and medium term is not health relevant. To be health relevant, targets should be presented in the context of overall emissions, i.e., emissions reductions minus emissions increases. An emission reduction from a particular source is only health-relevant if we can guarantee that there is not a corresponding emissions increase at another source nearby, because it is the absolute exposure that an individual experiences that affects the risk of an adverse health effect. Just as slowing the progression of a disease can never be considered a cure, attempting only to limit the growth of those emissions cannot result in true success by any measure. It is not until 2050 that the government has committed to achieving an absolute reduction in greenhouse gas emissions of between 45 - 65% of 2003 levels. Based on the emission intensity targets in the Clean Air Act, emissions and air pollution levels will, in fact, continue to rise as will the health consequences. In order to protect the health of Canadians the government needs to set policies, with targets and timelines that maximize absolute reductions in greenhouse gases, which are consistent with the scale and urgency of the challenge. To ensure that prescribed policies result in the intended environment and health outcomes, short and medium-term targets for absolute emission reductions would benchmark progress and allow for mid-course corrections, if they were needed. With respect to indoor air quality, physicians have long been proponents of initiatives to reduce exposure to contaminants such as second-hand tobacco smoke. The CMA is concerned about the impact on human health of exposure to high levels of radon and the associated increased risk of lung cancer. The intention to develop measures to address indoor air quality through a national radon strategy is a positive step. It is important that our patients are made aware of such threats in their homes, and also that they are presented with a way to reduce their exposure. Environmentally related illness is essentially the combined result of exposure and vulnerability. We are vulnerable because we are human beings; each human being has different physical strengths and weaknesses. Some vulnerabilities to environmental influences are genetic, and some the results of pre-existing disease. There is not much that government can do about this part of the equation. Our exposure, on the other hand is related to the air we breathe, water we drink and food we eat. This is where the federal government is critical, and where the measures of success will be the most important. Proxy measures for the health outcomes that matter must be relevant from a health perspective. Health-based success can only be measured by quantifiable reductions in the exposure levels of contaminants in our air as well as in our water and soil. Clean air is absolutely fundamental to a healthy population - without it all else is irrelevant. Actions to curb air pollution must be taken in all sectors and levels of society in a concerted, non-partisan effort with the health of the population and the planet as our yardstick of success. Thank you for the opportunity to provide our comments on Bill C-30, the Clean Air Act. We look forward to working with you to improve the Clean Air Act and ensure that the measure of its success will benefit the health of Canadians. Sincerely Colin J. McMillan, MD, CM, FRCPC, FACP President 1 S. Judek, B. Jessiman, D. Stieb, and R. Vet. 2005. Estimated Number of Excess Deaths in Canada Due to Air Pollution". Health Canada and Environment Canada. http://www.hc-sc.gc.ca/ahc-asc/media/ nr-cp/2005/2005_32bk2_e.html#top 2 Ontario Medical Association. 2005. The Illness Costs of Air Pollution: 2005-2026 Health and Economic Damage Estimates. Toronto: OMA. 3 B.C. Provincial Health Officer. 2004. Every Breath You Take: Air Quality in British Columbia, A Public Health Perspective. 2003 Annual Report. Victoria: Ministry of Health Services. 4 Ontario Medical Association , 2005 5 GLOBE/CTV POLL Climate concerns now top security and health One in four label environmental issues as most important, The Globe and Mail, Fri 26 Jan 2007, Page: A1, Section: National News , Byline: Brian Laghi 6 Health, the Environment and Sustainable Development, Canadian Medical Association , 1991 7 WMO Intergovernmental Panel on Climate Change, Climate Change 2001, IPPC Third Assessment Report: Working Group II: Impacts, Adaptation and Vulnerability, accessed Feb 7, 2007 http://www.grida.no/climate/ipcc_tar/wg2/348.htm

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CMA Response: Health Canada's Medical Marijuana Regulatory Proposal

https://policybase.cma.ca/en/permalink/policy10702

Date
2013-02-28
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Date
2013-02-28
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association welcomes the opportunity to comment on proposed changes to Health Canada's Marihuana for Medical Purposes Regulations, published in the Canada Gazette, Part I on December 15, 2012. CMA provided comments on the proposed changes when Health Canada first announced them in June 2011. Our position on these changes, and indeed on the entire Medical Marihuana Access Program (MMAP), has been consistent since the program was initiated. We remain deeply concerned that, though the program has made a physician's authorization the key to a patient's access to medical marijuana, physicians and other health professionals have little to no evidence-based information about its use as medical therapy. As our President, Dr. Anna Reid, noted in December, the regulatory proposals are "equivalent to asking doctors to prescribe while blindfolded." Health Canada gives two reasons for its regulatory proposal: first, to address concerns about the safety of home grow-ops; and secondly, to reduce the cost of administering a program that has proven more popular than anticipated. Neither of these reasons is related to improving patient care or advancing our clinical knowledge of marijuana as a medical treatment. CMA understands that many Canadians suffer constant pain from chronic or terminal illnesses and are searching for anything that will provide relief. We know that some patients find that use of marijuana relieves their symptoms and that some health professionals also believe it has therapeutic value. However, we are concerned that these claims remain inadequately supported by scientific research. Controlled studies of medical marijuana have been published recently and some have shown benefits. However, these studies are few in number, of short duration and with small samples, and knowledgeable clinicians say that more research is required. In addition, some say that marijuana has become more potent since it became a popular recreational drug in the 1960s, though others disagree,1 and growers say they can develop strains tailored to the needs of individual medical users.2 Though these claims are part of the popular understanding of medical marijuana, there is no scientifically valid evidence that supports them. What Physicians Have Told Us In May 2012, CMA surveyed members of its "e-panel" of physicians to obtain more information about their attitudes and needs regarding medical marijuana. The survey received just over 600 responses out of more than 2,200, for a 27 per cent response rate. Among the findings: * About 70 per cent of respondents had been asked by patients to approve medical marijuana, though only four per cent said they were asked to do so "often." Of those who were asked, one-third reported that they "never" supported such requests, while 18 per cent "usually" did so. * 64 per cent of respondents were concerned that patients who request medical marijuana may actually be using it for recreational purposes; * A large majority of respondents said they would find more information on the appropriate use of marijuana for medicinal purposes, and on its therapeutic benefits and risks, useful or very useful. * About two-thirds agreed or strongly agreed that they would feel more comfortable if: o Physicians wishing to use medical marijuana in their practices were required to undergo special training and licensing; and, o Health Canada offered them protection from liability. * In open-ended questions, some respondents expressed favourable views on marijuana's medical benefits. However, a larger number expressed concern over its harmful effects, such as: psychotic symptoms, especially in younger people; potential for addiction and dependency; and the risks to lung health from smoking it or any other substance. Marijuana is Not Like Other Therapeutic Products Theoretically, marijuana, when used for medicinal purposes, is regulated under the Food and Drugs Act. However, because of its unique legal position, Health Canada has exempted it from the applications of the Act and its regulations, and it has not undergone the scrutiny of benefits and risks required of other therapeutic products approved for use in Canada, be they prescription-only or over-the-counter. According to the Food and Drugs Act (FDA), all drugs requiring a health professional's authorization must be approved for use by Health Canada, based on evidence of effectiveness obtained from controlled clinical trials, which remain the best currently available means of validating knowledge. In addition, Health Canada has a system of post-market surveillance to keep track of problems that arise with prescription drugs in real-world use. Though the CMA has been critical of some aspects of this system,3 we acknowledge that it has added to our body of knowledge on drug safety risks. If marijuana were not an illegal product, it might have been assessed through some form of pre-approval and