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Direct-to-consumer advertising (DTCA)

https://policybase.cma.ca/en/permalink/policy188
Last Reviewed
2020-02-29
Date
2002-09-30
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2002-09-30
Replaces
Position paper on direct to consumer prescription drug advertising (1986)
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Direct-to-Consumer Advertising (DTCA) Policy Statement Canadians have a right to information about prescription drugs and other therapeutic interventions, to enable them to make informed decisions about their own health. This information must be evidence based and provide details about side effects and health risks as well as benefits. Brand-specific direct-to-consumer advertisements, such as those permitted in the United States, do not provide optimal information on prescription drugs. We are concerned that DTCA: * is not information but marketing, and sends the message that a prescription drug is a “consumer good” rather than a health care benefit. * may not provide enough information to allow the consumer to make appropriate drug choices. For example, it generally does not provide information about other products or therapies that could be used to treat the same condition. In addition, it may stimulate demand by exaggerating the risks of a disease and generating unnecessary fear. * may strain the relationship between patients and providers, for example if a patient’s request for an advertised prescription drug is refused. * drives up the cost of health care, and undermines the efforts of physicians, pharmacists and others to promote optimal drug therapy. Patient groups, health care providers, governments and pharmaceutical manufacturers should be supported in activities to develop objective, reliable plain-language information about prescription drugs to ensure that Canadians are able to make informed health care decisions. Therefore we: * Support the provision of objective, evidence-based, reliable plain-language information for the public about prescription drugs. * Oppose direct-to-consumer prescription drug advertising in Canada.
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A Public Health Perspective on Cannabis and Other Illegal Drugs : CMA Submission to the Special Senate Committee on Illegal Drugs

https://policybase.cma.ca/en/permalink/policy1968
Last Reviewed
2020-02-29
Date
2002-03-11
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-03-11
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Cannabis has adverse effects on the personal health of Canadians and the well-being of society. In making this submission to the Special Senate Committee on Illegal Drugs, the Canadian Medical Association (CMA) wishes to make it clear that any change to the criminal status of cannabis must be done so with the recognition that cannabis is an addictive substance and that addiction is a disease. The CMA believes that the government must take a broad public health policy approach to address cannabis use. Focusing on the decriminalization issue alone is inadequate to deal with the complexity of the problem. 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. Under such a multidimensional approach the CMA would endorse decriminalization. In this document, we primarily focus on the health effects of cannabis use. However, we also present information and recommendations on the use of other illegal drugs. While we understand that this goes beyond the intended scope of the Senate Committee's study, this information is important to the development of comprehensive policy, which we believe is required. We also recognize and welcome the fact that many of the CMA's recommendations will require a closer working relationship among health providers, justice officials and law enforcement. The CMA's recommendations are: Section 1: Illegal Drugs 1. A National Drug Strategy: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive national drug strategy on the non-medical use of drugs. 2. Redistribution of Resources: The vast majority of resources dedicated to combating illegal drugs are directed towards law enforcement activities. Government needs to re-balance this distribution and allocate a greater proportion of these resources to drug treatment, prevention, and harm reduction programs. Law enforcement activities should target the distribution and production of illegal drugs. 3. Addiction is a Disease: Addiction should be regarded as a disease and therefore, individuals suffering with drug dependency should be diverted, whenever possible, from the criminal justice system to treatment and rehabilitation. Additionally, the stigma associated with addiction needs to be addressed as part of a comprehensive education strategy. 4. Increased Research: All governments commit to more research on the cause, effects and treatment of addiction. Further research on the long- term health effects associated with chronic cannabis use is specifically required. Section 2: Cannabis 1. National Cannabis Cessation Program: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive program to minimize cannabis use. This should include, but not be limited to: * Education and awareness raising of the potential harms of cannabis use including risks associated with use in pregnancy; use by those with mental illness; chronic respiratory problems; and chronic heavy use; * Strategies to prevent early use in adolescence; and, * Availability of assessment, counselling and treatment services for those experiencing adverse effects of heavy use or dependence. 