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Proposed UN Convention on the rights of older persons

https://policybase.cma.ca/en/permalink/policy13925
Last Reviewed
2020-02-29
Date
2018-07-25
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Last Reviewed
2020-02-29
Date
2018-07-25
Topics
Population health/ health equity/ public health
Text
Dear Minister Freeland: We are a national consortium of experts who serve and advocate for the needs and rights of older people. We are delighted by the recent appointment of a new Minister of Seniors, and send our congratulations to the Honourable Filomena Tassi. We are also encouraged by our Government’s commitment to support the health and economic well-being of all Canadians, and heartened by your promise to listen to, and to be informed by feedback from Canadians. It is in this spirit that we are writing today regarding the need for Canada to provide support and leadership with a goal of developing and ratifying a United Nations (UN) Convention on the Rights of Older Persons. In the context of massive global demographic shifts and an aging population, insightful and careful reflection by the leaders of our organizations has led to universal and strong support for the creation and implementation of a UN Convention to specifically recognize and protect the human rights of our older persons. A UN Convention on the Rights of Older Persons will:
enshrine their rights as equal with any other segment of the population with the same legal rights as any other human being;
categorically state that it is unacceptable to discriminate against older people throughout the world;
clarify the state’s role in the protection of older persons;
provide them with more visibility and recognition both nationally and internationally, which is vitally important given the rate at which Canadian and other societies are ageing;
advance the rights of older women at home and as a prominent factor in Canada’s foreign policy;
have a positive, real-world impact on the lives of older citizens who live in poverty, who are disproportionately older women, by battling ageism that contributes to poverty, ill-health, social isolation, and exclusion;
support the commitment to improve the lives of Indigenous Peoples; members of the LGBTQ community, and visible and religious minorities; and,
provide an opportunity for Canada to play a leadership role at the United Nations while at the same time giving expression to several of the Canadian government’s stated foreign policy goals. We have projected that the cost and impact of not having such a Convention would have a significant negative impact on both the physical and mental health of older Canadians. The profound and tragic consequence would have a domino effect in all domains of their lives including social determinants of health, incidence and prevalence of chronic diseases, social and psychological functioning, not to mention massive financial costs to society. There is recognition of this need internationally and ILC-Canada, along with other Canadian NGOs and organizations have been active at the UN to help raise awareness of the ways a UN Convention on the Rights of Older Persons would contribute to all countries. Changes have already been implemented by our Government that are consistent and aligned with a UN Convention, such as improving the income of vulnerable Canadian seniors, funding for long term care and support for community based dementia programs. These initiatives are all in keeping with support for a Convention on the Rights of Older Persons. They are also reflective of our country’s commitment to engage more fully with the United Nations and provide Canada the stage to demonstrate leadership on a vital international issue. It is an opportunity to champion the values of inclusive government, respect for diversity and human rights including the human rights of women. Scientific evidence demonstrates that human rights treaties help to drive positive change in the lives of vulnerable groups of people. In many countries in the world, older people are not adequately protected by existing human rights law, as explicit references to age are exceedingly rare. Even in countries like Canada, where there are legal frameworks that safeguard older people, a Convention would provide an extra layer of protection, particularly if the Convention has a comprehensive complaints mechanism. Older adults need to be viewed as a growing but underutilized human resource. By strengthening their active role in society including the workforce, they have tremendous capacity, knowledge, and wisdom to contribute to the economy and general well-being of humankind. We are requesting you meet with our representatives, to discuss the vital role of a UN Convention on the Rights of Older Persons and the role your government could play in improving the lives of older people in Canada and around the world. The fact that Canada is ageing is something to celebrate. We are all ageing, whether we are 20 or 85. This is a ”golden opportunity” to showcase Canada as a nation that will relentlessly pursue doing the “right thing” for humanity by supporting a UN Convention that ensures that our future is bright. Please accept our regards, and thank you for your attention to this request. We await your response. Sincerely, Margaret Gillis, President, International Longevity Centre Canada Dr. Kiran Rabheru, Chair of the Board, International Longevity Centre Canada Linda Garcia, Director, uOttawa LIFE Research Institute cc: The Right Honourable Justin Trudeau Prime Minister of Canada The Honourable Filomena Tassi Minister of Seniors The Honourable Jean Yves Duclos Minister for Families, Children and Social Development Ambassador Marc-Andre Blanchard Permanent Representative to Canada at the United Nations The Honourable Ginette Petitpas Taylor Health Minister Margaret Gillis President International Longevity Centre Canada Dr. Kiran Rabheru Chair of the Board, International Longevity Centre Canada Linda Garcia, PhD Director LIFE Research Institute Dr. Laurent Marcoux President Canadian Medical Association Andrew Padmos, BA, MD, FRCPC, FACP Chief Executive Officer Dani Prud’Homme Directeur général FADOQ Peter Lukasiewicz Chief Executive Officer Gowling WLG Dr. Dallas Seitz, MD, FRCPC President, CAGP Dr. Frank Molnar President, Canadian Geriatrics Society Dr. David Conn Co-Leader Canadian Coalition for Senior’s Mental Health Claire Checkland Director - Canadian Coalition for Seniors’ Mental Health Joanne Charlebois Chief Executive Officer, Speech-Language & Audiology Canada Claire Betker President Canadian Nurses Association Janice Christianson-Wood, MSW, RSW Title/Organization: President, Canadian Association of Social Workers / Présidente, l’Association canadienne des travail- leurs sociaux François Couillard Chief Executive Officer/Chef de la direction Ondina Love, CAE Chief Executive Officer Canadian Dental Hygienists Association Jean-Guy Soulière President/Président National Association of Federal Retirees /Association nationale des retraités fédéraux Sarah Bercier Executive Director Laura Tamblyn Watts National Initiative for the Care of the Elderly Dr. Keri-Leigh Cassidy Founder Fountain of Health Dr. Beverley Cassidy Geriatric Psychiatris Seniors Mental Health Dalhousie University Dept of Psychiatry Jenny Neal and Janet Siddall CO Chairs, Leadership Team Grandmothers Advocacy Network (GRAN) Kelly Stone President and CEO Families Canada Dr. Becky Temple, MD, CCFP, CCPE President, CSPL Medical Director Northeast, Northern Health Medical Lead Privilege Dictionary Review, BCMQI J. Van Aerde, MD, MA, PhD, FRCPC Clinical Professor of Pediatrics - Universities of Alberta & British Columbia, Canada Associate Faculty - Leadership Studies - Royal Roads Univ, Victo- ria, BC, Canada Past-President - Canadian Society of Physician Leaders Editor-in-Chief / Canadian Journal of Physician Leadership Dr. Rollie Nichol, MD, MBA, CCFP, CCPE Vice-President, CSPL Associate Chief Medical Officer, Alberta Health Services Dr. Shannon Fraser, MSc, FRCSC, FACS Secretary / Treasurer, CSPL Chief General Surgery Jewish General Hospital Linda Gobessi MD FRCPC Medical Director Geriatric Psychiatry Community Services of Ottawa Ottawa Vickie Demers Executive Director / Directrice générale Services communautaires de géronto- psychiatrie d’ Ottawa Geriatric Psychiatry Community Services of Ottawa Ging-Yuek Robin Hsiung, MD MHSc FRCPC FACP FAAN Associate Professor Ralph Fisher and Alzheimer Society of BC Professor Director of Clinical Research Director of Fellowship in Behavioural Neurology UBC Hospital Clinic for Alzheimer and Related Disorders Division of Neurology, Department of Medicine University of British Columbia Adriana Shnall Senior Social Worker Baycrest Health Sciences Harinder Sandhu, D.D.S., Ph.D Professor and Past Director Schulich Dentistry & Vice Dean, Schulich School of Medicine & Dentistry Western University Dr. Christopher Frank, Chair of Geriatric Education and Recruitment Initiative Jennie Wells, MD Associate Professor, University of Western Ontario Department of Medicine Chair/Chief Division of Geriatric Medicine Parkwood Institute Laura Diachun, MD Program Director, Undergrad Geriatric Education University of Western Ontario Department of Medicine, Division of Geriatric Medicine Parkwood Institute Sheri-Lynn Kane, MD Program Director Internal Medicine Dept of Medicine Education Office Victoria Hospital Niamh O’Regan, MB ChB, Assistant Professor, University of Western Ontario Parkwood Institute Michael Borrie, MB ChB, FRCPC Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine Parkwood Institute Jenny Thain, MRCP (Geriatrics) Assistant Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine Victoria Hospital Peter R. Butt MD CCFP FCFP Assoc. Professor, Department of Family Medicine, College of Medicine, University of Saskatchewan Mamta Gautam, MD, MBA, FRCPC, CCPE Dept of Psychiatry, University of Ottawa Psychiatrist, Psychosocial Oncology Program, The Ottawa Hospital President and CEO, PEAK MD Inc. Dr. Shabbir Amanullah Chair, ICPA Arun V. Ravindran, MBBS, MSc, PhD, FRCPC, FRCPsych Professor and Director, Global Mental Health and the Office of Fellowship Training, Department of Psychiatry, Graduate Faculty, Department of Psychology and Institute of Medical Sciences, University of Toronto Sarah Thompson, MD, FRCPC Geriatric Psychiatrist Seniors’ Mental Health Team Addictions and Mental Health Program Louise Plouffe, Ph.D. Director of Research, ILC Canada (retired) Kimberley Wilson, PhD, MSW Assistant Professor, Adult Development & Aging, Department of Family Relations & Applied Nutrition, University of Guelph Andrew R. Frank M.D. B.Sc.H. F.R.C.P.(C) Cognitive and Behavioural Neurologist Medical Director, Bruyère Memory Program Bruyère Continuing Care Ottawa, Canada Diane Hawthorne Family Physician BSc, MD, CCFP, FCFP Dr. Ken Le Clair Prof Emeritus Queens University and. Lead Policy Physician Consultant to Ontario. Seniors Behavioral Support Initative Queens University
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Health Care Coverage for Migrants: An Open Letter to the Canadian Federal Government

https://policybase.cma.ca/en/permalink/policy13940
Date
2018-12-15
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Ethics and medical professionalism
  1 document  
Policy Type
Policy endorsement
Date
2018-12-15
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Ethics and medical professionalism
Text
Dear Prime Minister Trudeau & Ministers Taylor and Hussen, We are writing to you today as members of the health community to urge your action on a crucial matter pertaining to health and human rights. You will no doubt be aware that the United Nations Human Rights Committee (UNHRC) recently issued a landmark decision condemning Canada for denying access to essential health care on the basis of immigration status based on the case of Nell Toussaint. Nell is a 49-year-old woman from Grenada who has been living in Canada since 1999, and who suffered significant negative health consequences as a result of being denied access to essential health care services. The UNHRC’s decision condemns Canada’s existing discriminatory policies, and finds Canada to be in violation of both the right to life, as well as the right to equality and freedom from discrimination. Based on its review of the International Covenant on Civil and Political Rights, the UNHRC has declared that Canada must provide Nell with adequate compensation for the significant harm she suffered. As well, they have called on Canada to report on its review of national legislation within a 180-day period, in order “to ensure that irregular migrants have access to essential health care to prevent a reasonably foreseeable risk that can result in loss of life”. The United Nations Special Rapporteur has pushed for the same, calling on the government “to protect health-related rights to life, security of the person, and equality of individuals and groups in situations of vulnerability”. Nell is one of an estimated half million people in Ontario alone who are denied access to health coverage and care on the basis of their immigration status, putting their health at risk. As members of Canada’s health community, we are appalled by the details of this case as well as its broad implications, and call on the government to: 1. Comply with the UNHRC’s order to review existing laws and policies regarding health care coverage for irregular migrants. 2. Ensure appropriate resource allocation, so that all people in Canada are provided universal and equitable access to health care services, regardless of immigration status. 3. Provide Nell Toussaint with adequate compensation for the significant harm she has suffered as a result of not receiving essential health care services. For more information on this issue, please see our backgrounder here: https://goo.gl/V9vPyo. Sincerely, Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON Michaela Beder, MD, Psychiatrist, Toronto ON Ritika Goel, MD, Family Physician, Toronto ON This open letter is signed by the following organizations and individuals: Bathurst United Church TOPS 1. Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON 2. Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON 3. Michaela Beder, MD FRCPC, Psychiatrist, Toronto ON 4. Ritika Goel, MD, Family Physician, Toronto ON 5. Gordon Guyatt, MD FRCPC, Internal Medicine Specialist, McMaster University, Hamilton ON 6. Melanie Spence, RN, Nursing, South Riverdale Community Health Centre, Toronto ON 7. Yipeng Ge, BHSc, Medical Student, University of Ottawa, Ottawa ON 8. Stephen Hwang, MD, Professor of Medicine, University of Toronto, Toronto ON 9. Gigi Osler, BScMed, MD, FRCSC, Otolaryngology-Head and Neck Surgery, Canadian Medical Association, Ottawa ON 10. Anjum Sultana, MPH, Public Policy Professional, Toronto ON 11. Danyaal Raza, MD, MPH, CCFP, Family Medicine, Toronto ON 12. P.J. Devereaux, MD, PhD, Cardiologist, McMaster University, Brantford ON 13. Mathura Karunanithy, MA, Public Policy Researcher, Toronto ON 14. Philip Berger, MD, Family Physician, Toronto ON 15. Nanky Rai, MD MPH, Primary Care Physician, Toronto ON 16. Michaela Hynie, Prof, Researcher, York University, Toronto ON 17. Meb Rashid, MD CCFP FCFP, Family Physician, Toronto ON 18. Sally Lin, MPH, Public Health, Victoria BC 19. Jonathon Herriot, BSc, MD, CCFP, Family Physician, Toronto ON 20. Carolina Jimenez, RN, MPH, Nurse, Toronto ON 21. Rushil Chaudhary, BHSc, Medical Student, Toronto ON 22. Nisha Toomey, MA (Ed), PhD Student, University of Toronto, Toronto ON 23. Matei Stoian, BSc, BA, Medical Student, McMaster University, Hamilton ON 24. Ruth Chiu, MD, Family Medicine Resident, Kingston ON 25. Priya Gupta, Medical Student, Hamilton ON 26. The Neighbourhood Organization (TNO), Toronto, ON 27. Mohammad Asadi-Lari, MD/PhD Candidate, University of Toronto, Toronto ON 28. Kathleen Hughes, MD Candidate, McMaster University, Hamilton ON 29. Nancy Vu, MPA, Medical Student, McMaster University, Hamilton ON 30. Ananthavalli Kumarappah, MD, Family Medicine Resident, University of Calgary, Calgary AB 31. Renee Sharma, MSc, Medical Student, University of Toronto, Toronto ON 32. Daniel Voloshin, Medical Student , McMaster Medical School , Hamilton ON 33. Sureka Pavalagantharajah, Medical Student, McMaster University, Hamilton ON 34. Alice Cavanagh , MD/PhD Student, McMaster University, Hamilton ON 35. Krish Bilimoria, MD(c), Medical Student, University of Toronto, North York ON 36. Bilal Bagha, HBSc, Medical Student, St. Catharines ON 37. Rana Kamhawy, Medical Student, Hamilton ON 38. Annie Yu, Medical Student, Toronto ON 39. Samantha Rossi, MA, Medical Student, University of Toronto, Toronto ON 40. Carlos Chan, MD Candidate, Medical Student, McMaster University, St Catharines ON 41. Jacqueline Vincent, MA, Medical Student, McMaster, Kitchener ON 42. Eliza Pope, BHSc, Medical Student, University of Toronto, Toronto ON 43. Cara Elliott, MD, Medical Student, Toronto ON 44. Antu Hossain, MPH, Public Health Professional, East York ON 45. Lyubov Lytvyn, MSc, PhD Student in Health Research, McMaster University, Burlington ON 46. Michelle Cohen, MD, CCFP, Family Physician, Brighton ON 47. Serena Arora, Medical Student, Hamilton ON 48. Saadia Sediqzadah, MD, Psychiatrist, Toronto ON 49. Maxwell Tran, Medical Student, University of Toronto, Toronto ON 50. Asia van Buuren, BSc, Medical Student, Toronto ON 51. Darby Little, Medical Student, University of Toronto, Toronto ON 52. Ximena Avila Monroy, MD MSc, Psychiatry Resident, Sherbrooke QC 53. Abeer Majeed, MD, CCFP, Family Physician, Toronto ON 54. Oluwatobi Olaiya, RN, Medical Student, Hamilton ON 55. Ashley Warnock, MSc, HBSc, HBA, Medical Student, McMaster University, Hamilton ON 56. Nikhita Singhal, Medical Student, Hamilton ON 57. Nikki Shah, MD Candidate, Medical Student, Hamilton ON 58. Karishma Ramjee, MD Family Medicine Resident , Scarborough ON 59. Yan Zhang, MSc, Global Health Professional, Toronto ON 60. Megan Saunders, MD, Family Physician, Toronto ON 61. Pooja Gandhi, MSc, Speech Pathologist, Mississauga ON 62. Julianna Deutscher, MD, Resident, Toronto ON 63. Diana Da Silva, MSW, Social Worker, Toronto ON Health Care Coverage for Migrants: An Open Letter to the Canadian Federal Government Sign here - https://goo.gl/forms/wAXTJE6YiqUFSo8x1 The Right Honourable Justin Trudeau, Prime Minister of Canada The Honourable Ginette P. Taylor, Minister of Health The Honourable Ahmed D. Hussen, Minister of Immigration, Refugees and Citizenship CC: Mr. Dainius Puras, United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of health Dear Prime Minister Trudeau & Ministers Taylor and Hussen, We are writing to you today as members of the health community to urge your action on a crucial matter pertaining to health and human rights. You will no doubt be aware that the United Nations Human Rights Committee (UNHRC) recently issued a landmark decision condemning Canada for denying access to essential health care on the basis of immigration status based on the case of Nell Toussaint. Nell is a 49-year-old woman from Grenada who has been living in Canada since 1999, and who suffered significant negative health consequences as a result of being denied access to essential health care services. The UNHRC’s decision condemns Canada’s existing discriminatory policies, and finds Canada to be in violation of both the right to life, as well as the right to equality and freedom from discrimination. Based on its review of the International Covenant on Civil and Political Rights, the UNHRC has declared that Canada must provide Nell with adequate compensation for the significant harm she suffered. As well, they have called on Canada to report on its review of national legislation within a 180-day period, in order “to ensure that irregular migrants have access to essential health care to prevent a reasonably foreseeable risk that can result in loss of life”. The United Nations Special Rapporteur has pushed for the same, calling on the government “to protect health-related rights to life, security of the person, and equality of individuals and groups in situations of vulnerability”. Nell is one of an estimated half million people in Ontario alone who are denied access to health coverage and care on the basis of their immigration status, putting their health at risk. As members of Canada’s health community, we are appalled by the details of this case as well as its broad implications, and call on the government to: 1. Comply with the UNHRC’s order to review existing laws and policies regarding health care coverage for irregular migrants. 2. Ensure appropriate resource allocation, so that all people in Canada are provided universal and equitable access to health care services, regardless of immigration status. 3. Provide Nell Toussaint with adequate compensation for the significant harm she has suffered as a result of not receiving essential health care services. For more information on this issue, please see our backgrounder here: https://goo.gl/V9vPyo. Sincerely, Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON Michaela Beder, MD, Psychiatrist, Toronto ON Ritika Goel, MD, Family Physician, Toronto ON
Documents
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Health Canada’s consultation on new health-related labelling for tobacco products

https://policybase.cma.ca/en/permalink/policy13939
Date
2018-12-14
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2018-12-14
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to provide this submission in response to Health Canada’s Consultation on “New Health-Related Labelling for Tobacco Products - Document for Consultation, October 2018”. Canada's physicians have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use and for the past 30 years we have reiterated our long-standing support for the concept of tobacco products being sold in standardized packages in several briefs and policy statements. Our response will follow the questions posed in the consultation document. Labelling on Individual Cigarettes Displaying a warning on individual cigarettes provides another means of conveying important health warnings about the hazards of smoking. The warnings should be like those that will be displayed on the leaflets included in the cigarette packages as well as the packages themselves. They should be of sufficient size, font and colour that will draw the attention of the smoker to the message. They should also be placed as close to the filter end of the cigarette as possible to remain visible for as long as possible. Health Information Messages The CMA has always supported educational and public health initiatives aimed at countering tobacco manufacturers messages that would render smoking attractive and glamorous to their customers. The health information messages and any leaflets included in the package must be of sufficient size, colour and font to prevent manufacturers from using the leaflet as any sort of a promotional platform to minimize, for example, the impact of health warnings on the package exterior. The CMA supports strongly the concept of tobacco products being sold in standardized packages and we have recommended that only the “slide-and-shell” style of package be authorized and that the “flip-top” package be removed. This would allow for the largest possible surface area to be used to convey health warnings and other health-related information. The CMA has recommended that the measurements for the regular and king size cigarette packages be amended to allow for more surface area for warnings and to standardize packaging regulations across all Canadian jurisdictions. Toxic Statements (Includes Toxic Emissions Statements and Toxic Constituents Statements) The size, colour and design of new Toxic Statements proposed in the consultation document should be sufficient to be read and easily understood. The Statements should be rotated periodically to include new and updated information related to emissions and toxic constituents. Connecting Labelling Elements/ Quitline Information Tobacco manufacturers make frequent use of subtle marketing messages to render smoking attractive and glamorous, especially to young people. The CMA supports packages displaying prominent, simple and powerful health warnings, such as the graphic pictorial warnings, as well as quit tips and information on product content and health risks.2 Connecting the themes should help to reinforce the messages being conveyed with these labels. The size, colour, and placement of the proposed quitline and website information should be sufficient to maximize the noticeability of the information on various types of tobacco product packaging. Percentage of Coverage/Minimum Size of Health Warnings on Tobacco Products Other than Cigarettes and Little Cigars The amount of space given to the warnings should be sufficient to convey the maximum amount of information while remaining clear, visible, and legible. The warnings should be in proportion to the packaging available, like that of a regular cigarette package. Labelling for All Tobacco Products that Do Not Currently Require Labels The CMA supports mandatory health warnings being applied equally to all tobacco products. If package size allows, Health Warnings, Health Information Messages, and Toxic Statements should all be included. The messages should be relevant to the types of tobacco products they are covering. Labelling Rotation The rotation timeframe suggested in the consultation document of 12 to 18 months is a reasonable period. Government of Canada. New Health-Related Labelling for Tobacco Products. Document for Consultation Ottawa: Health Canada; 2018. Available: https://www.canada.ca/en/health-canada/programs/consultation-tobacco-labelling.html (accessed 2018 Oct 29). Canadian Medical Association (CMA) Tobacco Control (Update 2008). Ottawa: The Association; 2008. Available: http:// policybase.cma.ca /dbtw-wpd/Policypdf/PD08-08.pdf (accessed 2018 Dec 5). Canadian Medical Association (CMA). Letter in response to Health Canada’s Consultation on “Plain and Standardized Packaging” for Tobacco Products. Potential Measures for Regulating the Appearance, Shape and Size of Tobacco Packages and of Tobacco Products. Document for Consultation. Ottawa: The Association; 2016. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2016-09.pdf (accessed 2018 Nov 19). Canadian Medical Association (CMA). Health Canada Consultation on Tobacco Products Regulations (Plain and Standardized Appearance). Ottawa: The Association; 2018. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2019-01.pdf (accessed 2018 Nov 19). Canadian Medical Association (CMA). Policy Resolution BD88-03-64 - Smokeless tobacco. Ottawa: The Association; 1987. Available: https://tinyurl.com/y7eynl5q (accessed 2018 Dec 5).
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CMA Code of Ethics and Professionalism