post-approval surveillance. By exempting marijuana from the FDA's pre-approval and post-approval requirements, Health Canada has lost an opportunity to improve our knowledge of the drug's therapeutic uses. The Views of Canadians A recent online survey conducted by Ipsos-Reid on behalf of the CMA provides insight into the views of Canadians on Health Canada's regulatory proposal.4 The survey found: * 92 per cent of Canadians think it is very or somewhat important that Health Canada not remove itself from its oversight role until guidelines are put in place for physicians; * 90 per cent believe that research on the effectiveness, safety and risks of medical marijuana is needed before Health Canada removes itself from the authorization process; * 85 per cent of Canadians believe medical marijuana should be subject to the same rigorous testing and approval standards as other medicines; * 79 per cent agree that Health Canada has a responsibility to maintain its role in the authorization process.; The Role of the Physician The CMA cannot with certainty predict the consequences of these regulatory changes for the practising physician (and, if the regulations are approved, for the nurse practitioner as well). However, we have several causes for concern: * The gatekeeper role of health professionals: The most significant change, from our point of view, is that Health Canada is removing itself from the approval process, making it a transaction between the patient, the practitioner and the licensed producer. In addition, Section 125 of the regulatory proposal would reduce the content of the authorization form, from its current two-page format to a brief document requiring little more information than is required for a standard medical prescription. We are concerned that these changes will put an even greater onus on physicians than do the current regulations. The CMA agrees with the Federation of Medical Regulatory Authorities that the lack of evidence to support the use of marijuana for medicinal purposes signifies that it is not a medical intervention. In our opinion, putting physicians in the role of gatekeeper for access to marijuana is inappropriate and may be an abdication of responsibility on Health Canada's part.5 Such a move could increase physicians' liability risk and put them at odds with their medical regulatory authorities, which have no choice but to continue to advise physicians to exercise extreme caution. The CMA believes, as does the Canadian Medical Protective Association, that a drug's approval under the Food and Drugs Act does not impose a legal obligation on physicians or nurse practitioners to authorize its use if, in their judgment, it is clinically inappropriate. The Ontario Court of Appeal reached a similar decision recently in the case of R. v. Mernagh. * Protection of Physician Privacy. Under the proposed regulations, health information and physician data - such as the patient's name and date of birth, or the provider's licence number - will be collected by licensed producers who may not be subject to the same regulatory and privacy constraints as the health care sector. The draft regulations also indicate that the licensed producer is expected to confirm that the data on the "medical document" is correct and complete - in other words, health providers who authorize medical marijuana use will receive correspondence from the producer. We are very concerned about the risks this would pose to the privacy of patient and health care provider information. We believe Health Canada should conduct a privacy impact assessment of its proposed regulations or, if it has done so, to share the results. * Physicians as Dispensers. Section 124 of the proposed regulations would allow authorized health care practitioners to "sell, provide or administer dried marijuana." This is contrary to Article 46 of the CMA Guidelines for Physicians in Interactions with Industry, which states that "Physicians should not dispense pharmaceuticals or other products unless they can demonstrate that these cannot be provided by an appropriate other party."6 * Other possible consequences. We are also concerned about other potential consequences of the regulatory changes. Will more people go to health professionals requesting an authorization, on the assumption that the new regulations will make it easier to get? Will entrepreneurs seize the opportunity to establish "dispensaries" whose intended clientele are not those in legitimate medical need, as recent news stories have suggested?7 Will medical marijuana advocates put increased pressure on physicians to authorize its use? Meeting the Information Needs of Physicians In one respect, Health Canada has listened to physicians' concerns regarding the lack of evidence about medical marijuana, and acknowledged the need to remedy this problem. Though it is not addressed in the draft regulations, Health Canada has established an Expert Advisory Committee (EAC) to help provide comprehensive information to health professionals. The CMA has attended meetings of this committee in an observer capacity, suggested the names of practising physicians to serve as members, and made a presentation to the committee at its meeting in November 2012. If the EAC follows the CMA's suggestions, it will consider actively supporting the following activities: * Funding of scientific research on the clinical risks and benefits of marijuana; * Knowledge translation activities to convert this research into accessible, user-friendly tools for education and practice; * Development of best practice guidelines in the therapeutic use of marijuana. Though this guideline would of necessity be based on "C" level evidence, it would be an improvement on what now exists; and * Support for a compulsory training and licensing program for physicians wanting to authorize marijuana for medicinal purposes. The CMA believes that the EAC should be given the mandate and resources to undertake these activities. Conclusion Health Canada's stated mission is to help the people of Canada maintain and improve their health. The CMA believes that if Health Canada wants its Medical Marihuana Access Program to serve this mission, it should not withdraw from administering the program, leaving it to health professionals working within a large knowledge gap. Rather, it should support solid research into the use of marijuana as medication and make a commitment to share this knowledge with the health professional community and to support best clinical practices. 1 Bonsor K: "How marijuana works". Accessed at http://science.howstuffworks.com/marijuana5.htm 2 http://medicalmarijuana.ca/learning-center/marijuana-strains 3 CMA Submission to the House of Commons Standing Committee on Health: Post-Market Surveillance of Prescription Drugs (February 28, 2008). Accessed at http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Submissions/2008/brief-drug-en-08.pdf 4 Online survey of 1,000 Canadians the week of Feb. 24, 2013 conducted by Ipsos-Reid. Summary report of the poll can be accessed at www.cma.ca/advocacy/cma-media-centre. 5 Letter to Health Canada from Yves Robert, MD, President of the Federation of Medical Regulatory Authorities of Canada, November 4, 2011. 6 CMA. 2004. Guidelines for Physicians in Interactions with Industry. Guideline can be accessed online: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-01.pdf 7 Lee J. "Ross Rebagliati to Open medical marijuana franchise." Vancouver Sun. January 23, 2013. Accessed at http://www.vancouversun.com/health/Ross+Rebagliati+open+medical+marijuana+franchise/7860946/story.html

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CMA Submission: The need for health infrastructure in Canada

https://policybase.cma.ca/en/permalink/policy10705

Date
2013-03-18
Topics
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Date
2013-03-18
Topics
Health systems, system funding and performance
Text
In its Economic Action Plan 2011(Budget 2011), the Government of Canada committed to consult stakeholders on the next long-term plan for public infrastructure which would extend beyond the expiry of the current framework, the Building Canada Plan, on March 31, 2014. The CMA’s 2012-13 pre-budget brief recommends that the federal government ensure health infrastructure is eligible for funding as part of the next long-term plan for public infrastructure. The purpose of which is to address a particular health infrastructure deficit that is preventing the optimization of health care resources and exacerbating wait times and ensure that Canadian communities are able to meet the current and emerging care needs of their older seniors. The CMA has prepared this brief to provide further details on the scope of the proposed infrastructure funding for the health sector, its rationale and economic benefit, and how it could be applied. 