2. Driving Under the Influence Prevention Policy: The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education constitute the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports a similar multidimensional approach to the issue of the operation of a motor vehicle while under the influence of cannabis. 3. Decriminalization: The severity of punishment for simple possession and personal use of cannabis should be reduced with the removal of criminal sanctions. The CMA believes that resources currently devoted to combating simple marijuana possession through the criminal law could be diverted to public health strategies, particularly for youth. To the degree that having a criminal record limits employment prospects the impact on health status is profound. Poorer employment prospects lead to poorer health. Use of a civil violation, such as a fine, is a potential alternative. However, decriminalization should only be pursued as part of a comprehensive national illegal drug strategy that would include a cannabis cessation program. 4. Monitoring and Evaluation: Any changes need to be gradual to protect against any potential harm. In addition, changes to the criminal law in connection with cannabis, should be rigorously monitored and evaluated for their impact. This document also contains the policies and recommendations of the CMA affiliated association that has specific expertise in the field of substance use disorders the, Canadian Society of Addiction Medicine (CSAM). In addition, for an even broader health-sector perspective, the CMA has attached information on the policy positions of other key medical organizations from Canada and the United States in regard to decriminalization of cannabis. A PUBLIC HEALTH PERSPECTIVE ON CANNABIS AND OTHER ILLEGAL DRUGS INTRODUCTION The Canadian Medical Association (CMA) welcomes the opportunity to participate in the deliberations of the Special Senate Committee on Illegal Drugs. This document was developed by the CMA's new Office for Public Health in consultation with our Affiliate Societies, in particular the Canadian Society of Addiction Medicine, and our 12 provincial and territorial divisions. The use of illegal drugs and relevant policies is an extremely broad, multi-disciplinary and at times, controversial subject. Considering the breadth of this subject, the limited time-lines and the areas of particular interest of the Committee, this document will focus on the following: * What are the known health effects of cannabis and other illegal drugs? * What experience has there been with the decriminalization of cannabis? * What has been the impact of law enforcement on illegal drug use? * What changes need to be considered in Canada's approach to illegal drug use including the potential decriminalization of drugs? In addition to the above, this document will provide an overview of the relevant policy position statements and recommendations regarding cannabis and drug policy from other key medical organizations from both Canada and the United States. PUBLIC HEALTH PERSPECTIVE ON DRUG USE There are many different perspectives on the use of drugs including ethical and moral frameworks. This paper is prepared from a public health perspective where minimizing any harms associated with use is of primary concern. 1 This requires consideration of health issues related not only to the individual user and the drug being used, but also the key social factors associated with use. Drug use is a complex behaviour that is influenced by many factors. It is not possible to identify a single cause for drug use, nor will the set of contributing factors be the same among different drug users and populations. Public health objectives will vary depending upon the circumstances: preventing drug use in those who have not initiated use (e.g. pre-teens); avoiding use in circumstances associated with a risk of adverse outcomes (e.g. drug use and driving motor vehicle); assisting those who wish to stop using the drug (e.g. treatment, rehabilitation); and assisting those who intend to continue to use the drug to do so in such a manner as to reduce the risk of adverse effects (e.g. needle exchange program to reduce risk of HIV). To address this complexity, what is required is a public health strategy to combat drug use utilizing a comprehensive, multi-component approach. Public health strategies focus on the various predisposing, enabling, and re-enforcing factors that influence healthy behaviours and choices. 2 These sets of factors recognize the many influences upon individual behaviour including: individual and social attitudes, beliefs and values; skills; support, self-efficacy and re-enforcement. Public health actions can be grouped into the following major categories: 3 * Developing Personal Skills - education and skill-building (e.g. mass media, skill development to resist peer pressure, thinking skills); * Healthy Public Policy - policies, formal and informal that support health (e.g. school policy, substance use and driving, harm reduction initiatives); * Creating Supportive Environments - social and physical environments (e.g. adequate housing and food, community safety, non-chemical coping mechanisms); * Strengthen Community Action - community involvement in finding solutions (e.g. self-help, social support, community participation); * Health Services - range of services to meet needs (e.g. prevention, assessment, early intervention, treatment, rehabilitation, harm-reduction initiatives). This framework is useful in identifying the range of program components that need to be considered. Relative emphasis between components and the specific interventions selected will vary depending upon the target population (e.g. school students vs. injection drug users). The key is a balanced approach that will influence the factors contributing to less healthy behaviours with support for behaviour change and maintenance. CANNABIS Several commissions and task forces, in Canada and elsewhere, have addressed the issue of how to deal with cannabis use, although frequently their recommendations have not been implemented. 