https://policybase.cma.ca/en/permalink/policy13937
Date
2018-12-08
Topics
Population health/ health equity/ public health
  3 documents  
Policy Type
Policy document
Date
2018-12-08
Replaces
Code of ethics of the Canadian Medical Association (Update 2004)
Topics
Population health/ health equity/ public health
Text
CMA CODE OF ETHICS AND PROFESSIONALISM Compassion A compassionate physician recognizes suffering and vulnerability, seeks to understand the unique circumstances of each patient and to alleviate the patient’s suffering, and accompanies the suffering and vulnerable patient. Honesty An honest physician is forthright, respects the truth, and does their best to seek, preserve, and communicate that truth sensitively and respectfully. Humility A humble physician acknowledges and is cautious not to overstep the limits of their knowledge and skills or the limits of medicine, seeks advice and support from colleagues in challenging circumstances, and recognizes the patient’s knowledge of their own circumstances. Integrity A physician who acts with integrity demonstrates consistency in their intentions and actions and acts in a truthful manner in accordance with professional expectations, even in the face of adversity. Prudence A prudent physician uses clinical and moral reasoning and judgement, considers all relevant knowledge and circumstances, and makes decisions carefully, in good conscience, and with due regard for principles of exemplary medical care. The CMA Code of Ethics and Professionalism articulates the ethical and professional commitments and responsibilities of the medical profession. The Code provides standards of ethical practice to guide physicians in fulfilling their obligation to provide the highest standard of care and to foster patient and public trust in physicians and the profession. The Code is founded on and affirms the core values and commitments of the profession and outlines responsibilities related to contemporary medical practice. In this Code, ethical practice is understood as a process of active inquiry, reflection, and decision-making concerning what a physician’s actions should be and the reasons for these actions. The Code informs ethical decision-making, especially in situations where existing guidelines are insufficient or where values and principles are in tension. The Code is not exhaustive; it is intended to provide standards of ethical practice that can be interpreted and applied in particular situations. The Code and other CMA policies constitute guidelines that provide a common ethical framework for physicians in Canada. In this Code, medical ethics concerns the virtues, values, and principles that should guide the medical profession, while professionalism is the embodiment or enactment of responsibilities arising from those norms through standards, competencies, and behaviours. Together, the virtues and commitments outlined in the Code are fundamental to the ethical practice of medicine. Physicians should aspire to uphold the virtues and commitments in the Code, and they are expected to enact the professional responsibilities outlined in it. Physicians should be aware of the legal and regulatory requirements that govern medical practice in their jurisdictions. Trust is the cornerstone of the patient–physician relationship and of medical professionalism. Trust is therefore central to providing the highest standard of care and to the ethical practice of medicine. Physicians enhance trustworthiness in the profession by striving to uphold the following interdependent virtues: A. VIRTUES EXEMPLIFIED BY THE ETHICAL PHYSICIAN 2 B. FUNDAMENTAL COMMITMENTS OF THE MEDICAL PROFESSION Consider first the well-being of the patient; always act to benefit the patient and promote the good of the patient. Provide appropriate care and management across the care continuum. Take all reasonable steps to prevent or minimize harm to the patient; disclose to the patient if there is a risk of harm or if harm has occurred. Recognize the balance of potential benefits and harms associated with any medical act; act to bring about a positive balance of benefits over harms. Commitment to the well-being of the patient Promote the well-being of communities and populations by striving to improve health outcomes and access to care, reduce health inequities and disparities in care, and promote social accountability. Commitment to justice Practise medicine competently, safely, and with integrity; avoid any influence that could undermine your professional integrity. Develop and advance your professional knowledge, skills, and competencies through lifelong learning. Commitment to professional integrity and competence Always treat the patient with dignity and respect the equal and intrinsic worth of all persons. Always respect the autonomy of the patient. Never exploit the patient for personal advantage. Never participate in or support practices that violate basic human rights. Commitment to respect for persons Contribute to the development and innovation in medicine through clinical practice, research, teaching, mentorship, leadership, quality improvement, administration, or advocacy on behalf of the profession or the public. Participate in establishing and maintaining professional standards and engage in processes that support the institutions involved in the regulation of the profession. Cultivate collaborative and respectful relationships with physicians and learners in all areas of medicine and with other colleagues and partners in health care. Commitment to professional excellence Value personal health and wellness and strive to model self-care; take steps to optimize meaningful co-existence of professional and personal life. Value and promote a training and practice culture that supports and responds effectively to colleagues in need and empowers them to seek help to improve their physical, mental, and social well-being. Recognize and act on the understanding that physician health and wellness needs to be addressed at individual and systemic levels, in a model of shared responsibility. Commitment to self-care and peer support Value and foster individual and collective inquiry and reflection to further medical science and to facilitate ethical decision-making. Foster curiosity and exploration to further your personal and professional development and insight; be open to new knowledge, technologies, ways of practising, and learning from others. Commitment to inquiry and reflection 3 C. PROFESSIONAL RESPONSIBILITIES The patient–physician relationship is at the heart of the practice of medicine. It is a relationship of trust that recognizes the inherent vulnerability of the patient even as the patient is an active participant in their own care. The physician owes a duty of loyalty to protect and further the patient’s best interests and goals of care by using the physician’s expertise, knowledge, and prudent clinical judgment. In the context of the patient–physician relationship: 1. Accept the patient without discrimination (such as on the basis of age, disability, gender identity or expression, genetic characteristics, language, marital and family status, medical condition, national or ethnic origin, political affiliation, race, religion, sex, sexual orientation, or socioeconomic status). This does not abrogate the right of the physician to refuse to accept a patient for legitimate reasons. 2. Having accepted professional responsibility for the patient, continue to provide services until these services are no longer required or wanted, or until another suitable physician has assumed responsibility for the patient, or until after the patient has been given reasonable notice that you intend to terminate the relationship. 3. Act according to your conscience and respect differences of conscience among your colleagues; however, meet your duty of non-abandonment to the patient by always acknowledging and responding to the patient’s medical concerns and requests whatever your moral commitments may be. 4. Inform the patient when your moral commitments may influence your recommendation concerning provision of, or practice of any medical procedure or intervention as it pertains to the patient’s needs or requests. 5. Communicate information accurately and honestly with the patient in a manner that the patient understands and can apply, and confirm the patient’s understanding. 6. Recommend evidence-informed treatment options; recognize that inappropriate use or overuse of treatments or resources can lead to ineffective, and at times harmful, patient care and seek to avoid or mitigate this. 7. Limit treatment of yourself, your immediate family, or anyone with whom you have a similarly close relationship to minor or emergency interventions and only when another physician is not readily available; there should be no fee for such treatment. 8. Provide whatever appropriate assistance you can to any person who needs emergency medical care. 9. Ensure that any research to which you contribute is evaluated both scientifically and ethically and is approved by a research ethics board that adheres to current standards of practice. When involved in research, obtain the informed consent of the research participant and advise prospective participants that they have the right to decline to participate or withdraw from the study at any time, without negatively affecting their ongoing care. 10. Never participate in or condone the practice of torture or any form of cruel, inhuman, or degrading procedure. Physicians and patients Patient-physician relationship 4 11. Empower the patient to make informed decisions regarding their health by communicating with and helping the patient (or, where appropriate, their substitute decision-maker) navigate reasonable therapeutic options to determine the best course of action consistent with their goals of care; communicate with and help the patient assess material risks and benefits before consenting to any treatment or intervention. 12. Respect the decisions of the competent patient to accept or reject any recommended assessment, treatment, or plan of care. 13. Recognize the need to balance the developing competency of minors and the role of families and caregivers in medical decision-making for minors, while respecting a mature minor’s right to consent to treatment and manage their personal health information. 14. Accommodate a patient with cognitive impairments to participate, as much as possible, in decisions that affect them; in such cases, acknowledge and support the positive roles of families and caregivers in medical decision-making and collaborate with them, where authorized by the patient’s substitute decision-maker, in discerning and making decisions about the patient’s goals of care and best interests. 15. Respect the values and intentions of a patient deemed incompetent as they were expressed previously through advance care planning discussions when competent, or via a substitute decision-maker. 16. When the specific intentions of an incompetent patient are unknown and in the absence of a formal mechanism for making treatment decisions, act consistently with the patient’s discernable values and goals of care or, if these are unknown, act in the patient’s best interests. 17. Respect the patient’s reasonable request for a second opinion from a recognized medical expert. Physicians and the practice of medicine Patient privacy and the duty of confidentiality 18. Fulfill your duty of confidentiality to the patient by keeping identifiable patient information confidential; collecting, using, and disclosing only as much health information as necessary to benefit the patient; and sharing information only to benefit the patient and within the patient’s circle of care. Exceptions include situations where the informed consent of the patient has been obtained for disclosure or as provided for by law. 19. Provide the patient or a third party with a copy of their medical record upon the patient’s request, unless there is a compelling reason to believe that information contained in the record will result in substantial harm to the patient or others. 20. Recognize and manage privacy requirements within training and practice environments and quality improvement initiatives, in the context of secondary uses of data for health system management, and when using new technologies in clinical settings. 21. Avoid health care discussions, including in personal, public, or virtual conversations, that could reasonably be seen as revealing confidential or identifying information or as being disrespectful to patients, their families, or caregivers. Medical decision-making is ideally a deliberative process that engages the patient in shared decision-making and is informed by the patient’s experience and values and the physician’s clinical judgment. This deliberation involves discussion with the patient and, with consent, others central to the patient’s care (families, caregivers, other health professionals) to support patient-centred care. In the process of shared decision-making: Decision-making 5 22. Recognize that conflicts of interest may arise as a result of competing roles (such as financial, clinical, research, organizational, administrative, or leadership). 23. Enter into associations, contracts, and agreements that maintain your professional integrity, consistent with evidenceinformed decision-making, and safeguard the interests of the patient or public. 24. Avoid, minimize, or manage and always disclose conflicts of interest that arise, or are perceived to arise, as a result of any professional relationships or transactions in practice, education, and research; avoid using your role as a physician to promote services (except your own) or products to the patient or public for commercial gain outside of your treatment role. 25. Take reasonable steps to ensure that the patient understands the nature and extent of your responsibility to a third party when acting on behalf of a third party. 26. Discuss professional fees for non-insured services with the patient and consider their ability to pay in determining fees. 27. When conducting research, inform potential research participants about anything that may give rise to a conflict of interest, especially the source of funding and any compensation or benefits. 28. Be aware of and promote health and wellness services, and other resources, available to you and colleagues in need. 29. Seek help from colleagues and appropriate medical care from qualified professionals for personal and professional problems that might adversely affect your health and your services to patients. 30. Cultivate training and practice environments that provide physical and psychological safety and encourage help-seeking behaviours. 31. Treat your colleagues with dignity and as persons worthy of respect. Colleagues include all learners, health care partners, and members of the health care team. 32. Engage in respectful communications in all media. 33. Take responsibility for promoting civility, and confronting incivility, within and beyond the profession. Avoid impugning the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional conduct by colleagues. 34. Assume responsibility for your personal actions and behaviours and espouse behaviours that contribute to a positive training and practice culture. 35. Promote and enable formal and informal mentorship and leadership opportunities across all levels of training, practice, and health system delivery. 36. Support interdisciplinary team-based practices; foster team collaboration and a shared accountability for patient care. Physicians and self Physicians and colleagues Managing and minimizing conflicts of interest 6 38. Recognize that social determinants of health, the environment, and other fundamental considerations that extend beyond medical practice and health systems are important factors that affect the health of the patient and of populations. 39. Support the profession’s responsibility to act in matters relating to public and population health, health education, environmental determinants of health, legislation affecting public and population health, and judicial testimony. 40. Support the profession’s responsibility to promote equitable access to health care resources and to promote resource stewardship. 41. Provide opinions consistent with the current and widely accepted views of the profession when interpreting scientific knowledge to the public; clearly indicate when you present an opinion that is contrary to the accepted views of the profession. 42. Contribute, where appropriate, to the development of a more cohesive and integrated health system through interprofessional collaboration and, when possible, collaborative models of care. 43. Commit to collaborative and respectful relationships with Indigenous patients and communities through efforts to understand and implement the recommendations relevant to health care made in the report of the Truth and Reconciliation Commission of Canada. 44. Contribute, individually and in collaboration with others, to improving health care services and delivery to address systemic issues that affect the health of the patient and of populations, with particular attention to disadvantaged, vulnerable, or underserved communities. Approved by the CMA Board of Directors Dec 2018 37. Commit to ensuring the quality of medical services offered to patients and society through the establishment and maintenance of professional standards. Physicians and society
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Health Canada consultation on Canadian drugs and substances strategy

https://policybase.cma.ca/en/permalink/policy14017
Date
2018-12-04
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2018-12-04
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to provide this submission in response to Health Canada’s consultation on new and innovative ideas on how to further strengthen the federal government’s health-focussed approach to substance use issues through the Canadian Drugs and Substances Strategy (CDSS) Question 1 What sorts of circumstances do you see within your networks, communities or in society that you think contribute to problematic substance use? There are multiple factors that contribute to problematic substance use. It is a serious, chronic and relapsing medical condition for which there are effective treatments. However, using the social determinants as a framework, most health promotion and prevention efforts will take place outside of the traditional health and medical care services. . Many Canadians face barriers in their physical, social and economic environments which can contribute to problematic substance use, and certain populations are at higher risk given these circumstances. For example, early childhood is a critical time in the social, emotional, cognitive and physical development of a person. Experiences in early life can ‘get under the skin’, changing the ways that genes are expressed. Negative experiences such as poverty or family or parental violence can have significant impacts on this important period of development. What is necessary is a coordinated effort across government sectors to ensure that all policy decisions serve to increase opportunities for health. Improving population health and reducing inequities should be an overall objective for all governments in Canada. Question 2 Have you seen or experienced programs, practices or models at the local or regional level that could be expanded, or implemented more broadly, to improve circumstances or social determinants of health that influence substance use? Income is critical to individual health and is 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. Adequate consideration must be given to the social and economic determinants of health, factors such as income and housing that have a major impact on health outcomes. Minimizing poverty should be a top priority. In 2015, the CMA passed a resolution endorsing the concept of a basic income guarantee, which is a cash transfer from government to citizens not tied to labour market participation. It ensures sufficient income to meet basic needs and live with dignity, regardless of employment status. A basic income guarantee has the potential to alleviate or even eliminate poverty. It has the potential to reduce the substantial, long-term social consequences of poverty, including higher crime rates and fewer students achieving success in the educational system. Drug use must not be treated with a criminal justice approach, which does not address the determinants of drug use, treat addictions, or reduce the harms associated with drug use. More investments need to be made in prevention, harm reduction and treatment, keeping individuals out of the criminal justice system. Drug use is a complex issue, and collaboration among health and public safety professionals, and society at large, is essential. Question 3 What needs to change to make sure that opioid medications are being provided and used appropriately, based on the needs of each patient? Policy makers must recognize that prescription opioids are an essential tool in the alleviation of pain and suffering, particularly in palliative and cancer care. Doctors support patients in the management of acute and chronic pain, as well as problematic substance use, and as such have long been concerned about the harms associated with opioid use. Treatment options and services for both problematic substance use as well as pain management are woefully under-resourced in Canada. Experts believe that improved access to specialized pain treatment could reduce inappropriate use of pain medications. Current best practices in pain management include care by an interprofessional team that could include physiotherapists, occupational therapists, psychologists and other health professionals; non-pharmaceutical interventions such as therapy for trauma and social pain, social supports and coping strategies; appropriate pharmaceutical prescription options, covered by provincial formularies; and a focus on patient participation and empowerment.12 Availability and access of these critical resources varies by jurisdiction and region. The federal government should prioritize the expansion of these services. It is also important to support clinicians in their practice. The 2017 Opioid Prescribing Guidelines need to be kept current through ongoing funding. Physicians require tools, including those that facilitate monitoring of effectiveness and tolerance by tracking pain and physical function; screening for past and current substance use; screening for depression; and, tapering of problematic or ineffective doses. Question 4 How can we make sure that those who require prescription opioids to manage their pain have access to them, without judgement or discrimination? Governments need to incorporate the identification and elimination of stigma as a quality of care indicator in the ongoing monitoring of health system performance at all levels. They also need to implement and evaluate national public awareness and education strategies to counteract the stigma associated with substance use issues as well as enforcing legislation and regulations to guard against discrimination against people with mental and substance use issues. Health professionals need to have access to education on pain management and treatment of problematic substance use, recognizing both issues as serious medical conditions for which there are effective treatments. Question 5 Which kinds of messages would work best to help Canadians understand the serious harms that can result from stigma around substance use? A recent report from the Canadian Centre on Substance Use and Addiction (CCSA) and Public Safety Canada cited stigma as “an enormous barrier to individuals seeking and maintaining treatment.” Even though there is broad recognition that we are in a public health crisis, until very recently the focus of the federal National Anti-Drug Strategy was heavily skewed towards a criminal justice approach rather than a public health approach with an emphasis on enforcement, as opposed to prevention, treatment and harm reduction.8 This has serious implications in how society views people who use drugs. As noted in the CCSA-Public Safety report, “Language matters. Speak about people first, with compassion and respect.”13 A stigma reduction strategy must be core to the activities of the federal government. Stigma involves thoughts, emotions and behaviours; thus, a comprehensive approach includes interventions to target each of these dimensions at both the individual and population level. The strategy should include aspects of: * Public awareness and education to facilitate understanding about the importance of early diagnosis, treatment, recovery and prevention; * Enhanced provider/student education and support; * Policy analysis and modification of discriminatory legislation; * Support for a strong voluntary sector to voice the concerns of patients and their families; * Exposure to positive spokespeople (e.g. prominent Canadians) who have mental illness and/or addiction in order to highlight success stories; * Researching stigma. Question 6 How can we best act to reduce stigma across the country? Engagement with people who use drugs to help them share their stories and experiences with stigma with the public Question 7 What would you recommend to improve substance use treatment services in Canada? This challenge requires a complex and multifaceted solution; and to further this aim, Canada needs a comprehensive national strategy to address the harms associated with psychoactive drugs in Canada, whether illegal or prescription-based, complementing existing strategies to address the harms associated with the other two legal drugs - alcohol and tobacco. This comprehensive approach is necessary, as isolated measures can have unintended consequences, such as under-medicating people that require a medical treatment or constraining people to seek illegal drugs as an option when medications are made tamper-resistant. One of the fundamental principles of health care is that it be patient centred.11 CMA defines patient-centred care as “seamless access to the continuum of care in a timely manner … that takes into consideration the individual needs and preferences of the patient and his/her family and treats the patient with respect and dignity.” It is essential that patients be core members of the health care team, working with health care providers to address their individual needs, preferences and aspirations and to seek their personal paths to well-being. Physicians and other health professionals can help patients make choices about their treatment and can provide information and support to patients and their families as they seek to cope with the effects of problematic use and live functional lives. The health care provider community needs tools to assist in the reduction of stigma, access to resources and supportive environments. Question 8 What obstacles or barriers do people face when they want to access treatment in Canada? Obstacles to treatment include the lack of publicly-funded treatment centres, access to locations for remote areas, limited number of beds available, the cost of private treatment (lack of insurance), and stigma. The CMA supports the enhancement of access to options for treatment that address different needs.12 Treatment programs must be coordinated and patient-centred, and address physical, psychological, social and spiritual circumstances. For example, it is important that treatment programs be culturally relevant for Indigenous communities. Question 10 In addition to current harm reduction initiatives – such as supervised consumption sites, needle exchange programs – what other harm reduction services should governments consider implementing in Canada? There is a dire need to address harm reduction in prisons. Even back in 2005, the CMA recommended to the Correctional Service of Canada that it develop, implement and evaluate a pilot needle exchange program in prison(s) under its jurisdiction. These services are not widespread and accessible to prison populations. In Canada, people in prison face far greater risk of HIV and hepatitis C infection because they are denied access to sterile injection equipment as a harm reduction strategy. Hospitals need to incorporate harm reduction strategies as well, allowing people who use drugs to access much needed health services. Question 12 How can we better bring public health and law enforcement together to explore ways to reduce the cycle of involvement for people who use substances with the criminal justice system? Training for police and other frontline criminal justice and corrections workers in how to interact with people with substance use issues is essential. The CMA believes that the government must take a broad public health policy approach. Changes to the criminal law affecting cannabis must not promote normalization of its use and must be tied to a national drug strategy that promotes awareness and prevention and provides for comprehensive treatment.13 The CMA recognized that a blanket prohibition of possession for teenagers and young adults would not reflect current reality or a harm reduction approach. The possibility that a young person might incur a lifelong criminal record for periodic use or possession of small amounts of cannabis for personal use means that the long-term social and economic harms of cannabis use can be disproportionate to the drug's physiological harm. Question 13 What further steps can the federal government take to better address current regulation and enforcement priorities, such as addressing organized drug crime and the dangerous illegal drugs like fentanyl being brought into Canada? The federal government must continue to work closely with the RCMP, local and provincial law enforcement agencies, Canada Post, the Canadian Border Services Agency, Crown attorneys, the Canadian military, and international health officials and law enforcement agencies to address this issue. This topic was covered in the recent CCSA/Public Safety Canada report.10 Question 14 Recognizing Indigenous rights and self-determination, how can all governments work together to address the high rates of problematic substance use faced by some Indigenous communities? Difficulties in access are particularly acute for Canada's Indigenous peoples. Many live in communities with limited access to health care services, sometimes having to travel hundreds of miles to access care. Additionally, there are jurisdictional challenges; many fall through the cracks between the provincial and federal health systems. While geography is a significant barrier for Indigenous peoples, it is not the only one. Indigenous peoples 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 indigenous 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. Further, even when care is available it may not be culturally appropriate. Canada's indigenous 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. It is important that problematic substance use programs be culturally relevant for Indigenous communities. It is clear that the First Nations and Inuit peoples of Canada experience mental illness, problematic substance use and poor mental health at rates exceeding that of other Canadians.11 Individual, community and population level factors contribute to this including socioeconomic status, social environment, child development, nutrition, maternal health, culture and access to health services. The urgent need to work with these communities and identify the structures and interventions to reduce the burden of mental illness and substance use is critical to the health and wellness and future of First Nations and Inuit peoples. Enhanced federal capacity should be created through First Nations and Inuit Health that will provide increased funding and support for First Nations and Inuit community health strategies. The establishment of a working groups comprised of First Nations and Inuit health experts and accountable to First Nations and Inuit leadership is essential for the success of this initiative. Both expert and resource supports are integral elements to facilitate and encourage culturally appropriate strategies and programming in these communities. Question 15 What can we learn from Indigenous approaches to problematic substance use, such as using holistic approaches, that may help inform activities under the CDSS? The federal government must consult First Nations, Inuit, and Métis representatives to develop programs that are culturally relevant and appropriate for Indigenous communities. Question 16 How can governments, and the health, social, and law enforcement sectors design more effective substance use policies and programs for at-risk populations? The government must identify and consult those communities and populations most at risk. This includes First Nations, Inuit, and Métis representatives, community advocates, municipalities, and provincial and local public health officers. Data that describes rates of use and issues specific to each at risk group is important to be able to better understand and address needs. Question 17 What are effective policies and programs to help improve access to prevention, treatment, and harm reduction services for at-risk populations? There are innovative approaches to address the needs of high-volume users as well as at-risk populations. As many of these involve greater integration between health and the community sector and attention to issues not traditionally funded through health care payment systems, there is a need to provide access to funds to enable these innovations to continue and be spread across the country. A targeted, integrated approach to identify communities in need is required and this must be based on reliable community data (i.e., meaningful use of patient data) which can be used to integrate resources to improve health status. For example, the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is Canada's first multi-disease electronic medical records (EMR) surveillance and research system that allows family physicians, epidemiologists and researchers from across the country to better understand and manage chronic care conditions for their patients. Health information is collected from EMRs in the offices of participating primary care providers (e.g. family physicians) for the purposes of improving the quality of care for Canadians suffering from chronic and mental health conditions and three neurologic conditions including Alzheimer's and related dementias. CPCSSN makes it possible to securely collect and report on vital information from Canadians' health records to improve the way these chronic diseases and neurologic conditions are managed (http://cpcssn.ca/). Question 18 What urgent gaps related to substance use (in terms of data, surveillance, and/or research) need to be addressed in Canada? Improvements are being made in the collection of data in Canada. This is crucial to be able to assess the harms and track the trends and impact of the introduction of policy changes.12 As well, the government must continue to improve the ability of the Public Health Agency of Canada, the Canadian Institute of Health Information, the chief coroners of Canada and related agencies to collect, analyze and report data. One such program is the surveillance system in the United States called RADARS (Researched Abuse, Diversion and Addiction-Related Surveillance system) that is “a surveillance system that collects product-and geographically-specific data on abuse, misuse, and diversion of prescription drugs.” It surveys data involving opioids including poison control centres, treatment programs, on the “illicit acquisition or distribution of prescription opioids, stimulants, and other prescription drugs of interest from entities investigating drug diversion cases,” among other opioid-related issues. The CMA has recommended that all levels of government work with one another and with health professional regulatory agencies to develop a pan-Canadian system of real-time prescription monitoring. As a first step, the CMA recommends the establishment of consistent national standards for prescription monitoring. Prescription Monitoring Programs (PMP) should be compatible with existing electronic medical and pharmacy record systems and with provincial pharmaceutical databases. Participation in prescription monitoring programs should not impose an onerous administrative burden on health care providers. PMPs should not deter physicians from using controlled medications when necessary. Further, PMPs are a valuable component in addressing the gaps related to substance use. Question 19 How can we use research tools to better identify emerging substance use issues as early as possible? See above response to question 18 - “RADARS” Government of Canada. Consultation on strengthening Canada’s approach to substance use issues. Ottawa: Health Canada; 2018. Available: https://www.canada.ca/en/health-canada/programs/consultation-strengthening-canada-approach-substance-use-issues.html (accessed 2018 Sep 5). Canadian Medical Association (CMA). Health in all policies. Ottawa: The Association; 2015 Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-10.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Early childhood development. Ottawa: The Association; 2015. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-03.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Canadian Medical Association Submission on Motion 315 (Income Inequality). Ottawa: The Association; 2013. Available: http://policybase.cma.ca/dbtw-wpd/BriefPDF/BR2013-07.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). CMA’s recommendations for effective poverty reduction strategies. Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2017-04.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Bill C-2 An Act to amend the Controlled Drugs and Substances Act. Ottawa: The Association; 2015. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2015-11.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Statement to the House of Commons Committee on Health addressing the opioid crisis in Canada. Ottawa: The Association; 2016. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2017-15.pdf (accessed: 2018 Nov 26). Canadian Medical Association (CMA). Non-prescription availability of low-dose codeine products. Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2018-04.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Health Canada consultation on restriction of marketing and advertising of opioids. Ottawa: The Association; 2018. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2018-13.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Harms associated with opioids and other psychoactive prescription drugs. Ottawa: The Association; 2015. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-06.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Joint Canadian Medical Association & Canadian Psychiatric Association Policy - Access to mental health care. Ottawa: The Association; 2016. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Statement to the House of Commons Committee on Health addressing the opioid crisis in Canada. Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2017-15.pdf (accessed 2018 Nov 26). Public Safety Canada, Canadian Centre on Substance Use and Addiction. 2018 Law Enforcement Roundtable on the Opioid Crisis. Meeting Summary. Ottawa; 2018. Available: https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/lw-nfrcmnt-rndtbl-pd-crss-2018/index-en.aspx?utm_source=stakeholders&utm_medium=email&utm_campaign=opioidcrisis (accessed 2018 Nov 29). Canadian Medical Association (CMA). Study on Mental Health, Mental Illness and Addiction in Canada: Supplementary Submission to the Senate Standing Committee on Social Affairs, Science and Technology. Ottawa: The Association; 2006. Available: http://policybase.cma.ca/dbtw-wpd/BriefPDF/BR2006-01.pdf (accessed 2018 Nov 29). Canadian Medical Association (CMA). Harms associated with opioids and other psychoactive prescription drugs. Ottawa: The Association; 2015. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-06.pdf (accessed 2018 Nov 2018). Canadian Medical Association (CMA). Bill C-45: The Cannabis Act. Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2017-09.pdf (accessed 2018 Nov 28). Canadian Medical Association (CMA). Ensuring equitable access to health care: Strategies for governments, health system planners, and the medical profession. Ottawa: The Association; 2014. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD14-04.pdf (accessed 2018 23 Nov). Canadian Medical Association (CMA). Submission to Advisory Panel on Healthcare Innovation. Ottawa: The Association; 2014. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2015-06.pdf (accessed 2018 Nov 29). Radars System. 2018. Available: https://www.radars.org/. (accessed: 2018 Nov 29). Canadian Medical Association (CMA). Harms associated with opioids and other psychoactive prescription drugs. Ottawa: The Association; 2015 Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-06.pdf (accessed 2018 Dec 4). Sproule B. Prescription Monitoring Programs in Canada: Best Practice and Program Review. Ottawa, ON, 2015 Canadian Centre on Substance Abuse. Available: http://www.ccsa.ca/Resource%20Library/CCSA-Prescription-Monitoring-Programs-in-Canada-Report-2015-en.pdf (accessed 2018 Dec 4).
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Open letter to Ontario Minister of Health about the newly proposed “Consumption and Treatment Services” model