2. Overview of proposal The CMA recommends that the federal government ensure health sector infrastructure for long-term care facilities is eligible for funding under the next long-term infrastructure program. This funding should be applicable both for new capital projects and for renovating/retrofitting existing facilities. This recommendation, and the recognition of the need for additional capacity in the long-term care sector, is part of a pan-Canadian approach to redirect alternate level of care patients from hospitals to homes, communities and long-term care facilities, where they can receive more appropriate care at a lower cost. It costs $842 per day for a hospital bed versus $126 per day for a long-term care bed. If ALC patients were moved to more appropriate care settings, in this case, from hospital to long-term care, this would save the health care system about $1.4 billion a year. For the purposes of this recommendation, long-term care facilities include long-term care residential homes, assisted living units and other types of innovative residential models that ensure residents are in the setting most appropriate to their needs. The long-term care sector is facing significant change due to increasing numbers of older seniors and their increasingly complex care needs. These pressures not only relate to the construction of new facilities but apply to the need to maintain existing facilities, including retrofitting to meet higher regulatory requirements, as well as struggling to meet higher care needs of their increasingly elderly population. The CMA’s recommendation to ensure that long-term care infrastructure qualify under the next long-term infrastructure plan is one component of the association’s Health Care Transformation initiative and would support a pan-Canadian approach for continuing care, which would integrate home care and facility-based long-term, respite and palliative care services fully within the health care system. 3. Rationale The rationale behind the recommendation for health infrastructure to qualify for the next long-term infrastructure plan is based primarily on the care needs of Canada’s growing seniors’ population and its impact on Canada’s health care system. Communities across Canada face a common problem of a lack of resources to properly meet the housing and care needs of their seniors population. Demographic trends indicate this problem will only intensify. However, as demonstrated below, investing in seniors can generate substantial direct and indirect economic benefits. Meeting the needs of Canada’s growing seniors population and their changing care needs While all advanced countries are expected to age over the coming decades, the Canadian population is projected to age more rapidly than that of most other OECD countries, according to a recent report from Finance Canada. Statistics Canada reports the number of seniors (65+) in Canada is projected to increase from 4.2 million in 2005 to 9.8 million in 2036, with their share of the total population increasing from 13.2 per cent to 24.5 per cent. The number and proportion of older seniors – those 75 and older – are expected to increase significantly as well. Ontario’s population of people aged 75 and up is expected to grow by almost 30 per cent between 2012 and 2021. According to Statistics Canada’s medium-growth population projection scenario, the population aged 80 years or over will increase 2.6 times by 2036 – to 3.3 million persons. While the rate of residency in long-term care facilities among seniors has been declining, as the aging of Canada’s population accelerates, the demand for residential care will nonetheless increase significantly over the near term due to higher numbers of elderly seniors. Not only is the size of the elderly population increasing, but their health needs are changing too, particularly among those requiring residential care. Long-term care residents are older today than in previous years and have more complex health needs than ever before. A Canadian Institute for Health Information (CIHI) comparison of home care clients and seniors who are living in residential care found that “seniors in residential care were more likely to require extensive assistance with activities of daily living (ADLs), such as bathing and toileting (74 per cent versus 18 per cent). They were also more likely to have moderate to severe cognitive impairment (60 per cent versus 14 per cent). The number of residents with dementia is expected to increase. In 2011, 747,000 Canadians were living with cognitive impairment, including dementia – that’s 14.9 per cent of Canadians 65 and older. By 2031, this figure will increase to 1.4 million. At the request of the House of Commons Finance Committee, the CMA submitted a national dementia strategy. This proposal to fund long-term care facilities supports such a strategy. Many existing residential facilities are poorly equipped to meet the care needs of their residents, which are more complex now than when these facilities were originally built. For example, many facilities do not meet current building safety standards and the limited provincial and municipal funding available is usually insufficient to bring them up to code. Also, there is a lack of units with shared space to better support residents with dementia, as well as a shortage of appropriate units to care for residents who are disabled or obese. Renovations are also required to make better use of long-term care beds for other purposes such as providing short-stay respite care or transitional care. According to the Ontario Association of Community Care Access Centres, the lack of physical facilities necessary for care was the reason most often given by homes for declining to admit a long-term care wait-list client. Opportunity to improve health care efficiency and reallocate existing program spending We recognize that addressing the current gap in long-term care residency options is only one strategy to improve the effectiveness of Canada’s health care system. However, we believe it is a critical component of an integrated continuum of care strategy that provides for increased home and community supports. Improving options for seniors will have a positive cascading effect on many other elements of the system. Not only will seniors reside in more appropriate and safer settings but acute care resources will be better used. Consider that about 45 per cent of provincial and territorial governments’ health care spending in 2009 went toward those 65 years and older, while this group constituted only 14 per cent of the population. A major issue facing Canada’s health care system is the high number of alternate level of care patients (ALC) who occupy acute care beds. ALC patients are those who have completed the acute care phase of their treatment but remain in an acute care bed or who are admitted into a hospital bed due to the lack of a more appropriate care setting. In most cases, these people would be better served living in their own home with the appropriate level of supports or in a long-term care residence. The high number of ALC patients in hospitals is a problem experienced across the country. The total number of hospital bed days for ALC patients in 2007-2008 (latest figures) was 1.7 million. Furthermore, the lack of options for ALC patients also contributes to a high percentage of these patients being readmitted to hospital within 30 days of discharge (see Appendix A). According to CIHI figures, 85 per cent of ALC patients were older than age 65, with almost half waiting for placement in long-term care. A high percentage of ALC patients suffer from dementia. It costs $842 per day for a hospital bed versus $126 per day for a long-term care bed. If ALC patients were moved to more appropriate care settings, in this case, from hospital to long-term care, this would save the health care system about $1.4 billion a year. The presence of ALC patients in hospitals also lead to longer surgical wait times and longer delays in the emergency department as acute care beds remain unavailable. In fact, the Wait Time Alliance – an alliance of 14 national medical organizations and specialties – has said “the most important action to improve timely access to specialty care for Canadians is by addressing the ALC issue.” Available wait-time data (See Appendix B) for long-term care show that wait times to access a long-term care bed can often be measured in, not months or days, but years. Data from Ontario for 2004 to 2008 found that less than 50 per cent of seniors with high or very high needs were placed in a long-term care facility within a year of being put on a wait list. The average wait time for placement in Quebec is 13 months (ranging between five months and four years). The most recent report by Ontario’s Auditor General found that 15 per cent of patients on the provincial wait list for long-term care passed away while waiting for placement. The wait to access residential care can vary immensely depending on where one resides. Often the wait is longer for residents in small, rural and northern communities. Sometimes the only route to securing a placement is for the resident to move to a facility in another community. Investment required According to Statistics Canada, there are 261,945 long-term care beds in operation in Canada (latest figures, 2009/10.) How many residential beds will be required in the future to meet the growing number of elderly seniors? The Conference Board of Canada has produced a bed forecast tied to the growth of the population aged 75 and over and based on a decreased bed ratio demand of 0.59 per cent per year to reflect the greater shift to community-based services and supportive housing options being advanced at the provincial level. This bed ratio demand is described by the Canadian Healthcare Association as representing a modest shift from the current reliance on long-term care to community services. Based on these assumptions, it has been estimated that Canada will require an average of 10,535 new beds per year over the next 35 years, for a total of 637,721 beds by 2047. Demand would vary over the 35-year period, peaking between 2022 and 2040 (See Appendix C). The five-year projection for beds is as follows: Table 1: Projected shortage in long-term care beds, 2014 to 2019 [SEE PDF FOR CORRECT DISPLAY OF TABLE] Year Number of additional beds required 2014 4,331 2015 4,715 2016 6,028 2017 6,604 2018 8,015 Projected 5-year shortage 29,693 As shown, there is a projected shortage of 29,693 beds over the next five years. For the purposes of longer-term planning, the gap in beds