4, 5, 6 It has been suggested that "cannabis is a political football that governments continually duck...(but that) like a football, it bounces back." 7 This section of the paper will review current Canadian levels of use, health effects, law enforcement issues, and experience with decriminalization in other jurisdictions. Current Use The Ontario Student Drug Use Survey is conducted every two years in grades 7, 9, 11, and 13, although in 1999 all grades from 7-13 were surveyed. Use of cannabis within the preceding year increased from 11.7% of students in 1991, to 29.2% in 1999. 8 Increases were also observed for several other drugs during the same time period (tobacco, alcohol, glue, other solvents, hallucinogens, cocaine, PCP, and ecstasy). Increases in adolescent drug use have also been observed in the US, Europe and Australia through the 1990s. Compared with earlier cohorts, fewer students in 1999 reported early onset of cannabis use (before grade 7) compared with similarly aged students in 1997 and 1981. Past year drug use of cannabis, alcohol and tobacco by grade year is shown in Table 1. The proportion of students who have used one of these drugs increases with increasing grade level. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1 - Past Year Drug Use (%) by Grade Level, Ontario Students, 1999 7 8 9 10 11 12 13 Alcohol 39.7 53.7 63.1 74.9 82.0 84.6 83.0 Tobacco 7.4 17.8 27.8 37.4 41.7 38.6 38.0 Cannabis 3.6 14.9 25.5 36.4 48.1 39.4 43.3 1999 Ontario Student Drug Use Survey 9 [TABLE END] The last national survey of illicit drug use in Canada was conducted in 1994. 10 At that time, 23% of Canadians, aged 15 and over, reported having used cannabis more than once during their lifetime with 7% having used it within the preceding year. Current use is much more common in those under the age of 25 and diminishes significantly with age, (Table 2). Most cannabis use is sporadic with the majority of adult and adolescent users using it less than once a week. 11 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 2 - Lifetime and Current Use of Cannabis in Canada, 1994 Age Lifetime Use (%) Current Use (%) (past 12 months) 15-17 30 24.0 18-19 32.9 23.8 20-24 37.7 19.0 25-34 38.2 9.6 35-44 32.9 5.7 45-54 14.8 1.4 55-64 3.7 - 65+ 0.8 - Canada's Alcohol and Other Drugs Survey: 1994 [TABLE END] Health Effects Our understanding of the health effects of cannabis continues to evolve. Hall summarizes the effects into acute and chronic effects and whether these are probable or possible (Table 3). 12 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 3 - Summary of Probable and Possible Health Effects of Cannabis Use Pattern of Use Acute Chronic Probable anxiety, dysphoria, panic, cognitive impairment, psychomotor impairment; chronic bronchitis, lung cancer, dependence, mild cognitive impairment, exacerbation of psychosis; Possible (possible but uncertain, confirmation required in controlled studies) increased risk of traffic accident, psychosis, low-birth-weight babies; cancers in offspring, impaired immunity From CMAJ 2000; 162: 1690-1692. [TABLE END] Tetrahydrocannabinol (THC) is the main psychoactive substance in cannabis. THC is inhaled in the mainstream smoke and absorbed through the lungs, rapidly entering the bloodstream. Effects are perceptible within seconds and fully apparent in a few minutes. Cannabis combines many of the properties of alcohol, tranquilizers, opiates and hallucinogens; it has anxiolytic, sedative, analgesic and psychedelic properties. 13 Its acute toxicity is extremely low, as no deaths directly due to acute cannabis use have ever been reported. The main feature of its use is that it produces a feeling of euphoria (or 'high'). Toxic dose-related effects include anxiety, panic, depression or psychosis.14 It should also be noted that a significant incident of co-morbid addiction occurs in those with physical and mental diseases. People with major mental illnesses such as schizophrenia are especially vulnerable in that cannabis use can provoke relapse and aggravate existing symptoms. A chronic lack of energy and drive to work in chronic users has been referred to as an "amotivational syndrome," which is currently believed to represent an ongoing intoxication in frequent users. 14 Cannabis slows reaction times, impairs motor coordination and concentration as well as the completion of complex tasks. 13 Due to the extended presence of metabolites in the bloodstream, it is difficult to correlate blood levels with acute impairment making interpretation of crash data difficult. However, it is generally accepted that cannabis use is associated with an increased risk of motor vehicle and aircraft crashes. Impairments of attention, memory and the ability to process complex information can last for prolonged periods of time, even years, after cessation of heavy, chronic cannabis use. A cannabis withdrawal syndrome similar to alcohol, opiate and benzodiazepine withdrawal symptoms exist. 