https://policybase.cma.ca/en/permalink/policy13932
Date
2018-10-31
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2018-10-31
Topics
Population health/ health equity/ public health
Text
Dear Minister Elliott: We write to you as organizations concerned about the health and welfare of some of the most vulnerable Ontarians, in response to the October 22 announcement that your government plans to replace supervised consumption sites (SCS) and low-barrier overdose prevention sites (OPS) with “Consumption and Treatment Services.”1 While we welcome the stated commitment to maintain existing SCS and OPS in Ontario, we are deeply concerned that your government’s new approach to supervised consumption services is creating more barriers instead of facilitating the rapid-scale up of a diversity of much-needed supervised consumption services across the province. This is especially troubling in the context of the public health crisis in which we now find ourselves. In particular, we are concerned by the decision to impose one “Consumption and Treatment Services” model on service providers and essentially terminate low-threshold, flexible OPS. These life-saving services are part of a continuum of service models that should be made available to all people who use drugs who need them, including the most marginalized. Thousands of overdoses have been reversed using this model, and no deaths recorded at these sites. As you know, OPS were created in response to the urgent need for rapid roll-out of these vital services. A specific legal regime under a federal class exemption issued to Ontario was put in place to allow for their rapid implementation in response to the current crisis. The requirement for both OPS and SCS, including already authorized ones, to undergo a new application process for funding is sapping concerted efforts from the federal and provincial governments to respond to the overdose crisis. Not only does the new application process replicate the onerous federal exemption process for SCS (such as requiring applicants to engage in ongoing community consultations), it will also impose additional requirements including requiring applicants to provide treatment and rehabilitation services and to conduct seemingly more extensive data reporting, monitoring and evaluations — all without dedicating additional funding to allow organizations to adequately comply. Moreover, the requirement for service providers to provide treatment and rehabilitation services is not in line with harm reduction values of meeting people where they are. At the same time, the arbitrary decision to cap the number of sites at 21 without any justification means people who do not reside near existing or impending sites will be denied access to life-saving care, at a time when overdose deaths in Ontario are at an all-time high, with more than three people dying every day in 2017.2 Denying funding to new sites will undoubtedly mean more preventable overdose deaths and new HIV, hepatitis C and other infections. We agree that there are inadequate drug treatment, mental health services and supportive housing options available for people who use drugs, and providing greater support for these services is laudable. But this should not come at the expense of life-saving supervised consumption services, including low-threshold services that are varied, responsive and meet the needs of their communities. We urge you to reconsider the decision to create new hurdles for service providers to receive funding to provide supervised consumption services and to limit the number of sites to 21. We call on you to work with people who use drugs, community organizations and other health service providers to ensure greater, equitable access to SCS and OPS for the people of Ontario. Lives are at stake. Sincerely, Richard Elliott, Executive Director, Canadian HIV/AIDS Legal Network Ryan Peck, Executive Director, HIV & AIDS Legal Clinic Ontario Dr. F. Gigi Osler, President, Canadian Medical Association Michael Villeneuve, Chief Executive Officer, Canadian Nurses Association Ian Culbert, Executive Director, Canadian Public Health Association Sarah Ovens, Coordinator, Toronto Overdose Prevention Society Cc. The Honourable Doug Ford, Premier of Ontario 1 Ministry of Health and Long-Term Care News Release: Ontario Government Connecting People with Addictions to Treatment and Rehabilitation, October 22, 2018, online: https://news.ontario.ca/mohltc/en/2018/10/ontario-government-connecting-people-with-addictions-to-treatment-and-rehabilitation.html. 2 Public Health Ontario, “Opioid-related morbidity and mortality in Ontario” (May 23, 2018), online: https://www.publichealthontario.ca/en/dataandanalytics/pages/opioid.aspx#/trends.
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Meeting the demographic challenge: Investments in seniors care

https://policybase.cma.ca/en/permalink/policy13924
Date
2018-08-03
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2018-08-03
Topics
Population health/ health equity/ public health
Text
Recommendation: That the federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer. The Canadian Medical Association unites physicians on national health and medical matters. Formed in Quebec City in 1867, the CMA’s rich history of advocacy led to some of Canada’s most important health policy changes. As we look to the future, the CMA will focus on advocating for a healthy population and a vibrant profession. Introduction The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission, focused on the major challenges confronting seniors care in Canada. As Canada’s demographic shift advances, the challenge of ensuring quality seniors care will only become more daunting unless governments make critical investments in our health care system today. This is a national issue that will affect all provinces and territories (PTs). However, not all PTs will bear the costs equally. The current federal health transfer system does not take demographics into account. The CMA proposes the federal government fund a share of the health care costs associated with our aging population by means of a new “demographic top-up” to the Canada Health Transfer (CHT). Recommendation: That the federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer. Seniors Care: Challenges and Opportunities Canada, like most OECD economies, is grappling with the realities of a rapidly aging population. The population of seniors over the age of 65 in Canada has increased by 20% since 2011 and it has been projected that the proportion of Canada’s total population over 65 will exceed one-third by 2056 with some provinces like Newfoundland and Labrador reaching that point as soon as the mid-2030s.1 Census figures also show that the fastest growing demographic in Canada between 2011 and 2016 was individuals over 90, growing four times the rate of the overall population during this period.2 These demographic changes have a number of major implications for the future of Canadian society. Chief among them is the new pressure they add to our health care system. As the population ages, it is expected that health care costs will grow at a significantly faster rate than in previous years. As demonstrated in Chart 1 below, population aging will be a top contributor to rising health care costs over the decade ahead. By 2026–27, these increases will amount to $19 billion in additional annual health care costs associated with population aging, as shown in Chart 2. Many seniors experience varying degrees of frailty, which the Canadian Frailty Network (CFN) defines as “a state of increased vulnerability, with reduced physical reserve and loss of function across multiple body systems” that “reduces ability to cope with normal or minor stresses, which can cause rapid and dramatic changes in health.”3 About 75% to 80% of seniors report having one or more chronic conditions.4 It is primarily the care associated with management of these conditions as well as increased residential care needs that drive the higher costs associated with seniors care. The average annual per capita provincial/territorial health spending for individuals age 15 to 64 is $2,700 compared with $12,000 for seniors age 65 and over.5 Our medicare system, which was established over half a century ago, is not designed or resourced to deal with this new challenge. The median age of Canadians at the time of the Medical Care Act’s enactment in 1966 was 25.5 years. It is now 40.6 years and is expected to rise to 42.4 years in the next decade.5 While past governments have placed significant focus on hospital care (acute and sub-acute), transitional care, community supports such as home care and long-term care (LTC) have been largely underfunded. Demographic changes have already begun to place pressure on our health care system, and the situation will only become worse unless funding levels are dramatically raised. Chart 1: Major contributors to rising health care costs (forecast average annual percentage increase, 2017–26)5 Chart 2: Provincial/terrioritial health care costs attributable to population aging ($ billions, all PTs relative to 2016–17 demographics)5 Individuals in Ontario wait a median of 150 days for placement in a LTC home.6 In many communities across the country acute shortages in residential care infrastructure mean that seniors can spend as long as three years on a wait list for LTC.7 Seniors from northern communities are often forced to accept placements hundreds of kilometres from their families.8 The human and social costs of this are self-evident but insufficient spending on LTC also has important consequences for the efficiency of the system as a whole. When the health of seniors stabilizes after they are admitted to hospital for acute care, health care professionals are often confronted with the challenge of finding better living options for their patients. These patients are typically assigned Alternate Level of Care (ALC) beds as they wait in hospital for appropriate levels of home care or access to a residential care home/facility. In April 2016, ALC patients occupied 14% of inpatient beds in Ontario while in New Brunswick, 33% of the beds surveyed in two hospitals were occupied by ALC patients.9 The average length of hospital stay of all ALC patients in Canada is an unacceptable 380 days. Not only does ALC care lead to generally worse health outcomes and patient satisfaction than both LTC and home care, but it is also significantly more expensive. The estimated daily cost of a hospital bed used by a patient is $842, compared with $126 for a LTC bed and $42 per day for care at home.10 Moreover, high rates of ALC patients can contribute to hospital overcrowding, lengthy emergency wait times and cancelled elective surgeries.11 Committing more funding to LTC infrastructure would lead to system-wide improvements in wait times and quality of care by helping to alleviate the ALC problem. A recent poll found that only 49% of Canadians are confident that the health care system will be able to meet senior care needs and that 88% of Canadians support new federal funding measures.12 Fortunately, there have been some signs at both the provincial and federal levels that seniors care has become an issue of increasing importance. New Brunswick recently introduced a caregiver’s benefit while the Ontario government has recently committed to building 15,000 LTC beds over the next decade. The federal government highlighted home care as a key investment area in the most recent Health Accord bilateral agreements and has made important changes to both the Canada Pension Plan (CPP) and Old Age Security (OAS) programs. The Demographic Top-Up: Modernizing the CHT Despite these recent and important initiatives by governments in Canada, additional policy and fiscal measures will be needed to address the challenges of an aging population. Many provincial governments have shown a clear commitment to the issue, but the reality is that their visions for better seniors care will not come to fruition unless they are backed up by appropriate investments. This will not be possible unless the federal government ensures transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Projections in a recent report by the Conference Board of Canada, commissioned by the CMA, indicate that health transfers are expected to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.3 Over the next decade, unless changes are made, provinces/territories will need to assume an increasingly larger share of health care costs. If federal health transfers do not account for population aging, the federal share of health care spending will fall below 20% by 2026.5 Aging will affect some provinces more than others, as demonstrated in Figure 1 below. The overall cost of population aging to all of the provinces and territories is projected to be $93 billion over the next decade.5 The absence of demographic considerations in transfer calculations therefore indirectly contributes to regional health inequality as provinces will not receive the support they need to ensure that seniors can count on quality care across Canada. Figure 1: Increases in health care costs associated with population aging, 2017 to 2026 ($ billions)5 The CMA recommends that the federal government address the health costs of population aging by introducing a “demographic top-up” to the Canada Health Transfer. One model for this would require the federal government to cover a share of the costs projected to be added by population aging in each province/territory (see above) equal to the federal share of total health costs covered now (22%). The Conference Board of Canada estimates that the overall cost of such a change would be $21.1 billion over the next decade (see Table 1). This funding would greatly enhance the ability of the provinces and territories to make much-needed investments in seniors care and the health care system as a whole. It could be used to support the provinces’ and territories’ efforts to address shortages in LTC, to expand palliative care and home care supports and to support further innovation in the realm of seniors care. Table 1: Cost of demographic top-Up by province in $ millions5 Conclusion The evidence that our health care systems are not prepared or adequately funded to ensure appropriate and timely access to seniors care, across the continuum of care, is overwhelming. Wait times for LTC and home care are unacceptably high and complaints about lack of availability in Northern and rural communities are becoming increasingly common. Health care providers in the LTC sector regularly raise concern about overstretched resources and a lack of integration with the rest of the health care system. By introducing a new demographic top-up to the Canada Health Transfer, the federal government would demonstrate real leadership by ensuring that all provinces/territories are able to adapt to an aging population without eroding quality of care. Furthermore, improvements in how we care for our seniors will lead to improvements for patients and caregivers of all ages through greater system efficiencies (e.g., shorter wait times for emergency care and elective surgeries) and more coordinated care. The CMA has been, and will continue to be, a tireless advocate for improving seniors care in Canada. The CMA would welcome opportunities to provide further information on the recommendation outlined in this brief. References 1Statistics Canada. Age and sex, and type of dwelling data: key results from the 2016 Census. Ottawa: Statistics Canada; 2017. Available: https://www150.statcan.gc.ca/n1/daily-quotidien/170503/dq170503a-eng.htm 2Ministry of Finance Ontario. 2016 Census highlights, fact sheet 3. Toronto: Office of Economic Policy, Labour Economics Branch; 2017. Available: www.fin.gov.on.ca/en/economy/demographics/census/cenhi16-3.html. 3Canadian Frailty Network. What is frailty? Kingston: The Network; 2018. Available: www.cfn-nce.ca/frailty-in-canada/ 4Canadian Institute for Health Information (CIHI). Health care in Canada, 2011: a focus on seniors and aging. Available: https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf 5The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018. Available: www.cma.ca/En/Lists/Medias/Conference%20Board%20of%20Canada%20-%20Meeting%20the%20Care%20Needs%20of%20Canada%27s%20Aging%20Population.PDF 6Health Quality Ontario. Wait times for long-term care homes. Available: www.hqontario.ca/System-Performance/Long-Term-Care-Home-Performance/Wait-Times 7Crawford B. Ontario’s long-term care problem: seniors staying at home longer isn’t a cure for waiting lists. Ottawa Citizen 2017 Dec 22. Available: https://ottawacitizen.com/news/local-news/ontarios-long-term-care-problem-seniors-staying-at-home-longer-isnt-a-cure-for-waiting-lists 8Sponagle J. Nunavut struggles to care for elders closer to home. CBC News 2017 Jun 5. Available: www.cbc.ca/news/canada/north/nunavut-seniors-plan-1.4145757 9McCloskey R, Jarrett P, Stewart C, et al. Alternate level of care patients in hospitals: What does dementia have to do with this? Can Geriatr J. 2014;17(3):88–94. 10Home Care Ontario. Facts and figures – publicly funded home care. Hamilton: Home Care Ontario; n.d. Available: www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare 11Simpson C. Code gridlock: why Canada needs a national seniors strategy. Ottawa: Canadian Medical Association; 2014. Available: www.cma.ca/En/Lists/Medias/Code_Gridlock_final.pdf 12Ipsos Public Affairs. Just half of Canadians confident the healthcare system can meet the needs of seniors. Toronto: Ipsos; 2018. Available: www.ipsos.com/en-ca/news-polls/Canadian-Medical-Association-Seniors-July-17-2018
Documents
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Canada's Food Guide