required for the following five-year period (2019-2023) is as follows: Table 2: Projected shortage in long-term care beds, 2019 to 2023 [SEE PDF FOR CORRECT DISPLAY OF TABLE] Year Number of additional beds required 2019 8,656 2020 8,910 2021 10,316 2022 14,888 2023 14,151 As previously outlined, the rising gap in bed numbers is affected by the increased numbers in people aged 75 and older anticipated over the next 35 years. The estimated cost to construct 10,535 beds (the average number of beds required to be built per year from 2013 to 2047) is $2.8 billion, based on a cost estimate of $269,000 per bed. This figure could include both public and private spending. The purpose of this bed projection is to provide a sense of the immense challenge Canada faces in addressing the needs of a vulnerable segment of its older seniors population. It is important to note that this forecast does not include the significant investments required to renovate and retrofit the existing stock of residential facilities, not only to meet the current standards but to effectively respond to the complex care needs of residents requiring long-term care today and in the future. Similarly, the potential facility capacity expansions through retrofit or renovation are not included. Moreover, innovative capital investment in residential facilities can provide opportunities for their greater use by other members of the community. They can, for example, provide short-stay respite to support families and convalescent care programs such as those found in the United Kingdom. We also recognize that supportive housing and healthy aging programming are important components of an integrated solution to the ALC issue and to ensuring seniors reside in the most appropriate place. 4. How the funding would work Health infrastructure could qualify under a communities component of the next long-term infrastructure plan where this federal funding can be leveraged with provincial and and / or municipal investment (e.g. 1/3 federal component matched by + 2/3 provincial and / or municipal). This funding allocation could also include the use of public-private partnership models. Investing in Canada’s Continuing Care Sector Provides a Wide Range of Economic Benefits Construction of new residential care models and renovating/retrofitting existing facilities will provide significant economic opportunities for many communities across Canada (See Appendix E for detailed figures). Based on Conference Board of Canada estimates, the construction and maintenance of 10,535 long-term care beds (the average number of new beds needed per year from 2013 to 2047) will yield direct economic benefits on an annual basis that include $1.23 billion contribution to GDP and 14,141 high value jobs during the capital investment phase and $637 million contribution to GDP and 11,604 high value jobs during the facility operation phase (based on an average annual capital investment); and close the significant gap between the projected long-term care bed shortages and current planned investment. When indirect economic contributions are included, the total estimated annual contribution to Canada’s GDP reaches almost $3 billion, yielding 37,528 new jobs (construction, care providers and other sectors). Details on these economic benefits are provided in Appendix F, but a summary is presented below: Table 3: Average annual total economic contribution of new residential care facilities [SEE PDF FOR CORRECT DISPLAY OF TABLE] (10, 535 new beds per year at market prices) GDP (in 2013 $millions) Number of jobs created Average direct contribution to GDP of investing in new facilities (construction) $1,225.4 14,141 Average direct contribution to GDP of operating the new facilities $637.0 11,604 Average indirect contribution to GDP of investing in new facilities (construction) $969.9 10,115 Average indirect contribution to GDP of operating the new facilities $135.4 1,667 TOTAL (both direct and indirect) $2,968 37,528 For every 100 jobs created in the construction of long-term care facilities, an additional 72 jobs would be created in other sectors, while for every 100 jobs created in the long-term care sector, 14 jobs would be created in other sectors. The numbers provided above reflect the annual average contribution. On a time specific level, covering the five-year period between 2014 and 2018, an estimated 167,840 jobs would be created, based on the construction of 29,693 new beds. Another important economic benefit is the return in government revenues. The increase in construction and operating spending per average year will provide over $425 million in federal government revenues and over $370 million in provincial revenues (See Appendix G). As previously identified, an improved stock of long-term care beds will provide many other economic spinoffs, including savings in health care costs that can be reallocated to better meet Canadians’ health care needs and to provide greater support for families in their role as caregivers. Without adequate provision of long-term care resources, Canada’s labour force may experience a productivity drag through increased leaves and absenteeism to care for elderly relatives. 5. Conclusion The aging of our population touches all Canadians – from seniors who need the services to families who serve as caregivers and/or contribute financially to the care of aging relatives. Recent data show that 32 per cent of caregivers who provide more than 21 hours of care per week report distress in their role – four times the proportion of distressed caregivers who provide less than 10 hours of informal care per week. The federal government has a long history of allocating capital investment in the health sector. Previous examples include the Hospitals and Construction Grants Program in 1948, the Health Resources Fund established in 1966 and, more recently, the funding of capital projects at research hospitals under the Canada Foundation for Innovation Leading Edge and New Initiatives Funds in 2012. All communities across Canada are strongly affected by the social and health care needs of their growing senior and long-term care populations (see Appendix H for a sample of recent news stories.) Federal capital investment will help narrow the significant gap between the projected long-term care bed shortages and current planned investment in the area of residential care facilities. Further, it would have a cascading effect leading to a more effective and efficient Canadian health care system. Recommendation The Canadian Medical Association recommends that the federal government allocate $2.3 billion over a five-year period in the next long-term infrastructure plan for the construction, renovation and retrofitting of long-term care facilities. Long-term care facilities include long-term care residential homes, assisted living units and other types of innovative residential models that ensure residents are in the most care setting most appropriate to their needs. This funding could be delivered as part of the communities component of the next long-term infrastructure plan. 1 Department of Finance Canada. Economic and fiscal implications of Canada's aging population. Ottawa, 2012. 2 Office of the Auditor General of Ontario. 2012 annual report. 2012. http://www.auditor.on.ca/en/reports_en/en12/2012ar_en.pdf. Accessed 01/30/13. 3 Statistics Canada. Population projections for Canada, provinces and territories 2009 to 2036. June 2010. 91-520-X 4 Alzheimer's Society Ontario. Facts about dementia. http://www.alzheimer.ca/en/on/About-dementia/Dementias/What-is-dementia/Facts-about-dementia. Accessed 01/30/13. 5 Canadian Medical Association. Toward a Dementia Strategy for Canada. Ottawa, 2013. http://www.cma.ca/submissions-to-government Accessed 01/30/13. 6 Ontario Association of Non-Profit Homes and Services for Seniors. Proposals for the Ontario Budget. Fiscal Year 2012-13. March 2012. 7 David Walker. Caring for our aging population and addressing alternate level of care. Report Submitted to the Minister of Health and Long-Term Care. June 30, 2011. Toronto. 8 Long Term Care Innovation Expert Panel. Why not now? A bold, five-year strategy for innovating Ontario's system of care for older adults. March 2012. http://www.oltca.com/axiom/DailyNews/2012/June/LTCIEPFullREport_web_jun6.pdf. Accessed 01/30/13. 9 For an example of an integrated continuum of post-acute care model see CARP, One Patient: CARP's Care Continuum. http://www.carp.ca/wp-content/uploads/2013/01/One-Patient-Brief-Updated-Oct-18.pdf. Accessed 01/30/13. 10 Canadian Life and Health Insurance Association. Improving the accessibility, quality and sustainability of long-term care in Canada. CLHIA Report on Long-Term Care Policy. June 2012. 11 Wait Time Alliance. Time out! Report card on wait times in Canada. 2011. http://www.waittimealliance.ca/media/2011reportcard/WTA2011-reportcard_e.pdf. Accessed 01/30/13. 12 Correspondence with officials from Bruyère Continuing Care in Ottawa. January 2013. 13 Canadian Institute for Health Information. Health care in Canada, 2011 2011. . 14 Rapport du Vérificateur général du Québec à l'Assemblée nationale pour l'année 2012-2013. 15 Office of the Auditor General of Ontario. 2012 annual report. 2012. 16 The .59 per cent decrease in bed ratio is presented as Scenario 2 in Lazurko, M. and Hearn, B. Canadian Continuing Care Scenarios 1999-2041, KPMG Final Project Report to FPT Advisory Committee on Health Services, Ottawa. 2000. Presented in Canadian Healthcare Association, New Directions for Facility-Based Long-Term Care. 2009. http://www.cha.ca/wp-content/uploads/2012/11/CHA_LTC_9-22-09_eng.pdf. Accessed 01/30/13. 17 Canadian Institute for Health Information, Health Care in Canada, 2011.