14 Cannabis use increases heart rate and causes blood vessels to dilate. These present a risk for those with pre-existing cardiac disease. Smoke from cannabis preparations contains many of the same compounds as tobacco cigarettes including increased levels of tar. Chronic cannabis smoking is associated with bronchitis and emphysema. Chronic cannabis use may have risks of chronic lung disease and lung cancer comparable to cigarette smoking. With increasing study and experience, it is clear that cannabis, like other substances such as tobacco or alcohol, can have a number of adverse physical and psychological effects. 15 Law Enforcement The 1997 data is the latest year with national drug offences' data for possession, cultivation, trafficking and importation (Figure 1). 16 The proportion of drug incidents is heavily skewed towards cannabis. This is intriguing since the health concerns of cannabis are substantially less than those of heroin or cocaine. [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Figure 1: Proportion of All Drug Incidents by Drug Type, Canada, 1997 [FIGURE END] Of the 66,500 drug incidents in Canada in 1997, over 70% (47,908) were cannabis related. Of these, over two thirds (32,682) were for possession. The rate of cannabis offences has increased 34% since 1991 with cannabis-possession rates increasing steadily from 1991-1996 with a slight drop in 1997. Most (86%) of those charged with cannabis offences were under 25 years of age. It has been estimated that about 2,000 Canadians are sent to jail every year for cannabis possession.17 Despite the current level of enforcement, cannabis use has been increasing with over 40% of grade 11, 12 and 13 students having used cannabis in the preceding year. While it is obvious that only a small percentage of users are being charged, thousands of teens and young adults are being charged every year, receiving criminal records that can impact future employment, future interactions with the justice system, and be a barrier to acquiring citizenship. 11 Findings from several studies indicate that perceived health risk and social disapproval were much more important disincentives to cannabis use than legal threats. 18 Experience with Decriminalization in Other Jurisdictions A number of other jurisdictions have implemented alternative enforcement approaches to the personal use of cannabis. While none of these experiences directly predict what would happen in Canada, they do provide information to address some of the issues raised when decriminalization is considered. Despite the obvious interest in the impact of these policy changes, there is a paucity of well-designed evaluations (i.e. evaluations which were designed and implemented prior to policy change, rather than post-hoc analyses on available data). United States In the 1970s, several US states reduced the legal sanctions for possession of small amounts of cannabis to a maximum penalty of a fine. Despite the substantial potential interest in the effects of such policy changes, evaluative studies were relatively sparse. The available data, though based upon national high school student survey data as well as evaluations in two states, indicated that there was no apparent increase in cannabis use that could be attributed to decriminalization. 19 The high school student national survey data showed that while use of cannabis had increased in those states that had decriminalized possession, the rates of use had increased by a greater amount with stricter laws. California was one of the states which decriminalized possession, and similar to other states, experienced a decrease in cannabis use during the 1980s which based upon student surveys appeared to be due to changing perceptions of health risks rather than changes in the legal status of the drug. 19 Netherlands The Netherlands is the most frequently identified example of a country that altered its approach to marijuana. The Dutch impose no penalties for the possession of small amounts of cannabis and allow a number of coffee shops to openly sell the drug. 20 This policy therefore is not simply removing the potential for criminal records and imprisonment with possession, but actually partially legalized cannabis sales. This process began in 1976 and coffee shops were not allowed to advertise, could not sell hard drugs, no sales to minors, no public disturbances, and no sales transactions exceeding certain quantity thresholds. Initially this threshold was set at 30 gm of cannabis, a rather large amount which was reduced to 5 gm in 1995. Attempts have been made to compare the prevalence of cannabis use in the Netherlands with other countries. Since cannabis use changes dramatically with age and over different time periods, surveys need to be of similar populations during similar time periods to be comparable. Differences in the wording of questions between surveys also make comparison difficult. A recent review by MacCouin et al makes 28 comparisons between the Netherlands and the US, Denmark, West Germany, Sweden, Finland, France and the UK.21 Overall, it appears that Dutch rates are lower than rates of use in the US but somewhat higher than those of some of its European neighbours. Cannabis use is higher in Amsterdam compared to other Dutch cities and is comparable to use in the US. A limited number of surveys appear to show that from 1984 to 1992, there was a substantial increase in adolescent (aged 16 - 20) use of cannabis that did not occur in other countries. The increases observed from 1992 to 1998 however, were similar to the increases observed in other countries including Canada. Overall, it appears that while the increases in Dutch adolescent use started earlier than other countries, their prevalence of use was much lower than comparison countries so that by the late 1990s they had comparable rates of use to the US and Canada. Australia From 1987 to 1995, three Australian states decriminalized the possession and cultivation of cannabis for personal use by replacing penal sanctions with fines. 