https://policybase.cma.ca/en/permalink/policy13920
Date
2018-06-06
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Date
2018-06-06
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to provide this submission to the House of Commons Standing Committee on Health with respect to its study of Canada’s Food Guide. The CMA supports access to healthy foods to improve individual health and well-being and the overall health status of the population.1 1 Canadian Medical Association (CMA). Obesity in Canada: Causes, consequences and the way forward. Ottawa: CMA; 2015. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2015-12.pdf (accessed 2018 Feb 5). 2 Colapinto C, Graham J, St. Pierre S. Trends and correlates of frequency of fruit and vegetable consumption, 2007 to 2014. Health Reports. 2018 January;29(1):9-14. Available: http://www.statcan.gc.ca/pub/82-003-x/2018001/article/54901-eng.pdf (accessed 2018 Feb 5). 3 Van Vliet B, Campbell N. Efforts to reduce sodium intake in Canada: Why, what, and when? Can J Cardiol. 2011;27(4):437–445. 4 Canadian Medical Association (CMA). Early childhood development. Ottawa: CMA; 2014. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-03.pdf (accessed 2018 Feb 2). 5 Canadian Medical Association (CMA). Health equity and the social determinants of health: A role for the medical profession. Ottawa: CMA; 2013. Available http://policybase.cma.ca/dbtw-wpd/Policypdf/PD13-03.pdf (accessed 2018 Jan 30). 6 Health Canada. Eating well with Canada’s food guide. Ottawa: Health Canada; 2007. Available: https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/fn-an/alt_formats/hpfb-dgpsa/pdf/food-guide-aliment/view_eatwell_vue_bienmang-eng.pdf (accessed 2018 Jan 30). 7 Collier R. Calls for a better food guide. CMAJ. 2018 November 18;186(17):1281. Available: https://doi.org/10.1503/cmaj.109-4911 (accessed 2018 Jan 30). 8 Ministry of Health of Brazil. Dietary guidelines for the Brazilian population. 2nd ed. Brazil: Ministry of Health of Brazil; 2014. Available: http://www.foodpolitics.com/wp-content/uploads/Brazilian-Dietary-Guidelines-2014.pdf (accessed 2018 Feb 1). 9 Report of the Standing Committee on Social Affairs, Science and Technology. Obesity in Canada. A whole-of-society approach for a healthier Canada. Ottawa: Senate of Canada; 2016 March. Available: https://sencanada.ca/content/sen/committee/421/soci/rms/01mar16/Report-e.htm (accessed 2018 Feb 2). 10 Health Canada. Evidence review for dietary guidance: summary of results and implications for Canada’s food guide. Ottawa: Health Canada; 2015. Available: https://www.canada.ca/content/dam/canada/health-canada/migration/publications/eating-nutrition/dietary-guidance-summary-resume-recommandations-alimentaires/alt/pub-eng.pdf (accessed 2018 Feb 2). 11 Government of Canada. Guiding principles [Canada’s food guide consultation]. Ottawa: Government of Canada; 2017 April 5. Available: https://www.foodguideconsultation.ca/guiding-principles-detailed (accessed 2018 Feb 5). The CMA has been active on nutritional issues for many years, both directly through its policy and government advocacy as well as through membership in various coalitions. Some of the issues addressed include the nutrition facts table, front-of-package labelling, a ban on the marketing of food and beverages to children younger than 16 years of age, and a levy on the manufacturers of sugar-sweetened beverages. Canadians’ self-reported dietary intakes do not meet national dietary recommendations despite public education efforts concerning healthy eating and healthy diets. Children and adults are consuming fewer than the recommended number of servings of vegetables and fruits, an established proxy for healthy eating habits, and they are exceeding daily recommended intakes of sodium.2,3 The protection of vulnerable populations including children is of paramount concern to the CMA. Access to nutritious food is essential in early childhood development in support of later adult health.4 The availability of food security programs is a key element in preventing children from developing dietary deficiencies that would lead to an increased risk of chronic disease and greater difficulty in disease management later in life.5 The Food Guide has historically been a valued resource for Canadians, and physicians have found it useful in counselling their patients about healthy eating. However, there are serious concerns with the present Food Guide,6 which was released in 2007, and physicians have increasingly called for it to be reviewed.7 Other countries have made significant changes to their dietary guidelines. Brazil, for example, has developed a guideline that incorporates simple-to-follow, common-sense messaging, such as encouraging Brazilians to prepare meals from scratch and promoting the value of family meals.8 A new, modern Canadian guide is needed. Witnesses appearing before the Senate Committee on Social Affairs, Science and Technology characterized the current version as being “at best ineffective, and at worst enabling, with respect to the rising levels of unhealthy weights and diet-related chronic diseases in Canada.”9 Health Canada is in the process of revising the Food Guide, having done an extensive review of the evidence10 and releasing Guiding Principles.11 Recommendations for a revised Food Guide A new approach to a food guide that addresses the larger picture, beyond daily nutrient consumption recommendations, is fundamental to the effort to improve the health of all Canadians and to the larger goal of developing a food policy for Canada. Indeed, “coordinated investments in health promotion and disease and injury prevention, including attention to the role of the social determinants of health, are critical to the future health and wellness of Canadians and to the viability of the health care system.”12 12 Canadian Medical Association (CMA) and Canadian Nurses Association (CNA). Principles for health care transformation in Canada. Ottawa: CMA and CNA; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD1113.pdf (accessed 2018 Jan 30). 13 Nexus H. Primer to action: Social determinants of health. Toronto: Ontario Chronic Disease Prevention Alliance; 2007. Available: http://www.ocdpa.ca/sites/default/files/publications/PrimertoAction-EN.pdf (accessed 2018 Feb 1). 14 Tarasuk V, Mitchell A, Dachner N. Household food insecurity in Canada. Toronto: PROOF; 2016. Available: http://proof.utoronto.ca/resources/proof-annual-reports/annual-report-2014/ (accessed 2018 Feb 5). 15 Rao M, Afshin A, Singh G, et al. Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis. BMJ Open. 2013;3:e004277. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3855594/pdf/bmjopen-2013-004277.pdf (accessed 2018 Feb 5). 16Lee A, Mhurchu CN, Sacks G, et al. Monitoring the price and affordability of foods and diets globally. Obes Rev. 2013 Oct;14 Suppl 1:82–95. 17 Food Banks Canada. Hungercount2016: A comprehensive report on hunger and food bank use in Canada, and recommendations for change. Toronto: Food Banks Canada; 2016. Available: https://www.foodbankscanada.ca/hungercount2016 (accessed 2018 Jan 30). 18 Raine K. Improving nutritional health of the public through social change: Finding our roles in collective action. Can J Diet Pract Res. 2014;75(3):160-164. Available: https://doi.org/10.3148/cjdpr-2014-017 (accessed 2018 Feb 2). 19 Canadian Medical Association (CMA). CMA’s Support for Bill S-228: An Act to amend the Food and Drugs Act (prohibiting food and beverage marketing directed at children).Ottawa: CMA; 2017.Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2017-07.pdf (accessed 2018 Feb 2). 20 Howard, C., Culbert I., Food Guide revamp encouraging plant-based, low-meat diet is good for people and the planet CBC February 11, 2018 Available: http://www.cbc.ca/news/canada/manitoba/opinion-canada-food-guide-1.4530058 (accessed 2018 Feb 12) CMA recommendations: 1. The Food Guide must go hand in hand with efforts to increase access to affordable, healthy food Food insecurity does not affect all Canadians equally, and there are very clear social patterns of vulnerability.13 Analyses of population survey data consistently identify low income as a predictor of household food insecurity. In addition, rates of food insecurity are highest among Aboriginal Canadians, households reliant on social assistance, households headed by single mothers, and those renting rather than owning a home.14 More research is needed to understand decisions surrounding the purchase of healthy foods versus unhealthy foods.15,16 Food Banks Canada reported that in March 2016, 863,492 people received food from a food bank, an increase of 1.3% over 2015, with eight of 10 provinces showing an increase.17 As the report notes, “approximately 1.7 million Canadian households, encompassing 4 million people, experience food insecurity each year” with 340,000 of them experiencing severe food insecurity.17 Other determinants of healthy eating include a wide range of contextual factors, such as the interpersonal environment created by family and peers, the physical environment, which determines food availability and accessibility, the economic environment, in which food is a commodity to be marketed for profit, and the social environment. Within the social environment, social status (income, education and gender) and cultural milieu are determinants of healthy eating that may be working "invisibly" to structure food choice.15 2. The Food Guide must be based on sound nutritional research With unhealthy diets consistently linked with chronic disease such as cardiovascular diseases (heart disease, stroke, hypertension, diabetes, dyslipidemia) and with an estimated 60% of Canadian adults and close to one-third of children being overweight or obese, there is a need for evidence-based approaches in the development of healthy eating policies and practices in Canada. As the links between nutrition and disease and other impacts of nutrition on the health of our society are revealed and better understood, it is more important than ever to identify what influences healthy eating behaviours.18 Food choices are structured by a variety of individual determinants of behaviour, including one's physiological state, food preferences, nutritional knowledge, perceptions of healthy eating and psychological factors. The Food Guide needs to incorporate emerging research on nutrition and health, for example, by emphasizing the need to replace saturated fats with unsaturated fats, as opposed to focusing on total fats. It also must take into account the changes in consumer behaviour and in the food supply. 3. The Government of Canada must assure Canadians that the revision process is evidence based Canadians must be able to trust Canada’s Food Guide as a source of unbiased information, based on evidence. The Food Guide must be part of a larger coordinated approach that also looks at other critical issues, such as the role of the marketing of unhealthy foods and beverages to children.19 CMA is concerned that conflict-of-interest situations have arisen in the past where recommendations might favour certain products or food groups over others.20 Canadians must have confidence that their health and wellness is the primary focus of an evidence-based revision process. 4. The Food Guide must reflect changing eating patterns reflective of our evolving and increasingly multicultural society Canadian society is more ethnically diverse than in the past, so it is necessary to keep in mind cultural preferences. The current food groups do not always take into account an understanding of traditional foods and cultural eating practices. These are intrinsically linked to identity and culture and contribute to overall health. Advice needs to be tailored to different ages and cultural groups. There is also a need to emphasize patterns of eating, as opposed to a focus almost exclusively on nutrient requirements. It is important to promote eating as a social undertaking, recognizing the essential role that food has in bringing people together. It is also important to support the development of basic, practical culinary skills, which will reduce Canadians’ dependence on restaurant meals and ultra-processed foods. 5. The Food Guide must encourage Canadians to reduce their reliance on processed foods The production and consumption of ultra-processed foods has increased drastically in the last decades in both higher and lower income countries. Highly or ultra-processed food tends to contain less protein and dietary fibre than less processed foods and include high proportions of free sugar, total saturated fat, trans fat and salt. Typically, processed foods are energy dense (high in calories) but have fewer beneficial nutrients such as vitamins and proteins. Most processed foods encourage unhealthy ways of eating and have become popular because of their accessibility and convenience. These features have changed the way food and in particular these products are consumed compared with unprocessed foods: increased “grazing,” eating alone or eating while carrying out other activities such as work or driving. In addition, many calories consumed come in liquid form. Physicians are concerned with the Food Guide’s support for fruit juices, given the plethora of sugar-sweetened beverages, including milk and milk alternatives. There should be a maximum amount of juice recommended for children, and the Food Guide should instead support the consumption of actual fruit. 6. The Government of Canada must produce simple, practical products for Canadians and clear dietary guidance for health professionals Reliable, trustworthy sources of information are essential to support healthy eating. However, the new Food Guide must not be just another set of rules and lists or a long, cumbersome document. The challenge will be to take the evidence around nutrition and health and make it meaningful and useful. This is the only way that the Food Guide will actually be able to support and even provoke change. To do that it must focus on the needs of the Canadians, with tools that personalize information for different age and cultural groups. It should also be useful to people with certain health conditions who require regulation of their diet to improve health (e.g., people with diabetes or hypertension). It should support couples during pregnancy and breastfeeding. There can’t be only one set of guidance; rather, various versions should be produced that are adapted to different audiences. The Food Guide needs to be practical and simple to use. The concept of the number and size of servings of different foods, for example, has been very confusing. Research has shown that Canadians do not weigh or measure their foods and serving sizes are often underestimated, promoting overconsumption. The Food Guide must support Canadians in deciphering food labels and making informed choices about what they consume. The use of technology will allow information to be more accessible. The guidance must be sensitive to issues related to the social determinants of health and food security, with attention to the cost and accessibility of foods. A focus on good sources of proteins, for example, as opposed to red meats and dairy, could allow for more choice. The Food Guide should provide guidance to food banks and other programs that seek to provide food to low-income families in terms of what foods they should procure for their clients. As one of the most trusted sources of health information, physicians also need to be able to access the latest evidence in a user-friendly manner. Resources must be succinct and easy for physicians to access in a busy practice. They should allow a physician to go into more depth should that be required. As well, point-of-care tools that help clinicians explain technical facts to their patients in an accessible manner are needed. Recommendations 1. The Food Guide must go hand in hand with efforts to increase access to affordable, healthy food 2. The Food Guide must be based on sound nutritional research 3. The Government of Canada must assure Canadians that the revision process is evidence based 4. The Food Guide must reflect changing eating patterns reflective of our evolving and increasingly multicultural society 5. The Food Guide must encourage Canadians to reduce their reliance on processed foods 6. The Government of Canada must produce simple, practical products for Canadians and clear dietary guidance for health professionals
Documents
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Best practices for smartphone and smart-device clinical photo taking and sharing

https://policybase.cma.ca/en/permalink/policy13860
Date
2018-03-03
Topics
Health information and e-health
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Date
2018-03-03
Topics
Health information and e-health
Ethics and medical professionalism
Text
Clinical photography is a valuable tool for physicians. Smartphones, as well as other devices supporting network connectivity, offer a convenient, efficient method to take and share images. However, due to the private nature of the information contained in clinical photographs there are concerns as to the appropriate storage, dissemination, and documentation of clinical images. Confidentiality of image data must be considered and the dissemination of these images onto servers must respect the privacy and rights of the patient. Importantly, patient information should be considered as any information deriving from a patient, and the concepts outlined therefore apply to any media that can be collected on, or transmitted with, a smart-device. Clinical photography can aid in documenting form and function, in tracking conditions and wound healing, in planning surgical operations, and in clinical decision-making. Additionally, clinical photographs can provide physicians with a valuable tool for patient communication and education. Due to the convenience of this type of technology it is not appropriate to expect physicians to forego their use in providing their patients with the best care available. The technology and software required for secure transfer, communication, and storage of clinical media is presently available, but many devices have non-secure storage/dissemination options enabled and lack user-control for permanently deleting digital files. In addition, data uploaded onto server systems commonly cross legal jurisdictions. Many physicians are not comfortable with the practice, citing security, privacy, and confidentiality concerns as well as uncertainty in regards to regional regulations governing this practice.1 Due to concern for patient privacy and confidentiality it is therefore incredibly important to limit the unsecure or undocumented acquisition or dissemination of clinical photographs. To assess the current state of this topic, Heyns et al. have reviewed the accessibility and completeness of provincial and territorial medical regulatory college guidelines.2 Categories identified as vital and explored in this review included: Consent; Storage; Retention; Audit; Transmission; and Breach. While each regulatory body has addressed limited aspects of the overall issue, the authors found a general lack of available information and call for a unified document outlining pertinent instructions for conducting clinical photography using a smartphone and the electronic transmission of patient information.2 The discussion of this topic will need to be ongoing and it is important that physicians are aware of applicable regulations, both at the federal and provincial levels, and how these regulations may impact the use of personal devices. The best practices supported here aim to provide physicians and healthcare providers with an understanding of the scope and gravity of the current environment, as well as the information needed to ensure patient privacy and confidentiality is assessed and protected while physicians utilize accessible clinical photography to advance patient care. Importantly, this document only focusses on medical use (clinical, academic, and educational) of clinical photography and, while discussing many core concepts of patient privacy and confidentiality of information, should not be perceived as a complete or binding framework. Additionally, it is recommended that physicians understand the core competencies of clinical photography, which are not described here. The Canadian Medical Association (CMA) suggests that the following recommendations be implemented, as thoroughly as possible, to best align with the CMA policy on the Principles for the Protection of Patient Privacy (CMA Policy PD2018-02). These key recommendations represent a non-exhaustive set of best practices - physicians should seek additional information as needed to gain a thorough understanding and to stay current in this rapidly changing field. KEY RECOMMENDATIONS 1. CONSENT * Informed consent must be obtained, preferably prior, to photography with a mobile device. This applies for each and any such encounter and the purpose made clear (i.e. clinical, research, education, publication, etc.). Patients should also be made aware that they may request a copy of a picture or for a picture to be deleted. * A patient's consent to use electronic transmission does not relieve a physician of their duty to protect the confidentiality of patient information. Also, a patient's consent cannot override other jurisdictionally mandated security requirements. * All patient consents (including verbal) should be documented. The acquisition and recording of patient consent for medical photography/dissemination may be held to a high standard of accountability due to the patient privacy and confidentiality issues inherent in the use of this technology. Written and signed consent is encouraged. * Consent should be considered as necessary for any and all photography involving a patient, whether or not that patient can be directly recognized, due to the possibility of linked information and the potential for breach of privacy. The definition of non-identifiable photos must be carefully considered. Current technologies such as face recognition and pattern matching (e.g. skin markers, physical structure, etc.), especially in combination with identifying information, have the potential to create a privacy breach. * Unsecure text and email messaging requires explicit patient consent and should not be used unless the current gold standards of security are not accessible. For a patient-initiated unsecure transmission, consent should be clarified and not assumed. 2. TRANSMISSION * Transmission of photos and patient information should be encrypted as per current-day gold standards (presently, end-to-end encryption (E2EE)) and use only secure servers that are subject to Canadian laws. Explicit, informed consent is required otherwise due to privacy concerns or standards for servers in other jurisdictions. Generally, free internet-based communication services and public internet access are unsecure technologies and often operate on servers outside of Canadian jurisdiction. * Efforts should be made to use the most secure transmission method possible. For data security purposes, identifying information should never be included in the image, any frame of a video, the file name, or linked messages. * The sender should always ensure that each recipient is intended and appropriate and, if possible, receipt of transmission should be confirmed by the recipient. 3. STORAGE * Storing images and data on a smart-device should be limited as much as possible for data protection purposes. * Clinical photos, as well as messages or other patient-related information, should be completely segregated from the device's personal storage. This can be accomplished by using an app that creates a secure, password-protected folder on the device. * All information stored (on internal memory or cloud) must be strongly encrypted and password protected. The security measures must be more substantial than the general password unlock feature on mobile devices. * Efforts should be made to dissociate identifying information from images when images are exported from a secure server. Media should not be uploaded to platforms without an option for securely deleting information without consent from the patient, and only if there are no better options. Automatic back-up of photos to unsecure cloud servers should be deactivated. Further, other back-up or syncing options that could lead to unsecure server involvement should be ascertained and the risks mitigated. 4. Cloud storage should be on a Canadian and SOCII certified server. Explicit, informed consent is required otherwise due to privacy concerns for servers in other jurisdictions. 5. AUDIT & RETENTION * It is important to create an audit trail for the purposes of transparency and medical best practice. Key information includes patient and health information, consent type and details, pertinent information regarding the photography (date, circumstance, photographer), and any other important facts such as access granted/deletion requests. * Access to the stored information must be by the authorized physician or health care provider and for the intended purpose, as per the consent given. Records should be stored such that it is possible to print/transfer as necessary. * Original photos should be retained and not overwritten. * All photos and associated messages may be considered part of the patient's clinical records and should be maintained for at least 10 years or 10 years after the age of majority, whichever is longer. When possible, patient information (including photos and message histories between health professionals) should be retained and amalgamated with a patient's medical record. Provincial regulations regarding retention of clinical records may vary and other regulations may apply to other entities - e.g. 90 years from date of birth applies to records at the federal level. * It may not be allowable to erase a picture if it is integral to a clinical decision or provincial, federal, or other applicable regulations require their retention. 6. BREACH * Any breach should be taken seriously and should be reviewed. All reasonable efforts must be made to prevent a breach before one occurs. A breach occurs when personal information, communication, or photos of patients are stolen, lost, or mistakenly disclosed. This includes loss or theft of one's mobile device, texting to the wrong number or emailing/messaging to the wrong person(s), or accidentally showing a clinical photo that exists in the phone's personal photo album. * It should be noted that non-identifying information, when combined with other available information (e.g. a text message with identifiers or another image with identifiers), can lead to highly accurate re-identification. * At present, apps downloaded to a smart-device for personal use may be capable of collecting and sharing information - the rapidly changing nature of this technology and the inherent privacy concerns requires regular attention. Use of specialized apps designed for health-information sharing that help safeguard patient information in this context is worth careful consideration. * Having remote wipe (i.e. device reformatting) capabilities is an asset and can help contain a breach. However, inappropriate access may take place before reformatting occurs. * If a smartphone is strongly encrypted and has no clinical photos stored locally then its loss may not be considered a breach. * In the event of a breach any patient potentially involved must be notified as soon as possible. The CMPA, the organization/hospital, and the Provincial licensing College should also be contacted immediately. Provincial regulations regarding notification of breach may vary. Approved by the CMA Board of Directors March 2018 References i Heyns M†, Steve A‡, Dumestre DO‡, Fraulin FO‡, Yeung JK‡ † University of Calgary, Canada ‡ Section of Plastic Surgery, Department of Surgery, University of Calgary, Canada 1 Chan N, Charette J, Dumestre DO, Fraulin FO. Should 'smart phones' be used for patient photography? Plast Surg (Oakv). 2016;24(1):32-4. 2 Unpublished - Heyns M, Steve A, Dumestre DO, Fraulin FO, Yeung J. Canadian Guidelines on Smartphone Clinical Photography.
Documents
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Compensation for remote consultation

https://policybase.cma.ca/en/permalink/policy1505
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Health human resources
Health information and e-health
Physician practice/ compensation/ forms
Resolution
GC04-41
The Canadian Medical Association recommends that provincial and territorial authorities recognize that any type of remote consultation such as telemedicine and teleconsultation is a medical act to be duly compensated.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Health human resources
Health information and e-health
Physician practice/ compensation/ forms
Resolution
GC04-41
The Canadian Medical Association recommends that provincial and territorial authorities recognize that any type of remote consultation such as telemedicine and teleconsultation is a medical act to be duly compensated.
Text
The Canadian Medical Association recommends that provincial and territorial authorities recognize that any type of remote consultation such as telemedicine and teleconsultation is a medical act to be duly compensated.
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Combined fertilizer / pesticides

https://policybase.cma.ca/en/permalink/policy1514
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Health care and patient safety
Population health/ health equity/ public health
Resolution
GC04-50
The Canadian Medical Association calls on the federal government to rescind the registration of combined fertilizer/pesticides.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Health care and patient safety
Population health/ health equity/ public health
Resolution
GC04-50
The Canadian Medical Association calls on the federal government to rescind the registration of combined fertilizer/pesticides.
Text
The Canadian Medical Association calls on the federal government to rescind the registration of combined fertilizer/pesticides.
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Annual report on the status of Canada's health care system and its funding

https://policybase.cma.ca/en/permalink/policy1517
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC04-84
The Canadian Medical Association will ensure the development of an annual report on the status of Canada's health care system, including a component on the financial sustainability of the publicly funded medicare program.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC04-84
The Canadian Medical Association will ensure the development of an annual report on the status of Canada's health care system, including a component on the financial sustainability of the publicly funded medicare program.
Text
The Canadian Medical Association will ensure the development of an annual report on the status of Canada's health care system, including a component on the financial sustainability of the publicly funded medicare program.
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Adoption and implementation of sustainable funding framework for medicare

https://policybase.cma.ca/en/permalink/policy1518
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC04-85
The Canadian Medical Association advocates for the adoption and implementation of a sustainable funding framework for medicare based on the policy objectives set out in the Canada Health Access Fund.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC04-85
The Canadian Medical Association advocates for the adoption and implementation of a sustainable funding framework for medicare based on the policy objectives set out in the Canada Health Access Fund.
Text
The Canadian Medical Association advocates for the adoption and implementation of a sustainable funding framework for medicare based on the policy objectives set out in the Canada Health Access Fund.
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Delivery of publicly insured medical services by the private sector

https://policybase.cma.ca/en/permalink/policy1521
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC04-88
The Canadian Medical Association encourages the continued delivery of publicly insured medical services by the private sector provided that these services are funded entirely by the public sector.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC04-88
The Canadian Medical Association encourages the continued delivery of publicly insured medical services by the private sector provided that these services are funded entirely by the public sector.
Text
The Canadian Medical Association encourages the continued delivery of publicly insured medical services by the private sector provided that these services are funded entirely by the public sector.
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Promotion of physical activity among physicians