Documents

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Ensuring equitable access to health care: Strategies for governments, health system planners, and the medical profession

https://policybase.cma.ca/en/permalink/policy11062

Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
Ensuring equitable access to effective and appropriate health care services is one strategy which can help to mitigate health inequities resulting from differences in the social and economic conditions of Canadians. Equitable access can be defined as the opportunity of patients to obtain appropriate health care services based on their perceived need for care. This necessitates consideration of not only availability of services but quality of care as well.1 There is far ranging evidence indicating that access to care is not equitable in Canada. Those with higher socio-economic status have increased access for almost every health service available, despite having a generally higher health status and therefore a decreased need for health care. This includes insured services (such as surgery), as well as un-insured services such as pharmaceuticals and long-term care. Those from disadvantaged groups are less likely to receive appropriate health care even if access to the system is available. They are more likely to report trouble getting appointments, less testing and monitoring of chronic health conditions, and more hospitalizations for conditions that could be avoided with appropriate primary care. There is a financial cost to this disparity in equitable care. Reducing the differences in avoidable hospitalizations alone could save the system millions of dollars. Barriers to equitable access occur on both the patient and health care system or supply side. Common barriers include: (see pdf for correct display of table) Demand Side or Patient Barriers Supply Side or System Barriers Health literacy Services not located in areas of need Cultural beliefs and norms Patients lack family physicians Language Lack of management of chronic disease Cost of transportation Long waits for service Time off work for appointments Payment models which don't account for complexity of patients Access to child care Coordination between primary care and speciality care and between health care and community services Payment for medications or other medical devices/treatments Standardization of referral and access to specialists and social services Immobility- due to physical disabilities, and/or mental health barriers Lack of needs based planning to ensure that population has necessary services Cognitive issues, ie. Dementia, that adversely affect ability to access and comply with care Attitudes of health care workers To tackle barriers on the patient side there is a need to reduce barriers such as transportation and the prohibitive cost of some medically necessary services. Further, there is a need to increase the health literacy of patients and their families/caregivers as well as providing support to health care providers to ensure that all patients are able to be active participants in the management of their care. On the system side the strategies for action fall into four main categories: patient-centred primary care which focuses on chronic disease management; better care coordination and access to necessary medical services along the continuum of care; quality improvement initiatives which incorporate considerations of equity as part of their mandate; and health system planning and assessment which prioritizes equitable access to care. Recommendations are provided for CMA and national level initiatives; health care planners; and physicians in practice. Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. By removing barriers on both the patient and system side it is hoped that greater access to appropriate care will follow. Introduction: In Canada as in many countries around the world there are major inequities in health status across the population. Those lower on the socio-economic scale face higher burdens of disease, greater disability and even shorter life expectancies.2 Many of these disparities are caused by differences in social and economic factors such as income and education known as the social determinants of health.3,1 While many of these factors are outside of the direct control of the health care system, ensuring equitable access to effective and appropriate health care services can help to mitigate some of these disparities. The alternative can also be true. In health systems where access to care and appropriateness are unequal and skewed in favour of those of higher socio-economic status, the health system itself can create further inequities and add greater burden to those already at an increased risk of poor health. Physicians as leaders in the health care system can play a role in ensuring equitable access to care for all Canadians. Equitable Access to Health Care in Canada: Equitable access can be defined as the opportunity for patients to obtain appropriate health care services based on their perceived need for care. This necessitates consideration of not only availability of services but quality of care as well.4 Due to burden of disease and therefore need, those with lower socio-economic status should be utilizing more services along the continuum.5 That, however, is not the case. Individuals living in lower income neighbourhoods, younger adults and men are less likely to have primary care physicians than their counterparts.6 Primary care physicians deliver the majority of mental illness treatment and they are the main source of referrals to psychiatrists or other specialists. However, much of the care for people with mental illnesses, especially on the lower socio-economic end of the scale, is delivered in emergency rooms, which is both costly and episodic. This is due not only to a lack of primary care access but to a lack of community mental health services.7 Those with higher socio-economic status are much more likely to have access to and utilize specialist services.8 Examples include greater likelihood of catheterization and shorter waits for angiography for patients with myocardial infarction9; and greater access to in-hospital physiotherapy, occupational therapy, and speech language therapy for those hospitalized with acute stroke10. Low income men and women with diabetes were just as likely to visit a specialist for treatment as high income individuals despite a significantly greater need for care.11 There is a correlation between higher income and access to day surgery.12 A Toronto study found that inpatient surgery patients were of much higher income than medical inpatients.13 Additionally, utilization of diagnostic imaging services is greater among those in higher socio-economic groups.14 Access to preventive and screening programs such as pap smears and mammography are lower among disadvantaged groups.15 Geography can cause barriers to access. In general rural Canadians have higher health care needs but less access to care.16 People in northern and rural communities typically have to travel great distances to obtain health services as many, especially specialist services, cannot be obtained in their home community.17 Those living in the most rural communities in Canada are the least likely to have a regular family doctor, or to have had a specialist physician visit.18 According to data from the Society of Rural Physicians of Canada, 21% of the Canadian population is rural while only 9.4% of family physicians and 3% of specialists are considered rural.19 This lack of access to specialists and other medically necessary services can lead to delays in treatment and harm to health including unnecessary pain and permanent disability.20 Further, travel for necessary treatment often comes with a significant financial cost.21 It is not just access to insured services that is a problem in Canada. Many Canadians do not have access to needed pharmaceuticals. Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.22 The use of appropriate diabetes preventative services, medication, and blood glucose testing, has been shown to be dependent on out of pocket expenditures.23 Rehabilitation services are difficult for some Canadians to access as well. Services such as physiotherapy and occupational therapy are often not covered unless they are provided in-hospital or to people on certain disability support programs. This leads to long wait times for services that are covered or no access at all.24 Adding to these inequities is the fact that different programs are covered in different provinces and territories.25 Access to mental health services is a major challenge for Canadians. According to data from Statistics Canada, more than half a million Canadians who had a perceived need for mental health care services, reported that their needs were unmet. Access to counselling services was the most frequent unmet need reported.26 A number of important mental health professionals - notably psychologists and counsellors - are not funded through provincial health budgets, or are funded only on a very limited basis. Access to psychologists is largely limited to people who can pay for them, through private insurance or out of their own pockets.27,2 Access to subsidized residential care, long-term care, home care and end-of-life care is problematic as well. Those with means can access high quality long-term care services within their community, while those with inadequate resources are placed in lower quality facilities sometimes hours away from family and friends.28 Even with expansions promised by governments, home care will not be able to meet the needs of underserved groups such as those living in rural and remote areas.29 Finally, only a fraction of patients have access to or receive palliative and end-of-life care. Those living in rural or remote areas or living with disabilities