22 The courts in other states have tended to utilize non-penal sanctions such as a fine or a suspended sentence with a criminal record. The limited number of surveys conducted in Australia has failed to find evidence of any large impact on cannabis use (some of the surveys had small sample sizes and the trend in usage has been upwards in Australian states which did not decriminalize as well as in other countries that continue to prohibit cannabis use). Interestingly, despite the decriminalization, the number of notices issued by police exceeds the number of cannabis offences prior to the change in law. Summary The preceding sections have suggested that cannabis use is relatively common (particularly in teens and young adults); most use is sporadic; its use is increasing; and it is not harmless. Because of these potential harms, one would not wish to encourage its use. There is however, no necessary connection between adverse health effects of any drug or human behaviour and its prohibition by law. 22 The issue is therefore whether there are less coercive ways to discourage its use. Despite the current criminal justice approach where the bulk of all illegal drug charges are cannabis-related and the majority of these are for possession, use is increasing with thousands of teens and young adults receiving criminal records for possession each year. The available evidence from other jurisdictions suggests that decriminalization would not result in a substantial increase in use beyond baseline trends. Considering current trends, a comprehensive approach to discourage current usage is required. OTHER ILLEGAL DRUGS Illegal drugs other than cannabis present a different set of issues and concerns. While these drugs are not the primary focus of the Special Senate Committee's study, we have included a few key issues to better put the cannabis issue in proper context. Current Use The Ontario Student Drug Use Survey of students in grades 7, 9, 11 and 13 has shown that following a lengthy period of decline in drug use during the 1980s, there has been a steady increase in adolescent drug use. 8 Past year drug use in 1999 was reported as follows: ecstasy (4.8%); PCP (3.2%); hallucinogens (13.8%), and cocaine (4.1%). By comparison, tobacco, alcohol and cannabis were 28.3%, 65.7%, and 29.2% respectively. Canadian survey data of those aged 15 and over in 1994 found that about one in twenty reported any lifetime use of LSD, speed or heroin, or cocaine. 10 Rates of use of these drugs within the preceding year were 1% and 0.7% respectively. Health Effects The adverse effects of drugs such as heroin and cocaine are related not just to the drugs themselves, but also increasingly to their method of intake, which is predominantly by injection. Injection drug use (IDU) is an efficient delivery mechanism of drugs, but is also an extremely effective means of transmitting bloodborne viruses such as hepatitis B, hepatitis C and HIV. The proportion of HIV infections attributable to IDU has increased from 9% prior to 1985 to over 25% by 1995. 23 IDU is also the predominant means of hepatitis C transmission responsible for 70% of cases. 24 The increasing use of cocaine, which tends to be injected on a more frequent basis, increases the subsequent exposure to infection. It has been estimated that up to 100,000 Canadians inject drugs (not counting steroids). 25 Transmission of bloodborne pathogens is not limited to injection drug users as the disease can then be further spread to sexual contacts, including the sex trade, and vertical transmission from infected mother to child. An epidemic of overdose deaths among injection drug users has been experienced in British Columbia with over 2000 such deaths in Vancouver since 1991. 17 Despite the seriousness of the potential adverse effects of illegal drug use and the potential for this situation to worsen with increasing transmission of bloodborne diseases, on a population basis, legal drugs (alcohol and tobacco) are responsible for substantially more deaths, potential years of life lost and hospitalizations. 26 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 4 - The Number of Deaths, Premature Mortality and Hospital Separations for Illicit Drugs, Alcohol and Tobacco, Canada, 1995. Deaths Potential Years of Life Lost Hospital Separations Illicit Drugs 805 33,662 6,940 Alcohol 123,734 172,126 82,014 Tobacco 34,728 500,350 193,772 From: Single et al. CMAJ 2000: 162: 1669-1675 [TABLE END] Expenditures on Illegal Drugs The direct costs associated with illicit drugs based on 1992 Canadian data are shown in the figure below: [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [FIGURE END] The vast majority of expenditures related to illegal drugs are on law enforcement. Considering the distribution of drug incidents, a substantial proportion of these are related to cannabis offences although health and other costs will predominantly be associated with other drugs. A substantial proportion of drug charges are for possession as compared with trafficking or importation (cocaine 42%; heroin 42%; other drugs 56%). 