https://policybase.cma.ca/en/permalink/policy1525
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Ethics and medical professionalism
Health human resources
Population health/ health equity/ public health
Resolution
GC04-52
The Canadian Medical Association, in keeping with its vision of a healthy population and national advocacy mission, shall vigorously promote physical activity among physicians for the sake of their own wellness, which in turn enhances their ability to care for others and sets an important example in encouraging patients to be physically active.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2004-08-18
Topics
Ethics and medical professionalism
Health human resources
Population health/ health equity/ public health
Resolution
GC04-52
The Canadian Medical Association, in keeping with its vision of a healthy population and national advocacy mission, shall vigorously promote physical activity among physicians for the sake of their own wellness, which in turn enhances their ability to care for others and sets an important example in encouraging patients to be physically active.
Text
The Canadian Medical Association, in keeping with its vision of a healthy population and national advocacy mission, shall vigorously promote physical activity among physicians for the sake of their own wellness, which in turn enhances their ability to care for others and sets an important example in encouraging patients to be physically active.
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Bill C-12: An Act to prevent the introduction and spread of communicable disease : CMA’s Submission to the House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy1948
Last Reviewed
2012-03-03
Date
2004-11-23
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2004-11-23
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) appreciates the opportunity to appear before the House of Commons Standing Committee on Health to provide our observations concerning Bill C-12, an Act to prevent the introduction and spread of communicable disease, which will repeal and replace the current Quarantine Act. Since our founding in 1867, the CMA has had a long tradition in the field of public health and infectious diseases. For example, in 1885 we worked with the federal government to prevent an outbreak of cholera in Canada, while in 1891 we began a long campaign to encourage governments to deal with tuberculosis. And fast forward to 2003 and SARS, CMA worked along with many levels of government to deal with this public health crisis. While the CMA is particularly interested in how the proposed legislation will impact the practices of our more than 58,000 members across the country, we have reviewed this legislation through the lens of what is in the best interest of patients and the public. 1) Comprehensive Approach to Public Health Our comments call for and are embedded in the broader context of a comprehensive approach to public health. They are also based on previous recommendations CMA has made to the federal government including: a) Response to the Health Protection Legislative Renewal initiative carried out by Health Canada (2004). In this submission, CMA identified the Quarantine Act as a piece of legislation the CMA believed merited urgent updating; b) Review of the World Health Organizations’ draft revised International Health Regulations (IHR), (2004); c) Submission to the Naylor Advisory Committee on SARS and Public Health (2003); d) Submission to the Senate Standing Committee on Social Affairs, Science and Technology during its study of public health issues (2003); and e) Pre-budget submission to the House of Commons Standing Committee on Finance following September 11, 2001. These submissions are all available on request, or at www.cma.ca. The CMA is pleased that Parliament has identified revision of the Quarantine Act as a priority. The Act is more than a century old and the medical community and others have long called for it to be updated. Bill C-12 is an excellent start to modernizing the previous Act; however, we believe the proposed legislation does not go far enough in remedying its deficiencies. In this submission we present eight key recommendations for your consideration, along with questions about particulars in the implementation process, which we suggest Parliament address in subsequent review of the Act and its regulations. 2) Recommendations for Consideration in Review of Bill C-12 Recommendation 1: The Act should be part of a larger, comprehensive Emergency Health Measures Plan. In our brief to the Naylor Advisory Committee, CMA recommended the enactment of a comprehensive Emergency Health Measures Act, administered by the Chief Public Health Officer of Canada. This Act would consolidate and enhance existing legislation, allowing for a more rapid national response to health emergencies, in cooperation with the provinces and territories, based on a graduated, systematic approach. We also recommended that the Emergency Health Measures Act be part of a strong commitment, by all levels of government, to a public health strategy that also included a 5-year capacity enhancement program, development of research and surveillance capability; and funding for a communications initiative to improve technical capacity for real-time communication with front-line health providers during public health emergencies. Recommendation 2: The Chief Public Health Officer of Canada must have authority to enforce the Act The proposed legislation designates the Minister of Health as the person with ultimate responsibility for enforcing the Act; it grants the Minister sweeping powers including the power to overrule a health official’s quarantine. As medical professionals we believe that public health decisions should be made primarily on the basis of the best available medical and scientific evidence, and should be independent to the greatest extent possible of other considerations. Therefore we believe that responsibility for the implementation of the Act should rest with the Public Health Agency of Canada, and with the Chief Public Health Officer of Canada, not with the Minister of Health. In the provinces and territories, Medical Officers of Health do not require approvals from their Ministers to exercise their functions as health professionals; the same should hold true at the federal level. We understand that responsibility has been placed with the Minister of Health due to a lack of existing legislation setting out the mandate, roles, responsibilities and powers of the recently created Public Health Agency of Canada, and the newly appointed Chief Public Health Officer of Canada. We are also aware that enabling legislation is currently being prepared; we urge that this legislation be enacted as soon as possible. On enactment of this enabling legislation, the powers now vested in the Minister should be ceded to the Chief Public Health Officer. Locating responsibility for administration of the Act within the Public Health Agency of Canada will also combine enforcement with other needed functions of surveillance, monitoring and linkage with international monitoring agencies. As we stressed in our previous recommendation, these must all be part of a comprehensive Canadian emergency response strategy. Recommendation 3: The Act must address interprovincial as well as international traffic. We are happy that the provisions of Bill C-12 apply to goods and travellers leaving as well as entering Canada. This was a deficiency identified in the previous Quarantine Act. However, the Act must also expressly address goods and travellers crossing provincial or territorial boundaries. Currently, there is tremendous variation in public health system capacity among provinces and territories and, more particularly, among municipalities and local authorities. Inconsistencies in provincial approaches to public health matters have resulted in significant weaknesses in the “emergency shield” between and across provinces. Unless the potential consequences of these disparities are remedied through federal legislation they must, as a priority, be remedied through federal/provincial/territorial agreements. The role of the Public Health Agency of Canada in facilitating, equalizing and monitoring the management of public health emergencies nationwide must be enshrined in the legislation that establishes the Agency. CMA also hopes that the development of a pan-Canadian Public Health Network, acknowledged in the 2004 Throne Speech, will facilitate the nationwide collaboration essential for adequate and appropriate response to health emergencies. The CMA supports those provisions in Bill C-12 that give the Minister (preferably the Chief Public Health Officer of Canada) the power to establish quarantine centres anywhere in the country. In times of threat to national health security, such bold leadership would be both warranted and expected. Recommendation 4: “Public Health Emergency” must be adequately defined. Bill C-12 contains no definition of “public health emergency” or “public health emergency of international concern.” We believe these should be defined.1 Bill C-12 includes a schedule of specific communicable diseases to which its provisions would apply. We are concerned that this Schedule may limit Canada’s capacity to respond to emergencies. The next public health emergency may be a disease we have not heard of yet; or it may be a bio-terrorist attack, or a chemical or nuclear event. The Act must enable Canada to respond to new and emerging, as well as existing, threats to health. The World Health Organizations’ draft International Health Regulations (IHR) has proposed a set of criteria for assessing emergencies; these include: * Is the event serious? * Is the event unexpected? * Is there a significant risk of international spread? The CMA urges the Canadian government to consider a hybrid approach incorporating both known disease states and criteria such as the ones used by the IHR, for assessing new diseases or other public health emergencies. Recommendation 5: The Act, or its regulations, must clarify the roles, responsibilities and training requirements of emergency response personnel. Some provisions of Bill C-12 have raised questions in our minds about the scope of practice of personnel involved in disease screening, and we would appreciate clarification on these points. For example: Screening officers, the first point of contact for travelers entering or leaving Canada, are customs officers and others designated by the Minister. Their primary role under Section 14 of the Act is to use “non-invasive” screening technology to detect travelers entering and exiting Canada with communicable disease vectors, etc. According to Section 15 (3) screening officers, who are not health professionals, will have the power to “order any reasonable measure to prevent spread of a communicable disease”. Of what might these “reasonable measures” consist? Quarantine officers, by definition in Section 5(2) are medical practitioners or other health professionals or anyone else in this “class of persons”. Since the quarantine officer’s job description includes physical assessment of travellers to determine whether they should be detained – a function that requires the expertise of a health professional - we would appreciate clarification of the phrase “in this class”. Similarly, under Section 26, the quarantine officer has the power to order the traveler “to comply with treatment”. Which officer—screening/quarantine or medical—might actually prescribe the course of treatment? This function must be specifically delegated to medical officers. Bill C-12 gives authorities the powers to restrict personal movement and temporarily impound or seize property. The CMA believes that the government should also provide adequate resources and powers to allow for tracking down apparently well people who cross borders and are subsequently diagnosed with infectious diseases. The Act or its regulations should also address factors that hinder deployment of qualified health professionals, such as portability of licensure and coverage for malpractice and disability insurance. CMA has previously called for the establishment of a Canadian Public Health Emergency Response Service that would maintain a “reserve” of public health professionals who could be deployed to areas of need during times of crisis, and which would co-ordinate the logistics of the issues above mentioned. This would improve the capacity of health professionals to be deployed quickly in times of health emergency, to locations where they are most needed. Finally, CMA suggests that the Act or its regulations provide greater detail on training requirements for screening officers, to guarantee that they are appropriately trained. Recommendation 6: Privacy and confidentiality must be respected and safeguarded. Bill C-12 grants quarantine officers and the Minister some sweeping powers to arrest and detain people without warrants, including people who have refused to comply with testing. Though on rare occasions such measures may be required to protect the public, it is recognized that potential for their abuse may exist. In addition, Bill C-12 raises questions about the degree to which personal health information might be exposed to scrutiny. We note that Section 51 authorizes a quarantine officer to “order any person to provide any information or record…the officer might reasonably require.” This provision could include patient medical records in a doctor’s office, particularly if the Bill guarantees travellers the right to request a “second opinion” which we assume could be obtained from any practicing physician in Canada. Similarly, Sections 55 and 56 appear to give the Minister authority to “collect medical information in order to carry out the purposes of this Act” and to “disclose personal information obtained under the Act” to a host of entities. The CMA believes that the power to obtain and disclose information should be explicitly constrained and circumstances under which this power could be exercised must be outlined in the Act. Recommendation 7: The role of physicians and other health care workers must be respected. The health professional sector is on the front lines of response to health emergencies, as they were during the SARS outbreak. Therefore as a first principle the new Act should recognize the importance of health professionals having the power, subject to appropriate constraints, to make vital decisions in response to health emergencies. This is a legitimate delegation of power, because of the competencies of health professionals. During the SARS outbreak of 2003, physicians and other health care providers were not only partners in containing infection; many became ill or died as well. Since health care workers expose themselves to infection as they respond to health emergencies, protocols should ensure that care and attention is paid to their safety, through measures such as ensuring ready availability of proper masks The Act or regulations should address precautions required to protect quarantine officers and other health care workers from transmission of disease or the effects of becoming ill. For example, it should address compensation for quarantine officers who lose work because they become infected in the course of their duty. We would be remiss in our review of this act if we did not pursue with this Committee the issue of compensation and indemnification programs for physicians and trainees requiring quarantine because of exposure to a communicable disease while providing medical service, or who are required to close their offices for other public health reasons, or who cannot practice in hospitals because of closure of hospitals for public health reasons. Indeed, delegates to our annual general council meeting called on the CMA to do so. A number of these physicians were caught in such situations during the turmoil of the SARS outbreak. Recommendation 8: Decision-making should be evidence-based. At times, public perception and political considerations may widely influence the assessment and management of risk. While this is probably unavoidable, CMA believes that public policy should be founded first and foremost on the highest possible quality of scientific evidence. The Act should provide the requisite mechanisms to ensure that reviews of risk are independent and unbiased. We acknowledge, however, that this principle should not be rigidly applied; “we’re waiting for the evidence” must not be used as an excuse for inaction when action is urgently required. 3) Additional Comments In addition to the above recommendations, additional concerns remain regarding implementation of the Act. In particular we note that many crucial components, such as how physical examinations are to be carried out (section 62(1), medical practitioner’s review process (section 62(d), and the protection of personal information (62(g) are left to regulations. These regulations must be developed as soon as possible. We understand that the current Act constitutes “Phase I” of a longer-term strategy to enhance Canada’s capacity to respond to public health emergencies. Though we believe that the Quarantine Act merits attention at this time, we also believe that it should be looked at with a longer-term view. For instance, as we have already recommended, it should be incorporated into the broader legislative renewal of public health in Canada, with a view to enhancing this country’s ability to respond swiftly and effectively to public health emergencies, locally and nationwide. Above all, Canada must ensure a sustained and substantial commitment of resources to its public health emergency response program. Without this, the best-written laws will be inadequate. The Canadian Medical Association commends the Government of Canada for bringing this bill forward, and looks forward to working with the Government, and the Public Health Agency of Canada, to help keep Canadians safe in the event of a public health emergency. End Notes 1 A public health emergency has been defined by the US Model State Emergency Powers Act (http://www.publichealthlaw.net accessed July 7, 2003) as an occurrence or imminent threat of an illness or health condition of a temporary nature that is believed to be caused by: * the appearance of a novel or previously controlled or eradicated infectious agent or biological toxin; * a bioterrorist event; * a natural disaster * a chemical event or accidental release; or * a nuclear event or accident and that poses a high probability of any of the following harms: * a large number of deaths in the affected population; * a large number of serious or long-term disabilities in the affected population; or * widespread exposure to an infectious or toxic agent that poses a significant risk of substantial future harm to a large number of people in the affected population.
Documents
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Letter on Strengthening the Pan-Canadian Public Health System discussion paper

https://policybase.cma.ca/en/permalink/policy1957
Last Reviewed
2011-03-05
Date
2004-03-22
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Response to consultation
Last Reviewed
2011-03-05
Date
2004-03-22
Topics
Population health/ health equity/ public health
Text
I am writing in response to your letter inviting comment on the discussion paper Strengthening the Pan-Canadian Public Health System distributed in February 2004. The Canadian Medical Association (CMA) welcomes the opportunity to participate in this consultation process on a national public health system. Our country’s experience combating SARS brought home to all of us the critical need for a strong and effective public health system to ensure that we are never again found unprepared to deal with the consequences of an emerging infectious disease. The commitments to establish a strong and effective public health system, a Canada Public Health Agency and a Chief Public Health Officer detailed in the February 2, 2004 Speech from the Throne have raised expectations across the land, and particularly within the public health community. In June 2003 CMA detailed a Public Health Action Plan in its submission to the National Advisory Committee on SARS and Public Health (Naylor Committee). The CMA’s Plan was further elaborated in our October 2003 submission to the Standing Senate Committee on Social Affairs, Science and Technology (Kirby Committee) hearing on public health governance and infrastructure. The CMA is also a founding member and active supporter of the Canadian Coalition for Public Health in the 21st Century. Both of the CMA submissions and the Coalition stress the need for strong leadership, capacity building and appropriate funding to ensure that Canada’s public health system is able to deal with the challenges ahead. In this submission I will first focus on the responsibility and actions the federal government can take now to create a strong and effective public health system and then comment on issues raised in the Strengthening the Pan-Canadian Public Health System discussion paper. The CMA believes that the country today has a rare opportunity to build a public health system for Canada that can take the best elements from the past while embracing new innovative approaches to the future. But to achieve the Speech from the Throne commitment to “establish a strong and responsive public health system” strong leadership is needed now. The federal government has a critical role to play. In both the United Kingdom and the United States, national leadership has been instrumental in clearly defining health goals for the population and stating the role of the public health system, its key infrastructure elements and the development of strategies to attain them. The CMA is pleased with your commitment and that of your government to the establishment of a Canada Public Health Agency (CPHA) but we can not stress strongly enough the need for you and your cabinet colleagues to take the bold steps needed to ensure that a national public health agency is truly independent. A CPHA that is not adequately funded and independent of the government bureaucracy will only result in a shuffling of the deck chairs. A credible Chief Public Health Officer (CPHO) must be appointed to lead the Agency, be the federal government’s chief medical officer of health (CMOH) and the country's chief spokesperson for all public health issues. The CPHA and the Chief Public Health Officer should have a central role in providing public health services to those areas falling under federal jurisdiction where local and provincial Chief Medical Officers of Health do not have access or authority. Airports, railways, military bases, aboriginal peoples living on reserve, federal meat packing plants and national parks are examples of areas under federal jurisdiction. The delivery of public health in these jurisdictions has been especially compromised by the lack of comprehensive coordination between provincial and federal systems. The federal CMOH should have all the powers and responsibilities of a provincial /territorial CMOH with respect to public health in federal jurisdictions. While there is an urgent need for the federal government to address problems with the delivery of public health services within its own backyard, it also must enhance co-ordination within the various federal departments and agencies that address public health concerns. In its submission to the National Advisory Committee on SARS and Public Health the CMA also called for federal leadership in times of national health emergencies. The enactment of a Canada Emergency Health Measures Act would enhance the federal government’s “command and control” powers in a measured way during times of national health emergencies. The Act would give the federal government specific authority to act for a pre-determined, temporary period of time, during a declared extraordinary health emergency. It would also provide the authority for development of a graduated health alert system with corresponding public health interventions to enable a rapid co-ordinated response as a public health threat emerges.1 A systematic approach to health emergencies outlining roles, responsibilities and authority of jurisdictions would go a long way to avoiding the chaos and confusion that surrounded the country’s emergency response to SARS. Funding The public health infrastructure is the foundation that supports the planning, delivery and evaluation of public health activities. In 2001, a working group of the Federal, Provincial and Territorial (F/P/T) Advisory Committee on Population Health assessed the capacity of the public health system through a series of key informant interviews and literature reviews. The consistent finding was that public health had experienced a loss of resources and there was concern for the resiliency of the system infrastructure to respond consistently and proactively to the demands placed on it. It is essential that the federal government work with the provinces/ territories and municipalities to stop the hemorrhaging in public health across the country. We must stabilize and shore up the core public health capacity at the municipal, and provincial/territorial levels. At the federal level, in the short term, we must sustain our current capacity to tackle critical public health issues. The recent focus on infectious disease must not lead us to take monies from chronic disease prevention and health promotion to bolster efforts to manage outbreaks of infectious disease. Robbing Peter to pay Paul will only compound and exacerbate the challenges facing the public health system. All of the essential functions of public health must be recognized and resourced within a coherent public health strategy. This will require an investment of at least $1.5 billion over the next five years, beginning with an immediate commitment of $200 million in the upcoming budget. There is also a critical need for additional resources to reach the frontline public health workers in the many local agencies across Canada. In this regard, on March 12, 2004 the CMA, the Canadian Nurses Association, Canadian Pharmacists Association and the Canadian Healthcare Association wrote to the Prime Minister urging him to consider adding the recent one-time $2 billion transfer into the Canada Health Transfer (CHT) funding base and ear-mark 10% of this amount for public health action. Capacity building The infusion of $1.5 billion over the next five years would go a long way to provide federal, provincial/territorial and municipal governments with the tools needed to rebuild capacity in the public health system. An area needing immediate attention is human resource capacity. For the essential functions of the public health system to be realized, we need a public health workforce with appropriate and constantly updated skills. Unfortunately that workforce is extremely thin today. We need to invest in additional training capacity in all of the public health disciplines. CMA has proposed an investment of $50 million in 2004/05 to begin to strategically rebuild human resource capacity. To provide additional surge capacity CMA has further proposed the establishment of a Canadian public health emergency response service or Canadian Health Corps. The service would be made up of a core group of highly trained and mobile public health professionals, employed by the federal government, to be directed by the Chief Public Health Officer. A complementary ‘reserve pool’ or volunteer relief network would be made up of acute health care and public health professionals willing to be deployed anywhere in Canada on short notice to provide services during health emergencies. A predetermined and pre-licensed pool of professionals that can respond to a call to action in times of crisis is a critical resource that must be established before we are faced with another emergency situation. Canadians expect the federal government to assume its responsibility to provide national leadership in public health. Visionary leadership, investment and capacity building are essential components of a reinvigorated public health system. It is within this context that CMA has reviewed the Strengthening the pan-Canadian public health system discussion paper. Strengthening the pan-Canadian public health system The discussion paper Strengthening the Pan-Canadian Public Health System unfortunately positions the planning assumptions for a national public health strategy within the traditional F/P/T process. While we are encouraged with the commitment of the F/P/T Ministers of Health to work collaboratively on the creation of a Pan-Canadian Public Health Network, it is not what Canadians or CMA envisioned in terms of providing leadership on the development of a national public health strategy and a consistent and co-ordinated approach to health emergencies. The discussion paper is proposing that a CPHA be the centralized responsibility centre or ‘co-ordinating node’ of a Pan-Canadian Public Health Network that would develop national public health strategies and co-ordinate responses to public health emergencies. While the Network is necessary to facilitate intergovernmental co-operation, CMA believes that it is now time to move beyond traditional processes that, in the past, have often hindered the country’s ability to respond rapidly to address pan-Canadian problems. Therefore in its briefs to both the Naylor and Kirby Committees, the CMA proposed the creation of an independent CPHA to provide leadership and comprehensive public health expertise in the development of a strategic pan Canadian approach to public health planning and services. These CMA briefs speak to many of the issues pertaining to the CPHA and CPHO that are raised in the federal discussion paper. CMA proposals for a CPHA as outlined below address the questions of mission and mandate, accountability and transparency posed by the paper. The CPHA, as described by CMA, would become the lead national agency on public health matters with a broad mandate to co-ordinate all aspects of planning for national public health emergencies, provide ongoing national health surveillance and work closely with provinces/territories to reinforce other essential public health functions. To effectively carry out its mandate the CPHA structure must respect five guiding principles. It must be: * Independent – At arm’s length from government, insulated from day-to-day vagaries of political pressures while remaining accountable to Canadians. * Science-based – Adherence to the highest standards of risk assessment and decision-making with a view to safeguarding the health of Canadians. * Transparent – Open to public scrutiny and encouraging public participation in its activities. * Responsive – Characterized by a nimble decision-making process and a capability of deploying resources and expertise quickly and efficiently to any part of the country. * Collaborative – Partnership-oriented, fostering collaboration with other federal, provincial and non-governmental partners. CMA has recommended that the CPHA be established as an arms length, adequately resourced agency within the purview of the federal government. Under this approach, the CPHA would be structured on a corporate model in which decision-making powers are vested in an expert advisory board. The board, in turn, would be accountable to Parliament and the public for the exercise of these powers. The CPHA would be created through new federal legislation but would remain under the health portfolio, with accountability to Parliament through the health minister. The chief public health officer would head the CPHA, oversee the day-to-day operation of the office, be the federal government’s chief medical officer of health, and act as the lead scientific voice for public health in Canada. This structure would mark a departure from the status quo in that the level of professional autonomy would increase and the level of ministerial involvement in professional issues would be reduced. This would contribute to making the CPHA more credible as a science-based organization. The board governance structure would encourage participation from the broader public health community and could therefore be more effective in creating partnerships with other key players. Conclusion The CMA commends you and the federal and provincial/territorial governments for the evident commitment to address the public health challenges facing this nation. It is unfortunate that it took a public health tragedy to bring this commitment to the forefront but never the less the public health community in Canada stands ready to work with governments to achieve a strong and responsive public health system. As part of that community the medical profession is ready and willing to support initiatives that will improve public health programs and services that ultimately make Canada a safer and healthier place to live. We do not support a continuation of the status quo. We must seize this opportunity to create a public health system that that can take the best elements from the past while embracing new innovative approaches to the future. Sincerely, Sunil V. Patel, MB, ChB President SVP/ac 1 Answering the Wake-Up Call: Canada’s Public Health Action Plan, June 2003. Available: http://www.cma.ca/cma/menu/displayMenu.do?tab=422&skin=432&pMenuId=1&pSubMenuId=2&pageId=/staticContent/HTML/N0/l2/where_we_stand/political/index.htm
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Health Protection and a Canadian Public Health Strategy: A Comprehensive Approach To Public Health: Submission to Health Canada