have severely limited access to formal palliative care.30 Difficulties in access are particularly acute for Canada's Aboriginal peoples. Many live in communities with limited access to health care services, sometimes having to travel hundreds of miles to access care.31 Additionally, there are jurisdictional challenges; many fall through the cracks between the provincial and federal health systems. While geography is a significant barrier for Aboriginal peoples, it is not the only one. Aboriginals living in Canada's urban centres also face difficulties. Poverty, social exclusion and discrimination can be barriers to needed health care. Of all federal spending on Aboriginal programs and services only 10% is allocated to urban Aboriginals. This means that Aboriginals living in urban areas are unable to access programs such as Aboriginal head start, or alcohol and drug services, which would be available if they were living on reserve.32 Further, even when care is available it may not be culturally appropriate. Finally, Canada's Aboriginal peoples tend to be over-represented in populations most at risk and with the greatest need for care, making the lack of access a much greater issue for their health status.33 However, these examples are only part of the story as accessing care which is inappropriate cannot be considered equitable access.34 Those of lower socio-economic status are more likely to use inpatient services; show an increased use of family physician services once initial contact is made;35 and have consistently higher hospitalization rates; 36 This could be due to the higher burden of need or could demonstrate that the services that are received are not addressing the health care needs of those lower on the socio-economic scale.37 Women and men from low-income neighbourhoods are more likely to report difficulties making appointments with their family doctors for urgent non-emergent health problems. They were also more likely to report unmet health care needs.38 In terms of hospitalizations, people with lower socio-economic status were much more likely to be hospitalized for ambulatory care sensitive conditions (ACSC) and mental health39; admissions which could potentially be avoided with appropriate primary care.40 They were also found to have on average longer lengths of stay.41 According to a study of hospitals in the Toronto Central Local Health Integration Network, patients considered to be Alternate Level of Care were more likely to have a low-income profile.42 Further, people with ACSC in low-income groups, those living in rural areas, or those with multiple chronic conditions were twice as likely to report the use of emergency department services for care that could have been provided by a primary care provider.43 There is a financial cost to this disparity. According to a 2011 report, low-income residents in Saskatoon alone consume an additional $179 million in health care costs than middle income earners.44 A 2010 study by CIHI found increased costs for avoidable hospitalizations for ambulatory care sensitive conditions were $89 million for males and $71 million for females with an additional $248 million in extra costs related to excess hospitalizations for mental health reasons.45 Areas for Action: As the background suggests, equitable access is about more than just utilization of services. There are patient characteristics as well as complex factors within the health system which determine whether equitable access is achieved. Recent work has categorized access as having considerations on the supply of services and demand of patients for care. On the demand or patient side we must consider: ability to perceive; ability to seek, ability to reach, ability to pay, and ability to engage. On the supply side or health system considerations include: approachability; acceptability, availability and accommodation, affordability, and appropriateness. 46 The following table highlights some of the current barriers to equitable access. (See PDF for correct display of table) Demand Side or Patient Barriers Supply Side or System Barriers Health literacy Services not located in areas of need Cultural beliefs and norms Patients lack family physicians Language Lack of management of chronic disease Cost of transportation Long waits for service Time off work for appointments Payment models which don't account for complexity of patients Access to child care Coordination between primary care and speciality care and between health care and community services Payment for medications or other medical devices/treatments Standardization of referral and access to specialists and social services Immobility- due to physical disabilities, and/or mental health barriers Lack of needs based planning to ensure that population has necessary services Cognitive issues, ie. Dementia, that adversely affect ability to access and comply with care Attitudes of health care workers Patient based actions for improving equitable access: Low health literacy can lead to difficulties for some Canadians in perceiving a need for care.47 Evidence suggests that more than half of Canadian adults (60%), lack the capacity to obtain, understand and act upon health information and services in order to make health decisions on their own.48 Many physicians are undertaking strategies to minimize this lack of health literacy among their patients. Examples include plain language resources as well as teach-back exercises which allow physicians to determine whether patients have fully understood the information provided.49 These efforts should continue to be supported. Understanding how the health system works and where to access services can be a problem for some individuals.50 Beliefs about the need and value for certain services can also undermine the ability of patients in seeking care.51 Work needs to be done to ensure that disadvantaged groups are aware of the services that are available to them and the benefits of taking preventative steps in their health. Low-income Canadians are ten times more likely to report unmet needs of health care due to the cost of transportation.52 Other barriers include a lack of child care, and ability to get time off work to attend necessary health appointments.53 Strategies that provide patients with transportation to appointments or subsidies for such travel have seen some success. Extended office hours and evening appointments can increase access for those unable to take time off work. Additionally, programs that provide patients with home visits from health care providers can help to eliminate this barrier. Further support and expansion of these programs should be explored. There is also the inability to pay for services not covered by provincial plans such as pharmaceuticals, physiotherapy and other rehabilitation services.54 According to a 2005 report on diabetes in Canada, affordability and access to medical supplies was the biggest challenge for those Canadians living with diabetes.55 Access to services such as mental health counselling, subsidized residential care, and long-term care are also hindered by the inability to pay. Even if patients are able to obtain care they may not be able to fully engage. Language difficulties, low health literacy, cognitive challenges (ie. Dementia), cultural mores and norms, and discrimination or insensitivity of health care workers, may all act as barriers to full participation in care.56 Efforts should be made to develop teaching methods to improve engagement of patients and their families/caregivers from disadvantaged groups.57 Strategies to remove or minimize the barriers created by a lack of health literacy should be developed and shared with physicians and other health care providers. Further, programs which facilitate access to services including interpretation and translation of key health information should be supported.58 Finally, an understanding of a patient's cultural and social context is important. The Royal College of Physicians and Surgeons of Canada and the Association of Faculties of Medicine of Canada have developed training modules for physicians who will be working with Canada's Aboriginal peoples.59 Similar programs have been developed by the Canadian Paediatric Society, and the Society of Obstetricians and Gynaecologists of Canada. More of this training is needed and should focus on groups who are likely to experience disadvantage in health care access and appropriateness. Recommendations for action: CMA and National Level Initiatives The CMA recommends that: 1. Governments develop a national strategy for improving the health literacy of Canadians which takes into account the special needs of different cultures. 2. Governments provide accessible and affordable transportation options for patients requiring medical services when such services are unavailable locally. 3. Governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies. 4. Governments examine methods to ensure that low-income and other disadvantaged Canadians have greater access to needed medical interventions such as rehabilitation services, mental health, home care, and end-of-life care. 5. Governments explore options to provide funding for long-term care services for all Canadians. 6. Governments ensure that necessary interpretation and translation services are provided at all points of care. Physicians in Practice The CMA recommends that 7. Physicians be supported in addressing the health literacy of their patients and their families/caregivers. 8. Physician education programs continue to emphasize the important cultural and social contexts in which their patients live. System based actions for improving equitable access: On the system side there are two main areas that need to be addressed: making sure that people can access the services that they need (approachability, availability and accommodation, and affordability); and ensuring that once they have accessed the system that services are appropriate for their health needs (acceptability and appropriateness). Strategies for action include: patient-centred primary care which focuses on chronic disease management; better care coordination and greater access to necessary medical services along the continuum; quality improvement initiatives which incorporate equity as part of their mandate; and health system planning and assessment which prioritizes equitable access to care. 1. Patient-centred primary care which focuses on chronic disease management and which includes programs to increase access to those most at need. Comprehensive primary care offers the biggest possibility for increasing equitable access and reducing health disparities. Data from a large population study in Ontario indicates that inequities in access to primary care and appropriate chronic disease management are much larger than inequities in the treatment of acute conditions.60 Currently many primary care services are located outside of the neighbourhoods with the greatest need for care. While some are accessible through public transportation, there is still a need for more convenient access for these communities. Community health centres (CHC) offer a good model for addressing this challenge through location in disadvantaged neighbourhoods and the provision of culturally appropriate care.61 Additionally, CHCs offer a number of different health, and sometimes social services, under one roof making access to many different types of care more convenient for patients. More work needs to be done to to reduce barriers in access to Canadians living in rural and remote communities. Telemedicine is one strategy that has increased access for rural Canadians. The Ontario Telemedicine Network is one example of this innovative approach. Patients in rural communities can have access to specialists in urban centres through their local health providers. Examples include cardiac rehab follow-up, tele-homecare to support lifestyle changes, and psychiatric or mental health consultations.62 Programs which encourage recruitment and training of health professionals from rural and disadvantaged populations have been found to increase access as these individuals are more likely to return to their home communities to practice.63 Medical schools have been attempting to increase the diversity in their schools for a number of years. However, work still needs to be done. Data from the 2012 student component of the National Physician Survey shows that 278 of the 2000 students who responded to the survey (13.9%) come from families considered to be in the top 1% of earners in Canada. This is compared to only 46 (2.3%) of students whose family incomes place them in the bottom quintile of earners. 64 One of the suggested strategies for increasing diversity in medical schools is increasing the knowledge about the medical profession among rural and disadvantaged young people. An innovative program in Alberta called Mini Docs allows children between the ages of six and 12 to learn about being a doctor and how to stay healthy. The children get to wear medical scrubs for the day and use harmless medical tools such as stethoscopes and bandages. The day long program is run by medical students.65 Strategies to remove financial barriers to access, such as scholarships, should be expanded. Further, there is a need to modify the admissions process to recognize the differences in access to programs such as MCAT preps and overseas volunteer experiences based on the availability of financial resources as well as the necessity of employment for some students while in medical school. This necessary employment may limit the time available for volunteer and community service.66 Another strategy that can be effective in increasing access is programs that seek to link primary care providers with unattached and underserved patients. Programs such as Health Care Connect in Ontario and the GP and Me program in British Columbia actively seek to link sometimes hard to serve patients to appropriate primary care. The College of Family Physicians of Canada has developed a blueprint for comprehensive primary care for Canadians. The concept, a 'patient's medical home' seeks to link Canadians with a comprehensive health care team led by a family physician. These medical homes will take many forms but will be designed to increase both access and the patient-centredness of care.67 Another barrier to access is timeliness of service. Many patients are forced to use walk in clinics or emergency departments as they cannot receive the required care from their primary care providers. Use of walk-in clinics or emergency departments for primary care may lead to lost opportunities for prevention and health promotion.68 Advanced access programs can help to improve equitable access to care by facilitating timely appointments for all patients.69 The AIM (Access improvement measures) program in Alberta uses a system designed by the Institute for Healthcare Improvement to redesign practice to focus on same day appointments and elimination of unnecessary delays.70 Primary care which prioritizes chronic disease management offers the greatest potential for increasing appropriateness of care and reducing system costs. Those most likely to have chronic diseases are also those who face the biggest barriers to equitable access.71 Currently many people with ACSC do not receive the appropriate tests to monitor their conditions, management of their medications, or supports to self-manage their disease.72 Some programs do exist to encourage more effective management of chronic disease. The Champlain Local Health Integration Network (LHIN) in Ontario has developed a cardiovascular disease prevention network to improve care through the use of evidence based practices and better integration between all areas of the health care continuum.73 Primary Care networks in Alberta have similar goals designed to connect multiple physicians, clinics and regions together to support the health needs of the population.74 Further work is necessary to expand these types of programs and to provide appropriate compensation models for complex patients. Payment models in some jurisdictions undermine access by failing to take morbidity and co-morbidity into consideration in designing rates such as equal capitation.75 Finally, there is a need to encourage greater self-management of disease. Practice support programs in British Columbia are providing training to support physicians in increasing patient self-management and health literacy.76 Additional programs of this nature are necessary in all jurisdictions. 2. Better care coordination and greater access to necessary medical services along the continuum of care. Patient-centred care which integrates care across the continuum and which includes community services will be necessary to ensure not only greater access but greater acceptability of care.77 Innovative programs focused on increasing the coordination in terms of transition from hospital to home have shown some success in preventing readmissions particularly when vulnerable populations are targeted.78 Health Links in Ontario aims to reduce costs, based on the assumption that much of the utilization of high cost services, such as emergency department visits, could be prevented with better coordinated care. One of the pilot sites in Guelph aims to assign one person in primary care, likely a doctor or a nurse, to be the primary contact for patients deemed high need and to intervene on behalf of these patients to ensure better care coordination.79 Further work is needed to ensure greater coordination in speciality care. As the evidence demonstrates, access to specialist services are skewed in favour of high-income patients. To reduce this inequity it may be necessary to standardize the referral process and facilitate the coordination of care from the primary care providers' perspective.80 A new program in British Columbia is designed to reduce some of these barriers by providing funding and support to rapid access programs which allow family physicians to access specialist care through a designated hotline. If no specialist is available immediately there is a commitment that the call will be returned within two hours. Specialists available through this program include cardiology, endocrinology, nephrology, psychiatry, and internal medicine among others.81 Similar programs in other jurisdictions could help to increase coordination between primary and speciality care. Care coordination is only part of the problem, however. There is also a need to increase the access to services that are medically necessary across the care continuum. These include a lifetime prevention schedule82, diagnostic testing, specialty services, and access to appropriate rehabilitation services, mental health, long-term care and end of life care. 3. Quality improvement initiatives which incorporate considerations of equity as part of their mandate. Equity has become a key component of many quality improvement initiatives around the world. The Health Quality Council Ontario identified nine attributes of a high-performing health system: safe, effective, patient-centred, accessible, efficient, equitable, integrated, appropriately resourced, and focused on population health.83 The POWER study, a large study of Ontario residents found that where there were targeted programs for quality improvement fewer inequities were observed. In particular they referred to the actions of Cancer Care Ontario and the Ontario Stroke Network. Both of these groups had undergone large quality improvement initiatives to standardize care and increase coordination of services through evidence-based guidelines and ongoing performance measurement. Considerations of accessibility and equity were specifically included. As a result of these efforts, the POWER study found that acute cancer and stroke care in Ontario were quite equitable.84 Similar efforts are underway in other jurisdictions. The Towards Optimized Practice initiative in Alberta supports efforts in medical offices to increase the use of clinical practice guidelines for care as well as quality improvement initiatives.85 Encouraging more health services and programs to undertake such quality improvement initiatives could help to reduce the inequities in access for all Canadians. 