https://policybase.cma.ca/en/permalink/policy1958
Last Reviewed
2011-03-05
Date
2004-04-12
Topics
Population health/ health equity/ public health
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2011-03-05
Date
2004-04-12
Topics
Population health/ health equity/ public health
Text
This submission is the response of the Canadian Medical Association to Health Canada's request for feedback on its detailed "Health Protection Legislative Renewal" legislative proposal released in June 2003. Our submission calls for and is embedded in the broader context of a comprehensive approach to public health. The Canadian Medical Association is committed to working with others to realize the vision of a comprehensive, robust public health strategy as a vital component of Canada's health care system. This strategy should rest upon three pillars: * Emergency Response Empowering rapid and effective response to health emergencies, e.g. communicable disease outbreaks, water contamination, bio-terrorist attacks. * Health Protection: Ensuring that Canadians are protected from health risks in their daily environment; for example, risks associated with the use of health or consumer products, or with the potential spread of infectious disease. * Health Promotion and Disease Prevention Instituting programs to encourage healthy behaviour and advocating for public policy and fiscal policy that supports health. Though these three pillars have different foci and different legislative instruments, they must all be part of a strategy to enhance public health and public health service delivery in Canada. With specific reference to health protection, CMA believes that legislation should rest on the following principles: a) Commitment to the primacy of health and safety. b) Commitment to evidence-based decision making. c) A thorough risk-analysis procedure based on the relative risk of products or services. d) Support for informed patient decision-making. e) Accountability vested in the Government of Canada. f) A comprehensive, effective post-marketing surveillance system. g) Enforcement through effective, meaningful penalties for noncompliance. h) Flexibility to quickly and efficiently accommodate new technologies. i) Openness and transparency. j) Encouragement of collaboration and co-operation with other stakeholders, while respecting existing jurisdictions and legislative mechanisms. Recommendations A Canadian Public Health Strategy 1) That the federal government ensure that legislative and administrative measures related to public health complement one another in function and are connected through communications and co-ordination mechanisms. The Drug Review Process 2) That the federal government implement a timely and efficient drug review process to reduce review times to the fastest level consistent with ensuring improved health outcomes and the safety of the drug supply. 3) That the federal government consider co-operative agreements for drug review with comparable agencies in Europe, the United States and Australia, while retaining final authority as to whether a new product should be allowed on the Canadian market. 4) That the drug review and approval process be open and transparent, providing updates on review status and the opportunity for stakeholder input. 5) That Health Canada apply a priority review process to "breakthrough" drugs, i.e. those that demonstrate a substantial improvement over products already on the market. Patient Safety and Post-Marketing Surveillance 6) That Health Canada work in partnership with stakeholders including CMA and other national medical and health professional associations, to develop a rigourous post-marketing surveillance system to monitor the ongoing safety of marketed drugs. 7) That government accelerate activities to establish the Patient Safety Institute using a systems approach to support a culture of safety. 8) That all stakeholders join in supporting and encouraging outcome-based research to ascertain best practices in prescribing. 9) That the federal government invest in measures such as electronic communications networks, to increase physicians' capacity to report medication incidents and to improve the timeliness of adverse event reporting. Drug Information and Advertising 10) That all stakeholders work to ensure that Canadians have ready access to a source of comprehensive, reliable information on health products and their uses, and that governments fund development and dissemination of validated information to physicians and to the public. 11) That the legislation define "promotion" and "advertising" so as to clearly distinguish them from unbiased health information, and from counselling by health professionals. 12) That the current safeguards against deception be strengthened in order to * Forbid fraudulent or misleading health claims in advertisements, on labels or in any other promotional or descriptive material pertaining to the product; * ensure pre-clearance and ongoing review of all health claims by an objective agency; * provide meaningful penalties for infraction. 13) That Health Canada maintain the current ban on advertising health products for treatment, prevention and cure of conditions or disease states to be identified in a regulatory schedule or administrative list; the inclusion of conditions in this list should be determined through a set of criteria that are written into the Act or regulations. 14) That the existing ban on direct to consumer advertising of prescription drugs be maintained and enforced to the full extent of the law, and that the loophole that currently permits advertising the name, price and quantity of a prescription drug be closed. 15) That all stakeholders, including medical associations and industry groups, work together toward effective regulation of drug promotion to health practitioners. Safeguarding the Privacy of Health Information 16) That the Health Protection Act respect the provisions of the Charter of Rights and Freedoms, the Federal Privacy Act and the Personal Information Protection and Electronic Documents Act (PIPEDA). 17) That the privacy provisions in the Health Protection Act meet the legislative test outlined in Section 3.6 of CMA's Health Information Privacy Code. Other Issues 18) That the Health Protection Act give Health Canada a clear mandate to develop guidance documents to address health and safety issues raised by new technologies. 19) That Natural Health Products be regulated on a strict framework that ensures their safety, quality and efficacy as well as the provision of complete and unbiased information to the public. 20) That the Act provide Health Canada with a clear mandate to collaborate with provincial/territorial and local governments across Canada in reviewing legislation governing all aspects of drinking water from source to consumption to ensure that comprehensive programs are in place and being properly implemented. 21) That Health Canada urgently review the Quarantine Act and modernize its provisions. 1. Introduction This submission is the response of the Canadian Medical Association (CMA) to Health Canada's request for feedback on its detailed "Health Protection Legislative Renewal" legislative proposal released in June 2003. Our submission calls for and is embedded in the broader context of a comprehensive approach to public health. It also includes recommendations dealing with selected specific issues raised in the proposal, particularly those that have a potential major impact on physicians and other health professionals, and on the practice of medicine. The Canadian Medical Association supports the government's efforts to update and revitalize health protection legislation. Physicians are committed to working with others to realize the vision of a comprehensive, robust public health strategy as a vital component of Canada's health care system, in order to realize Canada's potential as a healthy nation. Recent headlines illustrate the diversity of public health challenges facing Canadians: * The spread of avian flu across Asia, and the reappearance of SARS in China; * Reports linking the use of Selective Serotonin Reutake Inhibitor antidepressants to increased suicide and other behavioural disorders in children and adolescents, which led to a public warning against their use in this population; * The rapidly rising rates of obesity in Canada and other developed countries. To deal with these problems and others, a comprehensive public health strategy is required. This strategy should rest upon three pillars: emergency response, health protection and health promotion (Figure 1). Each of these pillars is discussed in greater detail in the following section. 2. Three Pillars of a Canadian Public Health Strategy a) Pillar #1: Emergency Response The 2003 SARS outbreak shone a merciless light on the difficulties that Canada's stretched public health system can encounter when it needs to respond to health emergencies. The 21st century has brought a disturbing array of new public health risks (such as avian flu) and old risks revisited (such as contamination of water supplies). A comprehensive public health strategy should be able address these risks by: * Empowering rapid and effective response to health emergencies, e.g. communicable disease outbreaks, water contamination, bio-terrorist attacks. * Supporting health surveillance, screening and research, to identify potential health risks. [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Figure 1. The Three Pillars of Public Health [FIGURE END] CMA Position: CMA's 2003 submission to the National Advisory Committee on SARS and Public Health (the Executive Summary is attached as Appendix I) recommended a number of measures to strengthen Canada's capacity to respond to health emergencies. These included: * The enactment of a Canada Emergency Health Measures Act to allow for a more rapid national response to emergencies that pose an acute and imminent threat to human health and safety in Canada. * The creation of an independent Canada Public Health Agency, headed by a Chief Public Health Officer of Canada who would work with provinces and territories to develop and implement a pan-Canadian public health action plan. * Enhancements to the current system of disease surveillance and response, so that it remains privacy sensitive and ensures a two-way flow of information between public health experts and front-line clinicians. In 2004 CMA reiterated these recommendations to the Honourable Carolyn Bennett, Minister of State for Public Health, in response to her request for consultation on a Canada Public Health Agency. b) Pillar #2: Health Protection The Health Protection function ensures that Canadians are protected from health risks in their daily environment; for example, risks associated with the use of health or consumer products, or with the potential spread of infectious disease. Specific health protection functions include: * Ensuring that Canadians have access to the right pharmaceutical drugs, which have been proven safe and efficacious, at the right times, for the right prices. Our policy in this area is further discussed in our 2003 submission to the House Standing Committee on Health's review of prescription drugs, an executive summary of which is attached (Appendix II). * Monitoring Canada's pharmaceutical drug supply to ensure its safety, effectiveness and continued availability. * Ensuring the safety of natural health products, medical devices, hazardous products and other consumer products. This should include the regulation of toxic substances, including tobacco. * Regulating health claims for consumer products. * Monitoring the advertising and promotion of health products to the public. * Administering quarantine procedures. * Developing regulatory frameworks to ensure the safety and effectiveness of new technologies such as gene therapy and genetically modified foods. CMA Position: The principles that CMA believes should guide review of health protection legislation are discussed in Section 3. c) Pillar #3: Health Promotion and Disease Prevention For more than 30 years the federal government has incorporated the promotion of health, as well as the treatment of disease, into its mandate. Activities undertaken in pursuit of this function include: * Programs to encourage healthy behaviours, e.g. physical activity strategies. * Advocating for or implementing public policy that supports health e.g. bans on tobacco advertising and sponsorship, and fiscal policies, such as high tobacco taxes. * Research strategies to increase our understanding of the determinants of health. CMA Position: The CMA has called on the federal government to commit to the goal of establishing Canada as the top country in the world with regard to the health status of its citizens. Canada remains one of the few countries in the industrialized world without a clear statement of national health goals, targets and strategies. All levels of government should enable the Health Council of Canada to monitor and report on defined health goals and priorities. In addition, the CMA has developed policies and statements urging action on specific health promotion issues including: obesity control; injury prevention; physical activity; tobacco control; mental health; and many others. Though these three pillars have different foci and different legislative instruments, they must all be part of a comprehensive legislative agenda and strategy to renew and enhance public health and public health service delivery in Canada. Addressing issues under one pillar without reference to the other pillars or to a comprehensive public health framework and strategy fails to address the overall public health needs of Canadians. Recommendation 1. That the federal government ensure that legislative and administrative measures related to public health complement one another in function and are connected through communications and co-ordination mechanisms. 3. A Policy Framework for Health Protection Legislation This submission is a response to a legislative proposal regarding health protection; consequently the rest of this document will focus on the second of the three pillars described above, the "health protection" pillar. This section discusses the overall policy framework that the CMA believes should govern health protection in Canada. The CMA holds that health protection legislation should rest on the following principles: i) Primacy of Health and Safety. Legislation should commit to protection of public health and safety as its primary objective. ii) Core Values. Legislation should recognize the core values of Canadians, such as privacy of health and personal information, freedom of choice, and protection of vulnerable citizens, and be sensitive to cultural, gender, socio-economic and other factors where relevant. Where there is a conflict between Principle (i) and other values, this conflict and the grounds on which to resolve it should be explicitly stated. iii) Evidence-based Decision Making. Legislation should reflect a commitment to scientific, evidence-based decision making. It should provide for the requisite mechanisms to ensure that reviews of risk are independent and unbiased. iv) The Risk Assessment Process. Legislation should reflect a thorough risk-analysis procedure including risk assessment and evaluation. The pre-approval scrutiny to which a product1 is subjected should be based on its relative risk: regulatory requirements should be greater for products with greater risk and lower for those with less risk. Risk assessment should take into account risk to the community as well as to individuals. While the risk assessment process should be science-based, it should also recognize that public perception might influence the management and communication of risk. In areas of risk uncertainty, application of the precautionary principle could be considered on a case-by-case basis. v) General Safety Requirement. The CMA supports the proposal to include in the legislation a General Safety Requirement that would make it illegal for anyone to manufacture, promote or market a product that may present an undue risk to health, under reasonably foreseeable conditions of use. However, this overall requirement should not be used as a substitute for enacting regulations to cover specific products if evidence indicates that such regulations are necessary to protect public health. Nor should it be used as a rationale for relaxing regulatory regimes currently in place. vi) Support for Informed Patient Decision-Making. Legislation should ensure that Canadians have access to reliable, evidence-based information to support them in making decisions regarding their own health, and should ensure that the information they receive is not misleading or deceptive. vii) Accountability. Legislation should ensure that there is clear accountability for decision-making, and that this is vested in the Government of Canada. viii) Surveillance. Legislation should ensure comprehensive, effective post-marketing surveillance of drugs and other health products. This should be co-coordinated with surveillance and research programs governed by related public health acts such as the proposed Canada Emergency Health Measures Act. ix) Enforcement. Legislation should provide and enforce effective, meaningful penalties for noncompliance. x) Flexibility. Legislation should allow for flexibility in product approval, consistent with Principle i, in order to quickly and efficiently accommodate emerging issues (such as new technologies) developed in Canada and internationally. xi) Openness and Transparency. Legislation should operate transparently, incorporating ongoing, two-way communication with stakeholders, including health professionals and the public. xii) Working with Others. Legislation should encourage collaboration and co-operation with other federal departments, with provinces and territories, and with non-governmental and international organizations. At the same time it should respect existing jurisdictions and existing legislative and administrative mechanisms. 4. Impact of Health Protection Legislation on Medical Practice Physicians, along with other health professionals, play an important role in maintaining high health standards and communicating appropriate health information to Canadians. Some of the proposals included in the legislative proposal could have a significant positive or negative impact on medical practice. These include: a) The Drug Review Process Stakeholders have repeatedly drawn attention to the slowness and secrecy of Canada's drug approval process. Between 1996 and 1998 Canadian approval times (median 518 days) were significantly longer than Sweden (median 371 days), the UK (median 308 days) and the United States (median 369 days). These have not improved significantly even after Health Canada implemented a cost-recovery approach to funding drug reviews. In addition, the review process may not distinguish genuinely new and innovative "breakthrough" drugs from imitations of products already on the market. The legislative proposal discusses possible means of modernizing the drug review process, including co-operative agreements with comparable drug review agencies in other jurisdictions, and establishment of a mechanism for public comments. The CMA approves both these suggestions. To ensure that Canadians have access to the right drugs for their conditions as quickly as is consistent with safety, the CMA recommends: Recommendations 2. That the federal government implement a timely and efficient drug review process to reduce review times to the fastest level consistent with ensuring improved health outcomes and the safety of the drug supply. 3. That the federal government consider co-operative agreements for drug review with comparable agencies in Europe, the United States and Australia, while retaining final authority as to whether a new product should be allowed on the Canadian market. 4. That the drug review and approval process be open and transparent, providing updates on review status and the opportunity for stakeholder input. 5. That Health Canada apply a priority review process to "breakthrough" drugs, i.e. those that demonstrate a substantial improvement over products already on the market. b) Patient Safety and Post-marketing surveillance Recent reports have drawn public attention to the need for a rigourous, well-resourced post-marketing surveillance system to monitor the ongoing safety of marketed drugs and other health products in Canada. CMA strongly recommends that Health Canada work in partnership with stakeholders to develop such a system. The system should be non-punitive, supporting a "culture of safety" rather than one of blame, and should respect the privacy of patients and physicians. In this context the CMA supports the establishment of the Patient Safety Institute. In developing its post-marketing surveillance capacity, Health Canada should ensure that sufficient resources are in place to enable the system to: * Facilitate the reporting of adverse reactions by health professionals and others. The CMA supports activities that encourage the voluntary reporting of adverse reactions by physicians and others. For example, to facilitate timely and comprehensive reporting, forms should be easily accessible and the reporting process should be computerized, simple and transparent. * Collect and analyze data and produce information that health care professionals and policy makers can use in decision-making at the population level. With appropriate privacy safeguards, this information could also be used for a number of research purposes, e.g. monitoring the importation and use of drugs not yet licensed in Canada; ascertaining best practices in prescribing. * Communicate this information back to the provider in real time. The importance of real-time two-way communication with front-line practitioners and institutions cannot be overstated. The CMA has repeatedly called for sustained and substantial investment in a Health Communications and Coordination Initiative to improve the technical capacity of front-line health providers to communicate in real time with one another and with the rest of the health care system. This is a critical endeavour and should be undertaken immediately, using funds established for health surveillance in the March 2004 Federal Budget, and implemented within the next 6 months. This network could form the cornerstone of an adverse drug reaction reporting system. Recommendations: 6. That Health Canada work in partnership with stakeholders including CMA and other national medical and other health professional associations, to develop a rigourous post-marketing surveillance system to monitor the ongoing safety of marketed drugs. 7. That government accelerate activities to establish the Patient Safety Institute using a systems approach to support a culture of safety. 8. That all stakeholders join in supporting and encouraging outcome-based research to ascertain best practices in prescribing. 9. That the federal government invest in measures such as electronic communications networks, to increase physicians' capacity to report medication incidents and improve the timeliness of adverse event reporting. c) Drug Information and Advertising CMA believes that the public has a right to unbiased, accurate information on drugs and other therapeutic products. This information should be provided in accordance with CMA's "Principles for Providing Information about Prescription Drugs to Consumers" (Appendix III). Brand-specific product advertising is a less than optimal way of providing this information, and should be carefully monitored to discourage fraudulent or misleading claims. In particular, direct to consumer advertising of prescription drugs should not be permitted in Canada. Physicians and their associations are willing to work with Health Canada and other stakeholders in developing and disseminating accurate, unbiased information to the public and to health professionals about drugs and other health products. Recommendations: 10. That all stakeholders work to ensure that Canadians have ready access to a source of comprehensive, reliable information on health products and their uses, and that governments fund development and dissemination of validated information to physicians and to the public. 11. That the legislation define "promotion" and "advertising" so as to clearly distinguish them from unbiased health information, and from counselling by health professionals. 12. That the current safeguards against deception in advertising be strengthened in order to * Forbid fraudulent or misleading health claims in advertisements, on labels or in any other promotional or descriptive material pertaining to the product; * Ensure pre-clearance and ongoing review of all health claims by an objective agency; * Provide meaningful penalties for infraction. 13. That Health Canada maintain the current ban on advertising health products for treatment, prevention and cure of conditions or disease states to be identified in a regulatory schedule or administrative list; the inclusion of conditions in this list should be determined through a set of criteria that are written into the Act or regulations. 14. That the existing ban on direct to consumer advertising of prescription drugs be maintained and enforced to the full extent of the law, and that the loophole that currently permits advertising the name, price and quantity of a prescription drug be closed. 15. That all stakeholders, including medical associations and industry groups, work together toward effective regulation of drug promotion to health practitioners. d) Safeguarding the privacy of health information Patients must be able to feel assured that anything they tell their physicians will remain confidential, imparted to others only to the extent necessary to ensure optimal care. Accordingly, the privacy and confidentiality of patient-specific and physician-specific information should be safeguarded to the fullest extent possible. New technologies, e.g. electronic health records, have made the transfer of information simpler and more efficient. They have also made it more vulnerable to infringements on a patient's right to privacy. Several important pieces of legislation to safeguard privacy have already been enacted. In addition, the CMA has developed a Privacy Code (Appendix IV) that discusses confidentiality issues specific to health information. Section 3.6 of this Code contains a legislative test to which all proposed legislation, including the Health Protection Act, should be submitted. Recommendations 16. That the Health Protection Act respect the provisions of the Charter of Rights and Freedoms, the Federal Privacy Act and the Personal Information Protection and Electronic Documents Act (PIPEDA). 17. That the privacy provisions in the Health Protection Act meet the legislative test outlined in Section 3.6 of CMA's Health Information Privacy Code. e) Other Issues The legislative proposal discusses giving Health Canada the power to develop guidelines or regulatory frameworks for specific circumstances, e.g. for new products and technologies such as genetically modified foods; or for situations in which the health of the public may otherwise be at risk, such as contamination of drinking water. In addition, the proposal discusses the possibility of modernizing existing laws that have become outdated. The CMA supports the direction of these proposals. The Quarantine Act, for example, is a piece of legislation the CMA believe merits urgent updating; new legislation should incorporate quarantine provisions for possible vectors leaving as well as entering Canada, and for inter-provincial as well as international traffic. With regard to specific issues not addressed elsewhere in this submission, the CMA recommends: Recommendations 18. That the Health Protection Act give Health Canada a clear mandate to develop guidance documents to address health and safety issues raised by new technologies. 19. That Natural Health Products be regulated on a strict framework that ensures their safety, quality and efficacy as well as the provision of complete and unbiased information to the public. 20. That the Act provide Health Canada with a clear mandate to collaborate with provincial/ territorial and local governments across Canada in reviewing legislation governing all aspects of drinking water from source to consumption to ensure that comprehensive programs are in place and being properly implemented. 21. That Health Canada urgently review the Quarantine Act and modernize its provisions. 5. Conclusion Health protection is one of three pillars of an effective public health system, along with rapid and effective emergency response, and programs and policies to maintain health and prevent disease. The CMA is pleased to have been able to advise governments on all of these pillars, in order to establish the health of Canadians on a strong foundation. We look forward to continued consultation with Health Canada on the proposed Health Protection Act, both on its overall framework and on specific issues of concern to the medical profession. We trust that the result will be strong legislation, founded on fair and enduring principles, to safeguard the health and security of Canadians. APPENDIX I Answering the Wake-up Call: CMA's Public Health Action Plan CMA Submission to Naylor Advisory Committee on SARS and Public Health (Executive Summary) The public health system in Canada lies at the heart of our community values. It is the quintessential "public good" and is central to the continued good health of our population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong - like the Walkerton tragedy or when we are faced with a new threat like SARS - is the integral, ongoing role of public health really recognized. The Canadian Medical Association (CMA) has been warning that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to the latest crises. Canada's physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. Our public health system is the first - and often the only - line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health armaments must be in a constant state of "battle readiness." In today's climate of SARS, West Nile Virus, mad cow disease and monkey pox, even the thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians. Physicians have always been an integral part of the public health system serving as medical officers of health, community health specialists and other related roles. Indeed public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians. In this submission, we reflect on the lessons to be learned from our recent experience with SARS and reflect on the longer-term needs of the public health system as a whole. The objectives of the pan-Canadian Public Health Action Plan proposed by the CMA are, first to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies; and, second, to enhance the system's capacity to respond to public health threats across the country (see recommendations, below). To achieve these twin objectives, three broad strategies are presented for immediate attention. They are legislative reform; capacity enhancement; and research, surveillance and communications. Legislative reform (see recommendations 1-3) The country's response to SARS has brought into stark relief the urgent need for national leadership and coordination of public health activity across the country, especially during a health crisis. The apparent reluctance to act quickly to institute screening at airports, the delay in unifying the practice community for a concerted response and the appalling communications confusion worked against optimum handling of the outbreak - despite the best efforts of health care professionals. This is a wake-up call that highlights the need for comprehensive legislative reform to clarify the roles of governments with respect to the management of public health threats. A renewed and enhanced national commitment to public health should be anchored in new federal legislation to be negotiated with the provinces and territories. Specifically, the CMA recommends an Emergency Health Measures Act, to deal with emergent situations in tandem with the creation of a Canadian public health agency headed by a Chief Public Health Officer of Canada. Capacity enhancement (see recommendations 4-7) The SARS crisis has demonstrated the diminished capacity within the public health system. The Greater Toronto Area (GTA), with one of Canada's most sophisticated public and acute health systems, has not been able to manage the SARS crisis adequately and carry on other health programs. The acute care system virtually ground to a halt in dealing with SARS. There was little or no surge capacity in Canada's largest city. We should be grateful that SARS did not first strike a smaller centre in a far less-advantaged region of Canada. A critical element of the public health system is its workforce and the health professionals within the acute care system, such as hospital-based infectious disease specialists and emergency physicians who are the front-line interface. Let there be no doubt that the ongoing efforts of the GTA front-line providers are nothing short of heroic. However, the lack of coordinated contingency planning of hospital and community-based disease control efforts was striking. The overall shortage of critical care professionals and the inability of governments to quickly deploy the required professionals to areas of need contributed to the enormous strain on the public and health care system. Considering the importance of the public health system and its clearly limited capacity to protect and promote the health of Canadians, it is incomprehensible that we do not know how much is actually spent on the system. It is imperative that public health expenditures and capacity, in terms of both physical and human resources, be tracked and reported publicly. The CMA recommends a $1-billion, 5-year capacity-enhancement program to be coordinated with and through the new Canadian public health agency. Research, surveillance and communications (see recommendations 8-10) Canada's ability to respond to public health threats and acute events, such as SARS, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications. A concerted pan-Canadian effort is required to take full advantage of our capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. New-millennium challenges require moving beyond old-millennium responses. Enhanced surveillance is an overdue and integral part of public health, performing an essential function in early detection and response to threats of infectious diseases. Mandatory national reporting of identified diseases by all provinces and territories is critical for national and international surveillance. During times of crisis, rapid communication to the public, public health staff and front-line clinicians is of critical importance, but in many jurisdictions impossible. We tested our systems during the SARS outbreak and they came up short. The CMA recommends a one-time federal investment to enhance technical capacity to allow for real-time communication. Conclusion The CMA believes that its proposed three-pronged strategy, as set out in the attached recommendations, will go a long way toward addressing shortfalls of the Canadian public health system. Action now will help to ensure that Canadians can once again be confident that they are protected from any future threat of new infectious diseases. Action now will help Canada regain its position as a leader in public health. We wish the advisory committee well in its deliberations and offer the CMA's assistance at any time in clarifying the strategies set out in our submission. Recommendations to the National Advisory Committee on SARS and Public Health Legislative reform ($20 million / 5 years*) 1. The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. 