4. Health system planning and assessment which prioritizes equitable access to care Considerations of equity must be built specifically into all planning considerations. Too often services are designed without adequate consideration of the specific needs of disadvantaged groups. Planners need to do a better job of understanding their practice populations and tailoring programs to those most in need of care.86 This planning should be done in consultation with other sectors that play a role in influencing the health of their practice populations. Further, assessments of the equity and use of services is also needed. Some services may be designed in a way that is more appropriate for some than others, resulting in higher utilization among some groups and a lack of access for others.87 Innovative work is taking place in the Saskatoon Health Region to try and understand these barriers. Health care services are undergoing specific health equity assessments to ensure that all services meet the needs of diverse populations. This includes looking at the full spectrum of services from preventative care and education programs to tertiary level care such as dialysis. In Ontario, the local health integration networks (LHIN) have now been tasked with developing equity plans for their services. Clear goals and performance measurements are part of this work.88 One of the tools available to support this work is a health equity impact assessment tool developed by the Ontario Ministry of Health and Long-Term Care. This tool is intended for use by organizations within the health system as well as those outside the system who will impact on the health of Ontarians. The main focus of the tool is to reduce inequities that result from barriers in access to quality health services. Additionally, it is designed to identify unintended health impacts, both positive and negative, before a program or policy is implemented.89 Further work is needed to ensure that equity is included in the deliverables and performance management of health care organizations and provider groups across the country.90 To support these planning programs appropriate data will need to be collected. This data needs to be comprehensive for all services and needs to include specific data points which will allow planners as well as providers to understand the composition of their populations as well as measure and report on considerations of equity.91 Recommendations for action: CMA and National Level Initiatives The CMA recommends that: 9. Governments continue efforts to ensure that all Canadians have access to a family physician. 10. Appropriate compensation and incentive programs be established in all jurisdictions to support better management of chronic disease for all Canadians. 11. Governments provide funding and support to programs which facilitate greater integration between primary and speciality care. 12. With support from government, national medical organizations develop programs to increase standardization of care and the use of appropriate clinical practice guidelines. 13. Appropriate data collection and performance measurement systems be put in place to monitor equitable distribution of health services and greater appropriateness of care. Health System Planners The CMA recommends that: 14. Needs based planning be mandated for all health regions and health system planning. Equity impact assessment should be part of this planning to ensure that services meet the needs of all Canadians. 15. Chronic disease management and other supportive strategies for vulnerable patients at risk of frequent readmission to the acute care system be prioritized in all health systems. 16. Quality improvement initiatives be mandated in all care programs. These programs should include a specific focus on standardization of care and continuous quality improvement and should include equity of access as part of their mandate. Physicians in Practice The CMA recommends that: 17. Physicians be supported in efforts to offer timely access in primary care settings. 18. Physicians be supported in continued efforts to include all patients in decisions about their care and management of their illnesses. 19. Physicians be supported in continued efforts to standardize care and utilize evidence based clinical practice guidelines with a particular emphasis on the management of chronic disease. 20. Physicians be encouraged and adequately supported to participate in community-based interventions that target the social determinants of health. Conclusion: Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. For those that are most vulnerable, this lack of access can serve to further exacerbate their already increased burden of illness and disease. The strategies discussed above offer some opportunities for the health sector and the medical profession to intervene and mitigate this inequity. By removing barriers on both the patient and system side it is hoped that greater access to appropriate care will follow. While these strategies offer some hope, these actions alone will not be sufficient to increase the overall health of the Canadian population. Action is still required to tackle the underlying social and economic factors which lead to the disparities in the health of Canadians. References: 1 This paper represents a focus on equitable access to care. For a more general policy statement on the role of physicians in addressing the social determinants of health please see: Canadian Medical Association. Health Equity and the Social Determinants of Health: A Role for the Medical Profession. Ottawa, ON; 2012. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD13-03.pdf 2 The Canadian Medical Association is currently developing a policy paper on access to mental health services in Canada. It is anticipated that this policy statement will be completed in 2014. 1 Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013. Available: http://www.equityhealthj.com/content/12/1/18 (accessed 2013Mar 12) 2 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2011 Jan 14). 3 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 4 Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013. Available: http://www.equityhealthj.com/content/12/1/18 (accessed 2013Mar 12) 5 Oliver A, Mossialos E. Equity of access to health care: outlining the foundations for action. J Epidemiol Community Health 2004; 58: 655-658. 6 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter7-AccesstoHealthCareServices.pdf (accessed 2012 Dec 10). 7 Kirby M, Goldbloom D, Bradley L. 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Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7...; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 54 Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 55 Chiu S, Hwang SW. Barriers to healthcare among homeless people with diabetes. Diabetes Voice 2006; 51(4): 9-12. Available: http://www.idf.org/sites/default/files/attachments/article_473_en.pdf (2011 Feb 20), 56 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7.... Willems S, De Maesschalck S, Deveugele M, et al. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns 2004; 56: 139-146; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences... 57 Willems S, De Maesschalck S, Deveugele M, et al. Socio-economic status of the patient... 58 Bierman A, Angus J, Ahmad F, et al. 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Health-Care Utilization in Canada: 25 Years of Evidence... 81 Shared Care Partners in Care Annual Report 2011/12. Vancouver (BC): Government of British Columbia & British Columbia Medical Association. Available: https://www.bcma.org/files/SC_annual_report_2011-12.pdf (accessed 2013 Mar 12). 82 British Columbia Medical Association. Partners in Prevention: Implementing a Lifetime Prevention Plan. Vancouver, BC; 2010. Available: https://www.bcma.org/files/Prevention_Jun2010.pdf (accessed 2013 Sep 18). 83 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13... 84 Ibid. 85 Toward Optimized Practice. Edmonton (AB). Available at: http://www.topalbertadoctors.org/index.php (accessed 2013 Mar 12). 86 Ali A, Wright N, Rae M ed. Addressing Health Inequalities: A guide for general practitioners. London (UK); 2008. Available: http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z%20policy/Health%20Inequalities%20Text%20FINAL.ashx (accessed 2012 Jan 16); Gardner, B. Health Equity Road Map Overview. Toronto (ON): Wellesley Institute, 2012. Available: http://www.wellesleyinstitute.com/wp-content/uploads/2012/09/HER_Systemic-Health-Inequities_Aug_2012.pdf (accessed 2013 Feb 6). 87 Bowen, S. Access to Health Services for Underserved Populations... 88 Gardner B. Health Equity Into Action: Planning and Other Resources for LHINs. Toronto(ON) Wellesley Institute; 2010. Available: http://www.wellesleyinstitute.com/wp-content/uploads/2010/09/Health_Equity_Resources_for_LHINs_1.pdf (accessed 2013 Feb 6). 89 Ontario Ministry of Health and Long-Term Care. Health Equity Impact Assessment (HEIA) Workbook. Toronto, ON; 2012. Available: http://www.health.gov.on.ca/en/pro/programs/heia/docs/workbook.pdf (accessed 2013 Sep 30). 90 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12...; Gardner, B. Health Equity Road Map...; Glazier RH. Balancing Equity Issues in Health Systems... 91 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13...

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