2. The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm's length from government. 3. The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan. Capacity enhancement ( $1.2 billion / 5 years*) 4. The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals. 5. The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies. 6. Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the proposed Canadian Office for Disease Surveillance and Control. 7. Federal government funding in the amount of $1 Billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions. Research, surveillance and communications ($310 million / 5 years*) 8. An immediate, sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. 9. The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and intervention. 10. The one-time infusion of $100 million, with an additional $2 million a year, for a "REAL" (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies. APPENDIX II The Right Drugs, at the Right Times, for the Right Prices: Toward a Prescription Drug Policy for Canada CMA Submission to House of Commons Standing Committee on Health Every year, three hundred million prescriptions - about 10 for every man, woman and child - are filled in Canada. Prescription drugs have benefited both the health of Canadians, and the health care system itself; they have meant dramatically improved quality of life for many Canadians, and have saved the country a great deal in hospitalization, social benefits and other expenses. However, it could be questioned whether all of Canada's prescription drug use is appropriate; patients may be receiving too few medications, too many medications or suboptimal medications for their conditions. In addition, prescription drugs carry a price tag of their own. Since 1975, expenditures on prescription medication have risen faster than any other category in the health sector in Canada, and more is now spent on prescription drugs than on physician services. Governments, health care providers, drug manufacturers and the public must constantly strive to ensure that Canadians receive optimal and appropriate prescription drug therapy: the right drugs, at the right times, for the right prices. A considered, coherent, comprehensive, "made in Canada" approach to prescription drug policy should: * Put the health of the patient first; * Promote and enhance quality prescribing; * Respect, sustain and enhance the therapeutic relationship between patients and health professionals; * Promote patient compliance with drug therapy; * Respect the principles of patient confidentiality and the privacy of patient and prescriber information. Prescription drug policy in Canada should address: Access: to * efficacious new drugs within an appropriate time; * coverage for medically necessary drugs for catastrophic care; * generic drugs at reasonable prices; * a patient/physician consultation as part of the prescribing process; * continued research and development capacity in Canada. Information for health care providers and the public that is balanced and accurate. Safety: through mechanisms for the systematic monitoring of prescription drugs and their effects. Canada's doctors are committed to working with others to ensure that Canadians receive the right drugs, at the right times, for the right prices. Summary of CMA Recommendations: 1. That the federal government implement a timely and efficient drug review process to reduce review times to a level at or better than that in other OECD countries. 2. That the pharmaceutical industry give priority to research and development on drugs and delivery mechanisms that demonstrate a substantial improvement over products already on the market. 3. That Health Canada apply a priority review process to all drugs that demonstrate a substantial improvement over products already on the market. 4. That governments and insurance providers conduct research to identify the current gaps in prescription drug coverage for all Canadians, and develop policy options for providing this coverage, including consideration of the roles of public and private payers. 5. That the federal government monitor and, if necessary, regulate the export of prescription medications to ensure their continued availability to Canadians. 6. That prescribing of medication be done within the context of the therapeutic relationship which exists between the patient and the physician. 7. That brand-specific direct to consumer prescription drug advertising (DTCA) not be permitted in Canada, 8. That the federal government enforce the existing restrictions on DTCA found in the Food and Drug Act to the full extent of the law. 9. That the federal government develop and fund a comprehensive program to provide accurate, unbiased prescription drug information to patients. 10. That all stakeholders join in supporting and encouraging outcome-based research to ascertain best practices in prescribing. 11. That government accelerate activities to establish the Patient Safety Institute using a systems approach to support a culture of safety. 12. That a post-marketing surveillance system be implemented to monitor the ongoing safety of marketed drugs. APPENDIX III CMA POLICY Principles for Providing Information about Prescription Drugs to Consumers Approved by the CMA Board of Directors, March 2003 Since the late 1990's expenditures on direct to consumer advertising (DTCA) of prescription drugs in the United States have increased many-fold. Though U.S.-style DTCA is not legal in Canada 2 , it reaches Canadians through cross-border transmission of print and broadcast media, and through the Internet. It is believed to have affected drug sales and patient behaviour in Canada. Other therapeutic products, such as vaccines and diagnostic tests, are also being marketed directly to the public. Proponents of DTCA argue that they are providing consumers with much-needed information on drugs and the conditions they treat. Others argue that the underlying intent of such advertising is to increase revenue or market share, and that it therefore cannot be interpreted as unbiased information. The CMA believes that consumers have a right to accurate information on prescription medications and other therapeutic interventions, to enable them to make informed decisions about their own health. This information is especially necessary as more and more Canadians live with chronic conditions, and as we anticipate the availability of new products that may accompany the "biological revolution", e.g. gene therapies. The CMA recommends a review of current mechanisms, including mass media communications, for providing this information to the public. CMA believes that consumer information on prescription drugs should be provided according to the following principles. 3 Principle #1: The Goal is Good Health The ultimate measure of the effectiveness of consumer drug information should be its impact on the health and well-being of Canadians and the quality of health care. Principle #2: Ready Access Canadians should have ready access to credible, high-quality information about prescription drugs. The primary purpose of this information should be education; sales of drugs must not be a concern to the originator. Principle #3: Patient Involvement Consumer drug information should help Canadians make informed decisions regarding management of their health, and facilitate informed discussion with their physicians and other health professionals. CMA encourages Canadians to become educated about their own health and health care, and to appraise health information critically. Principle #4: Evidence-Based Content Consumer drug information should be evidence based, using generally accepted prescribing guidelines as a source where available. Principle #5: Appropriate Information Consumer drug information should be based as much as possible on drug classes and use of generic names; if discussing brand-name drugs the discussion should not be limited to a single specific brand, and brand names should always be preceded by generic names. It should provide information on the following: * indications for use of the drug * contraindications * side effects * relative cost. In addition, consumer drug information should discuss the drug in the context of overall management of the condition for which it is indicated (for example, information about other therapies, lifestyle management and coping strategies). Principle #6: Objectivity of Information Sources Consumer drug information should be provided in such a way as to minimize the impact of vested commercial interests on the information content. Possible sources include health care providers, or independent research agencies. Pharmaceutical manufacturers and patient or consumer groups can be valuable partners in this process but must not be the sole providers of information. Federal and provincial/territorial governments should provide appropriate sustaining support for the development and maintenance of up-to-date consumer drug information. Principle #7: Endorsement/ Accreditation Consumer drug information should be endorsed or accredited by a reputable and unbiased body. Information that is provided to the public through mass media channels should be pre-cleared by an independent board. Principle #8: Monitoring and Revision Consumer drug information should be continually monitored to ensure that it correctly reflects current evidence, and updated when research findings dictate. Principle #9: Physicians as Partners Consumer drug information should support and encourage open patient-physician communication, so that the resulting plan of care, including drug therapy, is mutually satisfactory. Physicians play a vital role in working with patients and other health-care providers to achieve optimal drug therapy, not only through writing prescriptions but through discussing proposed drugs and their use in the context of the overall management of the patient's condition. In addition, physicians and other health care providers, and their associations, can play a valuable part in disseminating drug and other health information to the public. Principle #10: Research and Evaluation Ongoing research should be conducted into the impact of drug information and DTCA on the health care system, with particular emphasis on its effect on appropriateness of prescribing, and on health outcomes. APPENDIX VI CMA POLICY HEALTH INFORMATION PRIVACY CODE This Code articulates principles for protecting the privacy of patients, the confidentiality and security of their health information and the trust and integrity of the therapeutic relationship. Its provisions are more exacting than those currently in place in the Canadian health care system. Although a patchwork of laws across Canada permit or require health information collection, use, disclosure and access without patient consent, or even knowledge, this Code would require that all of these laws and any proposed laws be reviewed for consistency with its provisions. Moreover, existing practices and initiatives concerning health information collection, use, disclosure and access, including health information systems or networks, may be contrary to patient expectations and the physician's duty of confidentiality. These practices and initiatives must also be reviewed for consistency with this Code. Many laws, practices and initiatives may not withstand the kind of scrutiny deemed necessary and reasonable for the protection of privacy and the trust and integrity of the therapeutic relationship. CMA issues this Code in recognition that its implementation raises numerous issues and challenges, and that the changes it envisions will require time and the expenditure of resources. CMA appreciates that, given the complexity of the health care system, agreement and cooperation among a wide range of users and collectors of health information will be essential to the successful implementation of this Code. In view of these challenges, CMA issues this Code to the Canadian health care community at this time as an ideal to strive for, to guide and coordinate the efforts that need to be made to protect the privacy of patients, the confidentiality and security of their health information and the trust and integrity of the therapeutic relationship. Moreover, this Code is issued in the understanding that those to whom it applies will not be able to achieve full compliance with its provisions until such time as numerous implementation issues have been clarified and resolved through cooperation and the coordinated efforts of many different stakeholders. Consequently, companion implementation documents are being developed that provide for a gradual implementation of the Code's provisions over a five-year span and outline work that needs to be done to achieve the ideal it envisions. Section A: Scope This Health Information Privacy Code ("Code") has been produced by physicians to protect the privacy of their patients, the confidentiality and security of their health information and the trust and integrity of the therapeutic relationship. This Code is based on the Canadian Standards Association's Model Code for the Protection of Personal Information ("CSA Code") as a sectoral code of the CSA Code. This Code provides instruction and guidance respecting health information collection, use, disclosure and access. 1. This Code describes the minimum requirements to protect the privacy of patients and the security and confidentiality of their health information. 2. This Code has been developed by physicians in their capacity as clinicians and in recognition of their principal obligation to patients. 3. This Code recognizes the potential benefits of the use of health information for secondary purposes, including teaching, research and system planning, and contains provisions to permit such use under clearly defined terms and conditions. 4. This Code has been developed as a sectoral code of the Canadian Standards Association's Model Code for the Protection of Personal Information and consequently adopts the minimum standards contained in the CSA Code and augments them to meet the special circumstances of health information. 5. The development of this Code has been inspired by the report of the House of Commons Standing Committee on Human Rights and the Status of Persons with Disabilities, entitled Privacy: Where Do We Draw The Line? 6. The Code applies to all health information and to all individuals, groups or organizations that collect, use, disclose or access such information. Its objective is to instruct in the development and implementation of policies, practices, health information systems or networks and legislation. 7. The principles that make up this Code are interrelated. Health information custodians adopting this Code shall adhere to these principles as a whole. 8. Health information custodians must subscribe to the principles contained in this Code and agree to uphold them, but may tailor this Code by modifying or adding principles provided the changes afford no less protection to the privacy of patients and the confidentiality and security of their health information. 9. Statements containing "shall" or "must" indicate requirements that must be met by any health information custodian who wishes to adopt this Code and be recognized for having done so. The use of "should" indicates a recommendation or aspiration. Section B: Definitions The following definitions apply in this Code: "Access" means the ability to acquire or possess health information in any information format. "Accountability" means having clearly defined and understood responsibilities in connection with health information, agreeing to accept those responsibilities and being subject to appropriate sanctions for failing to fulfil accepted responsibilities. "Authorized" means that which occurs with patient consent or within the provisions of this Code and applies to purposes, collection, use and disclosure of, or access to, health information. "Authorized user" is someone permitted to collect, use, disclose or access health information under the provisions of this Code, who is properly instructed on his or her limits and responsibilities, and who can be held accountable for his or her compliance. "Collection" means the act of accessing, receiving, compiling, gathering, acquiring or obtaining health information from any source, including third parties, and by any means. It includes information collected from the patient, as well as secondary collection of this information in whole or in part by another provider or user. "Confide" and "confided" mean the revelation of information by a patient within the therapeutic context. "Confidentiality" and "confidential" mean that health information that is confided by a patient is to be kept secret and not disclosed or made accessible to others unless authorized by patient consent. A breach of confidentiality occurs whenever a health professional discloses or makes health information available to others without or inconsistent with the patient's consent. "Consent" means a patient's informed and voluntary agreement to confide or permit access to or the collection, use or disclosure of his or her health information for specific purposes. Express consent is given explicitly, either orally or in writing. Express consent is unequivocal and does not require any inference on the part of the provider seeking consent. Implied consent arises where agreement may reasonably be inferred from the action or inaction of the individual and there is good reason to believe that the patient has knowledge relevant to this agreement and would give express consent were it sought. "Disclosure" means the provision of health information to a third party for any reason, or making health information available for a third party to collect. It includes any transfer or migration of health information from one provider or user to another. "Duty of confidentiality" means the duty of physicians and other health professionals in a fiduciary relationship with patients to ensure that health information is kept secret and not disclosed or made accessible to others unless authorized by patient consent. "Emergency situations" mean those instances when health care must be provided to preserve life or prevent severe harm to a patient who is unable, owing to the circumstances, to be cognizant of the context and whose surrogate is not immediately available to make decisions on the patient's behalf. "Fiduciary duty" means the obligation to act with the utmost good faith for the benefit of another. "Health information" means any information about a patient that is confided or collected in the therapeutic context, including information created or generated from this information and information that is not directly or indirectly linked to the provision of health care. It includes all information formats. "Health information custodian" means any organization or institution that has custody, care or control of health information, and includes hospitals, regional boards, governments, corporations and solo or group medical practices. "Information format" means any form containing or recording health information, including: (a) a form that identifies or could identify a specific patient, either directly or indirectly; (b) a form that removes the link between the patient and information about him or her and which could, either directly or indirectly, be manipulated to reconnect the link between the patient and information about him or her ("deidentified-relinkable"); (c) a form that removes the link between the patient and information about him or her with the intent of preventing any reconnection of the link between the patient and information about him or her in accordance with recognized standards ("anonymous"); or (d) the composite form produced when health information is linked to any information about the patient from any other source, whether or not it is also health information. "Integrity of health information" means the preservation of its content throughout storage, use, transfer and retrieval so that there is confidence that the information has not been tampered with or modified other than as authorized. "Health professional" is any person having a fiduciary duty to patients who is registered and entitled by provincial or territorial law to practise or provide health care in that province or territory. "Knowledge" means the patient's awareness of what can or must happen with the health information he or she confides or permits to be collected. "Linkage" is the joining together of health information with information from any other source or database, in whatever form. When health information is linked to any other information, the composite is also health information. "Nonconsensual" collection, use, disclosure or access, whether justified or not, occurs without a patient's consent and contravenes the patient's right of privacy. "Patient" means the person about whom health information is collected and, for the purposes of this Code, may also mean a surrogate or guardian acting on behalf of this person. "Physician" means a person who is registered and entitled under the laws of a province or territory to practise medicine in that province or territory. "Primary" means that which occurs for the therapeutic benefit of a particular patient. Secondary means not directly related to the therapeutic benefit of the particular patient from whom the information has originated. "Purpose" means an end or aim for which health information is collected, used, disclosed or accessed. A description of purpose can be general enough to incorporate a range of like information uses provided that the generic description is sufficiently narrow and limited so as to communicate to the ordinary person a clear understanding of the potential information uses that could reasonably be expected to be relevant to their consent. The primary therapeutic purpose is the delivery of health care to a particular patient with respect to a particular and immediate health need or problem. It encompasses consultation with and referral to other providers on a need-to-know basis. A primary longitudinal purpose concerns developing composite health information about a particular patient, such as a detailed medical history, beyond direct application to any particular and immediate health need or problem, in order to enhance ongoing care to that person. Secondary legislated purposes have been subjected to the legislative test specified in this Code and have subsequently been written in law. Secondary nonlegislated purposes are any other purposes, such as education or research not governed by legislation, that meet the provisions of this Code and the secondary nonlegislative test provided by this Code. "Provider" means a health professional or institution that delivers health care services or products in the therapeutic context. "Right of privacy" includes a patient's right to determine with whom he or she will share information and to know of and exercise control over use, disclosure and access concerning any information collected about him or her; it entails the right of consent. Nonconsensual collection, use, disclosure or access violates the right of privacy, even if it is justified. "Security" means reasonable precautions, including physical and technical protocols, to protect health information from unauthorized collection, use, disclosure and access, and to ensure that the integrity of the information is properly safeguarded. A breach of security occurs whenever health information is collected, used, disclosed or accessed other than as authorized, or its integrity compromised. "Sensitivity" of health information refers to the patient's interest in keeping the information secret. It varies according to the nature of the information, its form, and the potential negative repercussions of its collection, use or disclosure on the patient's interests. "Therapeutic context" means a setting in which information is confided by or collected from, about or on behalf of a patient who: (a) is in a therapeutic relationship with or under the care of a physician or health professional; (b) is resident in or seeking health care within a facility or institution whose principal purpose is the provision of health care, including physicians' offices, hospitals and other health care facilities; (c) confides information within a fiduciary relationship to a health care professional and with the belief that the health care professional will maintain its confidentiality, subject to very limited exceptions; or (d) confides information in the belief that it is necessary for the safe, timely and effective delivery of health care. "Transparency and openness" are the characteristics of policies, procedures and practices that seek to ensure that patients know what can or must happen with the health information they confide or permit to be collected, used, accessed or disclosed. "Use of health information" means any processing of health information including storage, retention, retrieval, manipulation, connection or linkage to other sources of information in any format. Section C: Principles Principle 1: The Right of Privacy The right of privacy is fundamental in a free and democratic society. It includes a patient's right to determine with whom he or she will share information and to know of and exercise control over use, disclosure and access concerning any information collected about him or her. The right of privacy and consent are essential to the trust and integrity of the patient-physician relationship. Nonconsensual collection, use, access or disclosure violates the patient's right of privacy. The right of privacy is important and worthy of protection, not just for the good of individuals in society but also for the good of society as a whole. 1.1 Canadians are entitled to expect and enjoy fundamental privacy rights and guarantees, which include: (a) physical, bodily and psychological integrity and privacy; (b) privacy of personal information; (c) freedom from surveillance; (d) privacy of personal communications; and (e) privacy of personal space. 1.2 The basic duties owed to others to ensure that their privacy rights are adequately respected include: (a) the duty to ensure consent; (b) the duty to take all the steps necessary to respect adequately others' privacy rights or, if their rights must be infringed, to interfere with privacy as little as possible; (c) the duty to be accountable; (d) the duty to be transparent; and (e) the duty to build privacy protection features into technological systems and designs. 1.3 The specific duties related to the protection of the patient's right of privacy in health information include: (a) the duty to hold health care information in trust; (b) the duty to limit information collection to what is necessary and justifiable for the benefit of the patient; (c) the duty to ensure that patients are informed by reasonable means about purposes for collection, use, disclosure or access at or before the time of collection, including the potential for such to occur nonconsensually; (d) the duty to ensure that the information is accurately recorded; (e) the duty to ensure consent by reasonable means, except in limited circumstances where the right of privacy and of consent are justifiably infringed by some compelling right, good or duty; (f) the duty to ensure that the right of privacy and the right to consent are infringed no more than is necessary by the compelling right, good or duty; (g) the duty to use and disclose health information only as consistent with the purposes identified at or before the time it was collected; (h) the duty to keep health information only for as long as necessary to fulfil identified purposes; (i) the duty not to disadvantage people because they elect to exercise their right of privacy; and (j) the duty of physicians and other health professionals to hold information in confidence. 1.4 Although the patient's interests and concerns about health information may vary depending on the sensitivity of the information, the right of privacy extends to all health information in whatever format. Principle 2: Special Nature of Health Information Governing principles and rules for health information must recognize the patient's right of privacy in health information, its highly sensitive nature, the circumstances of vulnerability and trust under which it is confided or collected, and the fiduciary duties of health professionals in relation to this information. The patient-physician relationship as defined by trust and a professional promise of confidentiality is a societal good worthy of protection. 2.1 Principles and rules governing health information must recognize: (a) its high level of sensitivity and protect the patient's right of privacy accordingly; (b) that the principal purpose for confiding and collecting this information is to benefit the patient; (c) that in the therapeutic context patients may be vulnerable and under duress, and must not be subjected to manipulation, coercion or exploitation; (d) that patients confide information to physicians and other health professionals under a very special trust, and that physicians and other health professionals have fiduciary duties to patients, including a duty to hold information in confidence. 2.2 Principles and rules governing health information must ensure that physicians and other health professionals can discharge their fiduciary duties and therefore shall take into account that: (a) patients may be in a situation of vulnerability owing to infirmity or incapacity, urgent need, lack of knowledge and power, or simply because they have needs and have to rely or depend upon providers to meet those needs; (b) patients confide information that is ordinarily considered by them to be private because they have certain needs that require the care of a provider and believe the information is required by the provider to help meet those needs; (c) were it not for those needs, and the expectation that the provider can help patients meet them, the occasion for the collection of the health information would not exist and the information would remain private; (d) were it not for the reputation of health professionals for trustworthiness and the expectation that information disclosed to them will be held in confidence, patients would be less willing to confide health information fully and truthfully in the therapeutic context; and (e) to the extent that provisions for health information inhibit patients from confiding health information fully and truthfully, their health care will be adversely affected. Principle 3: Constraints on Purposes and Limitation on Collection, Use, Disclosure and Access The principal purpose for the collection of health information is to benefit the patient who confides or permits information to be collected for a therapeutic purpose. Secondary purposes for the use of the information shall not be pursued if they inhibit patients from confiding information for the primary purpose, exploit patients' vulnerability, compromise the ability of physicians to discharge their fiduciary duties to patients or borrow on the trust patients invest in physicians for the primary therapeutic purpose. Collection, use, disclosure or access for secondary purposes shall be restricted to what is necessary for those purposes and shall not impede the confiding or collection of information for primary purposes. Nonconsensual access to and collection, use or disclosure of health information is a violation of a patient's right of privacy, compromises the physician's duty of confidentiality and is potentially disruptive of the trust and integrity of the therapeutic relationship. Therefore, it must only occur in very limited circumstances - namely emergency situations, in accordance with legislation that meets the requirements of this Code, or in response to a court decision or order. Even consensual collection, use, disclosure or access may erode the right of privacy and the trust and integrity of the therapeutic relationship. Therefore, it must only occur with due consideration of possible negative impacts and with measures designed to maximize privacy protection. 3.1 Provided that the principles contained in this Code are adhered to, and in particular that the principles related to patient consent are rigorously applied, health information may be collected, used, disclosed or accessed for the following purposes: (a) Primary purposes: (i) Primary therapeutic purpose is the initial reason for a patient seeking or receiving care in the therapeutic context, and pertains to the delivery of health care to a particular patient with respect to the presenting health need or problem. It encompasses consultation with and referral to other providers on a need-to-know basis. (ii) Primary longitudinal purpose concerns developing composite health information about a particular patient, such as a detailed medical history, beyond direct application to the presenting health need or problem, in order to enhance ongoing care to that person. (b) Secondary purposes: (i) Secondary legislated purpose refers to health information collection, use, disclosure or access required or permitted by legislation or regulation that meets the provisions of this Code and the legislative test provided by this Code. (ii) Secondary nonlegislated purpose is any other purpose, such as education or research not governed by legislation, that meets the provisions of this Code and the secondary nonlegislative test provided by this Code. 3.2 Health information collection, use, disclosure or access for the primary therapeutic and longitudinal purposes may be as extensive as necessary to fulfil these purposes and reflect the high level of trustworthiness and accountability of health professionals in the therapeutic context. 3.3 Health information collection, use, disclosure or access for any secondary purposes shall be as minimal as necessary in recognition of the need to protect the patient's right of privacy in the therapeutic context. 3.4 Health information collection, use, disclosure or access without patient consent shall only occur in the limited circumstances provided by this clause. Nonconsensual health information collection, use, disclosure or access, including the conversion of health information from one information format to another, is a violation of a patient's right of privacy, may compromise the physician's duty of confidentiality, and is potentially disruptive of the trust and integrity of the therapeutic relationship. Therefore, it must only occur under strict conditions and in these very limited circumstances: (a) when permitted or required by legislation or regulation that meets the requirements of this Code; or (b) when ordered or decided by a court of law. 3.5 Any existing or proposed secondary purpose for health information collection, use, disclosure or access, including health information systems or networks, shall be subjected to a patient privacy impact analysis that shall include an evaluation of: (a) the likely impact of the proposed measures on the right of privacy of patients; (b) the likely impact of the proposed measures on the relationship between patients and their physicians, and in particular on the duty of confidentiality and the trust within this relationship; (c) the likely impact of the proposed measures on the willingness of patients to disclose health information; (d) the likely impact of the proposed measures on the ability of patients to receive health care; and (e) compelling evidence to demonstrate broad public support for the proposed measures. 3.6 Any proposed or existing legislation or regulation made under legislative authority that permits or requires health information collection, use, disclosure or access shall be subjected to the following legislative test: (a) There must be demonstration that: (i) a patient privacy impact assessment has been conducted, the analysis has been made public and has been duly considered prior to the introduction of legislation; (ii) collection, use, disclosure and access will be limited to the greatest degree possible to ensure that - the collection of health information by persons external to the therapeutic context will neither trade on nor compromise the trust of the patient-physician relationship; - patients are not likely to be inhibited from confiding information for primary purposes; - the ability of physicians to discharge their fiduciary duties to patients will not be compromised; and - patient vulnerability will not be exploited; (iii) collection, use, disclosure and access will be restricted to what is necessary for the identified purpose(s) and will not impede the confiding or collection of information for primary purposes; (iv) provisions exist for ensuring that patients are provided with knowledge about the purpose(s) and that, subject to 3.6(b), patient consent is clearly voluntary; (v) the means used are proportionate and the collection will be limited to purposes consented to or made known to the patient; (vi) the patient's privacy will be intruded upon to the most limited degree possible in light of the purpose(s) consented to or made known to the patient; (vii) linkage of the health information will be limited; and (viii) unless clear and compelling reasons exist, - all reasonable steps will be taken to make health information anonymous; and - if it has been demonstrated that making health information anonymous would render it inadequate for legitimate uses, the information will be collected and stored in a deidentified-relinkable format. (b) When nonconsensual collection, use, disclosure or access is permitted or required by legislation or regulation that meets the requirements of this Code, the following conditions must also be met: (i) the right of privacy has to be violated because the purpose(s) could not be met adequately if patient consent is required; and (ii) the importance of the purpose(s) must be demonstrated to justify the infringement of the patient's right of privacy in a free and democratic society. (c) Any legislative provision or regulation that permits or requires health information collection, use, disclosure or access nonconsensually shall not, without compelling reasons, be applied retroactively to existing health information. 3.7 Any proposed or existing secondary nonlegislated purpose shall be subjected to the following nonlegislative test: (a) Before a health information custodian uses health information in its custody for secondary nonlegislated purposes, or before it releases or makes health information accessible to an external third party for secondary nonlegislated purposes, it must demonstrate or require the third party to demonstrate that: (i) a patient privacy impact assessment has been conducted, the analysis has been made public, the results have been duly considered and uses for that purpose will not be pursued if there is an adverse effect on privacy; (ii) collection of health information by persons beyond the therapeutic context will not exploit or compromise the trust of the patient-physician relationship; (iii) patients are not likely to be inhibited from confiding information for primary purposes; (iv) the ability of physicians to discharge their fiduciary duties to patients will not be compromised; (v) patient vulnerability will not be exploited; (vi) collection will be restricted to what is necessary for the identified purpose(s) and will not intrude upon primary purposes; (vii) patients will be fully informed of the purpose(s) and patient consent will be clearly voluntary; (viii) patient privacy will be intruded upon to the most limited degree possible in light of the purpose(s) consented to; (ix) linkage of health information will be restricted and consented to by the patient; (x) unless clear and compelling reasons exist, - all reasonable steps will be taken to make health information anonymous; - if it has been demonstrated that making health information anonymous will render it inadequate for legitimate uses, then the information will be collected and stored in a deidentified-relinkable format; (xi) any third party to whom health information is released has adopted this Code or has equivalent provisions in place; and (xii) the purpose(s) will not be applied retroactively to existing health information unless patient consent is given. 3.8 Health information shall not be collected by means that are unlawful, unfair or exploit the patient's vulnerability, nor shall any of the patient's beliefs or potentially false expectations about subsequent collection, use, disclosure or access be exploited. 3.9 Courts of law should respect the provisions of this Code when issuing orders or decisions. 3.10 Health information shall be retained only as long as it is necessary to fulfil authorized purposes. Once the authorized purposes are fulfilled it shall be securely destroyed, unless some issue or decision related to the patient and pertinent to the patient's health information is pending. Principle 4: Knowledge and Specification of Purpose, Collection, Use, Disclosure and Access In the therapeutic context, health information is confided by or collected from patients under the patient's presumption that it is necessary to meet his or her therapeutic needs. The potential that health information, in whole or in part, may be subsequently collected, used, disclosed or accessed for other purposes without their consent, and what those purposes might be, must be made known to the patient by reasonable means before it is confided or collected for primary purposes. It is not acceptable to withhold such knowledge from patients deliberately out of concern that knowledge could inhibit them from confiding important information fully and truthfully. 4.1 A health information custodian must have documentation that lists all purposes for which it uses or discloses the health information it collects, including to whom it permits access to what information, in what format and whether consent is required. 4.2 Within the therapeutic context health information is confided or provided by patients in the knowledge or with the belief that it is necessary to achieve therapeutic purposes. Patients must be explicitly informed about any other purposes. 4.3 Health information must not be used for purposes not identified to the patient at or before the time it is confided or collected, unless patient consent is subsequently sought and obtained. 4.4 Patients must either have or be provided by reasonable means with knowledge about what can or must happen with their health information. The degree of detail or specificity of this knowledge is what could be presumed germane to the decision of a reasonable person in the circumstances of the patient. 4.5. Unless a particular patient has given indication to the contrary, the conveyance of generic information is a reasonable means of providing knowledge. When the preferences of a particular patient for being informed are known or can be reasonably inferred given his or her circumstances, the provision of knowledge should as much as possible be tailored to these known preferences. 4.6 The goal of providing knowledge to patients is to ensure that before they confide information or permit information to be collected they actually understand what can or must subsequently happen with their information, particularly without their consent. Principle 5: Consent The patient's ability to decide with whom he or she will share information is crucial for the protection of the right of privacy and for the preservation of trust in the therapeutic context. Only the patient's consent to health information collection, use, disclosure and access for the primary therapeutic purpose can be inferred. Except for the very limited nonconsensual purposes addressed in this Code, any other collection, use, disclosure or access requires express consent. Nonconsensual collection, use, disclosure or access infringes the right of privacy and compromises the trust of the fiduciary relationship. To satisfy the requirement that consent be informed, the patient must have, or by reasonable means be provided with, knowledge about the potential for subsequent nonconsensual collection, use, disclosure or access before he or she confides any information. 5.1 Except for the very limited conditions set out in 3.4 concerning nonconsensual collection, use, disclosure or access, consent is required for health information collection, use, disclosure or access for any purpose. 5.2 For the purposes of this Code, consent for health information collection, use, disclosure or access in emergency situations is deemed to have been given to the extent necessary to allay the emergency as consistent with legal principles governing emergency medical care. The protection accorded this information shall be consistent with the provisions of this Code. 5.3 Consent to health information collection, use, disclosure and access for the primary therapeutic purpose may be inferred. Consent to subsequent collection, use, disclosure and access on a need-to-know basis by or to other physicians or health providers for this purpose, and for this purpose alone, may be inferred, as long as there is no evidence that the patient would not give express consent to share the information. 5.4 Interpretation of "need-to-know" shall be guided by consideration of what the reasonable person in similar circumstances would expect, or otherwise authorize by his or her consent. If expectations are unclear or ambiguous, care should be taken to ascertain those expectations and to make the flow of information among providers in the therapeutic context consistent with those expectations. 5.5 Consent to collection, use, disclosure and access for longitudinal primary purposes must be express unless the provider has good reason to infer consent. 5.6 For the purposes of this Code, disclosure of health information to the patient's relatives or significant others is recognized as assisting in primary purposes. Consent to this disclosure must be express unless the provider has good reason to imply patient consent. 5.7 Consent can only be inferred in the case of primary purposes, and for primary purposes alone; collection, use, disclosure or access thus authorized must be limited either to the known expectations of a particular patient or to what the reasonable person in similar circumstances would likely believe necessary to receive health care. 5.8 Implied consent does not deprive the patient of the right to refuse consent or the right to challenge the provider's finding of implied consent. 5.9 Patient consent for secondary nonlegislated purposes shall be express, voluntary and fully informed. 5.10 Where express consent is required, patients must be informed of their right to refuse consent. It is not acceptable to compromise care deliberately as a consequence of the patient's refusal to provide express consent or to exploit any fear the patient might have that this could occur. 5.11 Consent shall not be obtained by coercion, deception or manipulation. Failure to inform the patient by reasonable means of relevant information pertinent to consent invalidates this consent. 5.12 Although all health information is sensitive and should be treated as such, the more sensitive the health information is likely to be, given what is known about the circumstances or preferences of the patient, the more important it is to ensure that consent is voluntary and informed. Principle 6: Individual Access Patients have the right of access to their health information. In rare and limited circumstances, health information may be withheld from a patient if there is a significant likelihood of a substantial adverse effect on the physical, mental or emotional health of the patient or substantial harm to a third party. The onus lies on the provider to justify a denial of access. 6.1 The patient is entitled to know about, and subject to 6.5 to have access to, any information about himself or herself under the custody of the health information custodian. 6.2 Patients should be informed that they have the right to access their health information, to read it and to have copies of it. 6.3 Patients who wish to access their information should be given the opportunity to do so with explanation from a health professional who is knowledgeable about this information and capable of interpreting it for the patient. 6.4 Patients must be able to receive copies of their health information at a reasonable cost that does not exceed the cost of providing the information. 6.5 Providers may, in rare and limited circumstances, withhold health information from a patient if there is a significant likelihood of a substantial adverse effect on the physical, mental or emotional health of the patient or substantial harm to a third party. The onus is on the provider to justify a denial of access. 6.6 Patients are entitled to know who has gained access to their health information and for what purposes. Principle 7: Accurate Recording of Information Accurate recording is important to protect the patient's right of privacy and to meet the purposes for its collection, use, disclosure or access. 7.1 Health information shall be recorded as accurately as possible, and shall be as complete and current as necessary for authorized purposes. 7.2. The recording of statements of fact, clinical judgements and determinations or assessments should reflect as nearly as possible what has been confided by the patient and what has been ascertained, hypothesized or determined to be true using professional judgement. 7.3 Patients who have reviewed their information and believe it to be inaccurately recorded or false have the right to suggest amendments and to have their amendments appended to the health information. 7.4 Whenever possible, health information should be recorded in a form that allows for authorized secondary purposes consented to by the patient. Any standardization of recording requirements relevant to subsequent secondary purposes shall not impede recording of information for primary purposes. Principle 8: Security Security safeguards must be in place to ensure that only authorized collection, use, disclosure or access occurs. Such safeguards must also assure the integrity of the available information. 8.1 Health information, regardless of the information format, shall be protected by security safeguards to ensure compliance with the provisions of this Code. 8.2 The development of security safeguards with respect to levels of access for various users shall recognize the differences in the sensitivity of health information and permit access accordingly. 8.3 Security safeguards shall impede as little as possible health information collection, use, access and disclosure for primary purposes. 8.4 A health information custodian shall ensure that persons are able to collect, use, disclose or access health information in its control only as authorized. Persons thus authorized must have a clear understanding of the authority, parameters, purposes and responsibilities of their access, and of the consequences of failing to fulfil their responsibilities. 8.5 An authorized person's access to health information, including persons or groups external to the health information custodian, shall be limited to only the information needed for the authorized purpose(s), in the least intrusive format. 8.6 Security safeguards shall include both physical and human resource safeguards to prevent unauthorized health information collection, use, disclosure and access. Physical security measures include such safeguards as locked filing cabinets, restricted access to certain offices or areas, and the use of passwords, encryption and lock-boxes. Human resource security measures include security clearances, sanctions, training and contracts. 8.7. Health information custodians must protect health information in their custody so as to ensure its integrity and have assurance that the integrity of information received from other health information custodians has been similarly safeguarded. 8.8 Security safeguards should incorporate identification, authentication, information integrity/availability and non-repudiation, as appropriate. Principle 9: Accountability Accountability is owed first and foremost to the patient. Health information custodians must have in place policies and procedures that recognize this principal accountability and health professionals' duty of confidentiality to the patient. Anyone a health information custodian authorizes to have access to health information must be capable of being held accountable for his or her actions. In addition, health information custodians must designate a qualified person responsible and accountable for monitoring and ensuring internal compliance with this Code. 9.1 Health information custodians are responsible for the security of health information they collect, use, disclose or permit access to. 9.2 Health information custodians must ensure that persons, including administrative and technical support staff, receive authorization to access health information only as necessary to fulfil authorized purposes. 9.3 A health information custodian must ensure that anyone permitted to have access to health information has clearly defined and understood responsibilities in connection with health information, agrees to accept those responsibilities, and is subject to appropriate sanctions for failing to fulfil the accepted responsibilities. 9.4 Health information custodians must designate a qualified person responsible and accountable for monitoring and ensuring internal compliance with this Code. The designated accountable person shall have the autonomy, authority, and resources necessary to ensure the health information custodian's adherence to the Code. In the case of small private practices, practitioners may designate themselves. 9.5 Policies and procedures to ensure compliance with this Code must consider the special, direct accountability of health professionals to their patients. The high level of trust vested in health professionals is crucial to the initial confiding of health information for the therapeutic purpose. 9.6 Health information custodians must ensure that third parties privy to health information have adopted this Code or are bound by equivalent provisions. Provided that this has been determined before health information is disclosed or made accessible, health information custodians are not accountable for the actions of third parties or for what subsequently happens to the information. 9.7 Although it is the responsibility of the health information custodian to ensure that patients are appropriately informed, secondary users whose information requirements impose a burden upon the health information custodian are responsible for covering their share of any related costs or resource requirements (e.g., preparation of brochures). Health information custodians may reasonably require secondary users to cover their own costs as a condition of making health information available to them as authorized. Principle 10: Transparency and Openness Policies, procedures and practices relating to health information must be transparent so that patients can clearly understand the extent and circumstances of health information collection, use, disclosure and access. They must be explicit enough that patients are adequately informed and able to acquire knowledge germane to their confiding of information, and must be open to scrutiny and challenge. 10.1 Health information custodians must have transparent, explicit and open policies, procedures and practices, tailored to their practice setting, that seek to ensure that patients are provided with information about what can or must happen with their health information without their consent. 10.2 Policies, procedures and practices shall be as explicit as necessary to ensure that patients are aware of any considerations that could be relevant to deciding what information they elect to freely confide or consent to be collected, used, disclosed or accessed. Nothing must be left implicit that, if made explicit, could reasonably be expected to alter a patient's decision to freely confide information. Information about nonconsensual collection, use, disclosure and access must be made explicit. 10.3 Patients should be able to discuss the health information custodian's policies, procedures and practices concerning health information with a knowledgeable person and have specific questions about their own health information answered in a timely fashion. 10.4 A health information custodian's policies, procedures and practices shall ensure that patients can understand what might, can or must happen to their health information, that consent is sought as required by this Code and that nothing is left implicit or unknown to patients that if known or made explicit could reasonably be expected to alter a patient's decision to freely confide information. 10.5 Patients shall be able to challenge the health information custodian's compliance with the provisions of this Code by addressing their concerns to the designated accountable person. 10.6 Procedures shall be in place to receive and respond to complaints or inquiries about policies, procedures and practices relating to health information collection, use, disclosure and access. The complaint process must be easily accessible and simple to use. 10.7 Patients who make inquiries or lodge complaints shall be informed of the existence of relevant complaint mechanisms. 10.8 All complaints shall be investigated. If a complaint is found to be justified, appropriate remedial measures shall be taken such as amending policies, procedures or practices. Section D: Health Information Policies Health information custodians must have in place and implement policies, procedures and practices that give effect to the principles of this Code. 1.1 Health information policies, procedures and practices should be tailored to the specific health care setting of the custodian and shall address and provide for: (a) complying with and giving effect to the principles of this Code; (b) protecting the security of health information; (c) ensuring the accurate recording and integrity of health information; (d) documentation of all purposes for which the health information custodian uses or discloses the health information it collects, including to whom it permits access to what information, in what format and whether consent is required; (e) documentation of what health information may be linked to other pieces of information; (f) documentation of what health information is made available to third parties; (g) allowing access only to authorized users in the appropriate format and for the limited purposes for which they are authorized; (h) identification of the person who is accountable for the policies, procedures and practices and to whom complaints or inquiries can be made; (i) receiving and responding to complaints and inquiries; (j) ensuring that persons who collect, use, disclose or access health information can be held accountable and are under an enforceable duty to keep information secure; (k) ensuring that persons who work for or in the health institution know and receive sufficient training about this Code and related institutional policies, procedures and practices to ensure accountability; (l) the means of gaining access to one's own health information held by the health institution; (m) making available information that a particular patient specifically requests or reasonably can be presumed to wish to know; (n) ensuring that patients have, or by reasonable means are provided with, knowledge about their health information and that consent is sought and obtained as appropriate; and (o) specification of minimum and maximum retention periods and rules for the succession, transfer and destruction of health information. 1.2 The health information custodian's policies must be readily available to patients and should include information about practices and procedures. 1 Though this submission uses the word "product" in this context, it is understood that services, e.g. therapeutic procedures, may also be covered by the Health Protection Act. 2 DTCA is not legal in Canada, except for notification of price, quantity and the name of the drug. However, "information-seeking" advertisements for prescription drugs, which may provide the name of the drug without mentioning its indications, or announce that treatments are available for specific indications without mentioning drugs by name, have appeared in Canadian mass media. 3 Though the paper applies primarily to prescription drug information, its principles are also applicable to health information in general.
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Toward a National Strategy on Mental Illness and Mental Health : CMA Presentation to the Senate Standing Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy2008
Last Reviewed
2011-03-05
Date
2004-03-31
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2011-03-05
Date
2004-03-31
Topics
Population health/ health equity/ public health
Text
Thank you, honourable Senators, for the opportunity to speak on the critical need to address mental health and mental illness in Canada. In my remarks today I want to talk briefly about the dimensions of the issues, the instruments available to government to address them, and the CMA’s specific thoughts and recommendations on moving forward. Dimensions of the problem As the members of this committee know, the economic toll exacted by mental health disorders, including stress and distress topped 14 billion dollars in 1998. The human cost, however, extends far beyond dollars and cents. Estimates show that about one in five Canadians — close to six million people — will be affected by mental illness at some point in their life. This problem climbs still higher if one includes the serious problem of addiction to illicit drugs, alcohol, prescription drugs and the increasingly serious emerging problem of gambling addiction. Yet our society and health care system remains woefully inadequate in promoting mental health and in delivering care and treatment where and when needed. These systemic shortcomings have been exacerbated by the twin barriers of stigma and discrimination. These barriers have a detrimental effect on recovery from mental illness and addictions by hindering access to services, treatment and acceptance in the community. This is especially unfortunate because effective treatment exists for most mental illnesses and addictions. Poor mental health affects all aspects of a person’s life and requires a collaborative approach. Family physicians, psychiatrists, psychologists, social workers, nurses and other counselors can be involved in one patient’s mental health care. While family physicians can deal with a number of mental illnesses, most are not trained in the complicated medical management of severe mental illness. Many family physicians’ offices are also not sufficiently resourced to deal with family counseling, or related issues such as housing, educational and occupational problems often associated with mental illness. As a family physician myself I should be assured that, when a patient’s mental health care requires additional expertise, the appropriate resources are available for my patients and their families. Physicians are striving to ensure that the care is provided by the appropriate caregiver at the appropriate time. For example the Shared Mental Health Care initiative of the College of Family Physicians of Canada and the Canadian Psychiatric Association is designed to lead to better outcomes for patients. I know the committee will hear more about this initiative from the Canadian Psychiatric Association. I mention it now simply as a reminder that progress is being made and even more could be gained with the establishment of a national strategy to address mental illness and mental health. Canada is the only G8 nation without such a national strategy. This oversight has contributed significantly to fragmented mental health services, chronic problems such as lengthy waiting lists for children’s mental health services and dire health human resource shortages. Case in point, there are no child psychiatrists in the northern territories, where such care is so desperately needed. Planning to correct the problem The fragmented state of mental health services in Canada did not develop overnight and it would be overly simplistic to say problems can be solved immediately. However, it is important to understand that there are means available to the federal government to better meet its obligations with respect to surveillance, prevention of mental illness and promotion of mental health. The way forward has been clearly described by the Canadian Alliance for Mental Illness and Mental Health, and the October 2002 National Summit on Mental Health and Mental Illness hosted by the CMA, and the Canadian Psychological and Psychiatric Associations. This gathering helped define the form that a national strategy should take. Participants recommended a focus on national mental health goals, a policy framework that includes research, surveillance, education, mental health promotion and a health resources plan, adequate and sustained funding; and an accountability mechanism. In addition to a national strategy, the CMA believes it is also important to recognize the deleterious effect of the exclusion of a “hospital or institution primarily for the mentally disordered” from the application of the Canada Health Act. Simply put, how are we to overcome stigma and discrimination if we validate these sentiments in our federal legislation? The CMA firmly believes that the development of a national strategy and action plan on mental health and mental illness is the single most important step that can be taken on this issue. The plan also requires support, wheels if you will, to overcome the inertia that has foiled attempts thus far. Those wheels come in the form of five specific actions that are listed at the back of the presentation. But, to summarize, they would include: * Amending the Canada Health Act to include psychiatric hospitals. * Adjusting the Canada Health Transfer to provide for these additional insured services. * Re-establishing an adequately-resourced federal organizational unit focused on Mental Illness and Mental Health and addictions. * The review of federal health policies and programs to ensure that mental illness is on par in terms of benefits with other chronic diseases and disabilities. * An effective national public awareness strategy to reduce the stigma associated with mental illnesses and addictions in Canadian society. Looking inward While my remarks have focused on the broad status of mental health initiatives in Canada, the mental health status of Canadian health care providers is also of concern to the CMA. In recent years, evidence has shown that physician stress and dissatisfaction is rising and morale is low. The CMA’s 2003 Physician Resource Questionnaire found that 45.7% of physicians are in an advanced state of burnout. Physicians, particularly women physicians, appear to be at a higher risk of suicide than the general population. The CMA has been involved in a number of activities to address this situation, including last year’s launch of the Centre for Physician Health and Well-Being. The Centre functions as a clearinghouse and coordinating body to support research and provide trusted information to physicians, physicians in training and their families. A first activity of the Centre was to provide, through partnership with the CIHR’s Institute of Neurosciences, Mental Health and Addiction, $100,000 in physician health research funding. This funding is currently supporting two research projects. One will develop a guide of common indicators for Canadian physician health programs. This will generate a national profile of the physicians who use the programs, the services provided, and their outcomes. The second will study the psychodynamics of physicians’ work to allow for a better understanding of the dynamics of problems such as stress, burnout, addiction and violence in the workplace. These efforts must be bolstered - other health providers are also impacted by mental illness and need support. The health care provider community needs help in terms of the reduction of stigma, access to resources and supportive environments. Conclusion I know some of what I have said today will have been familiar to members of the committee given the impressive list of roundtables, witness testimony and submissions you have reviewed already as part of your study on mental health. I only hope my comments will be of help in your important efforts and lead to real progress on addressing the largely unmet mental health and mental illness needs in Canada. Recommendations for Action CMA Submission to the Senate Social Affairs, Science and Technology 1. That the federal government make the legislative and/or regulatory amendments necessary to ensure that psychiatric hospital services are subject to the five program criteria of the Canada Health Act. 2. That, in conjunction with legislative and/or regulatory changes, funding to the provinces/territories through the Canada Health Transfer be adjusted to provide for federal cost sharing in both one-time investment and ongoing cost of these additional insured services. 3. That the federal government re-establishes an adequately resourced organizational unit focused on Mental Illness and Mental Health and addictions within Health Canada or the new Canadian Agency for Public Health. This new unit will coordinate mental health and mental illness program planning, policy coordination and delivery of mental health services in areas of federal jurisdiction. The unit would also work with provinces and territories, and the Canada Health Council to enact the National Action Plan endorsed at the National Summit on Mental Illness and Mental Health. Specific responsibilities would include fostering research through federal bodies such as the Canadian Institute for Health Research (CIHR), and disseminating best practices in the provision of mental health programs and services in Canada. 4. That the federal government review federal policies such as disability policy, tax policy, income support policy to ensure that mental illness is on par in terms of benefits with other chronic diseases and disabilities. 5. That the federal government work with the provinces and territories and the Canadian Alliance on Mental Illness and Mental Health to develop an effective national public awareness strategy to reduce the stigma associated with mental illnesses and addictions in Canadian society.
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