16 Despite illegal drug use being primarily a health and social issue, current expenditures do not reflect this and are heavily skewed towards a criminal justice approach. Unfortunately, prisons are not an ideal setting for treating addictions with the potential for continued transmission of bloodborne viruses. RECOMMENDATIONS The Need for Balanced, Comprehensive Approaches Reasons for drug use, particularly "hard drugs," are complex. It is not clear how a predominantly law enforcement approach is going to address the determinants of drug use, treat addictions, or reduce the harms associated with drug use including overdoses and the transmission of bloodborne viruses including HIV. Costs of incarceration are substantially more than the use of effective drug treatment. 27 It appears that there is an over dependence on the law when other models might be more effective in achieving the desired objective of preventing or reducing harm from drug use. 18 Aggressive law enforcement at the user level could exacerbate these harms by encouraging the use of the most dangerous and addictive drugs in the most concentrated forms, 28 because these are easier to conceal and the efficacy of injecting is greater than that of inhaling as drug costs increase in response to prohibition and enforcement. 29 There have been several recent sets of recommendations from expert groups regarding the need for a comprehensive set of approaches to address the public health challenges due to drug use, particularly those associated with injection drug use (IDU). 17, 25, 30, 31 Recommendations include the following components: * address prevention; * treatment and rehabilitation; * research; * surveillance and knowledge dissemination; * national leadership and coordination. Many of the recommendations will require close working relationships with justice/enforcement officials. Drug abuse and dependency is a chronic, relapsing disease for which there are effective treatments.32 A criminal justice approach to a disease is inappropriate particularly when there is increasing consensus that it is ineffective and exacerbates harms.33 The CMA's recommendations have been separated into two separate sections. The first set of recommendations is focused on policies affecting illegal drugs in general. While this goes beyond the intended scope of the Senate Committee's study, in our opinion, these recommendations are equally important for the Committee to consider. The second set of recommendations is specifically focused on cannabis. Our recommendations in this section take into consideration the health impact profile of cannabis, current levels of use, extent and impact of law enforcement activities and experience from other jurisdictions. Section 1: Illegal Drugs The CMA recommends: 1. A National Drug Strategy: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive national drug strategy on the non-medical use of drugs. 2. Redistribution of Resources: The vast majority of resources dedicated to combating illegal drugs are directed towards law enforcement activities. Government needs to re-balance this distribution and allocate a greater proportion of these resources to drug treatment, prevention, and harm reduction programs. Law enforcement activities should target the distribution and production of illegal drugs. 3. Addiction is a Disease: Addiction should be regarded as a disease and therefore, individuals suffering with drug dependency should be diverted, whenever possible, from the criminal justice system to treatment and rehabilitation. Additionally, the stigma associated with addiction needs to be addressed as part of a comprehensive education strategy. 4. Increased Research: All governments commit to more research on the cause, effects and treatment of addiction. Further research on the long- term health effects associated with chronic cannabis use is specifically required. Section 2: Cannabis The CMA recommends: 1. National Cannabis Cessation Program: The federal government develop, in cooperation with the provinces and territories and the appropriate stakeholder groups, a comprehensive program to minimize cannabis use. This should include, but not be limited to: * Education and awareness raising of the potential harms of cannabis use including risks associated with use in pregnancy; use by those with mental illness; chronic respiratory problems; and chronic heavy use; * Strategies to prevent early use in adolescence; and, * Availability of assessment, counselling and treatment services for those experiencing adverse effects of heavy use or dependence. 2. Driving Under the Influence Prevention Policy: The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education constitute the most effective approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports a similar multidimensional approach to the issue of the operation of a motor vehicle while under the influence of cannabis. 3. Decriminalization: The severity of punishment for simple possession and personal use of cannabis should be reduced with the removal of criminal sanctions. The CMA believes that resources currently devoted to combating simple marijuana possession through the criminal law could be diverted to public health strategies, particularly for youth. To the degree that having a criminal record limits employment prospects the impact on health status is profound. Poorer employment prospects lead to poorer health. Use of a civil violation, such as a fine, is a potential alternative. However, decriminalization should only be pursued as part of a comprehensive national illegal drug strategy that would include a cannabis cessation program. 4. Monitoring and Evaluation: Any changes need to be gradual to protect against any potential harm. In addition, changes to the criminal law in connection with cannabis, should be rigorously monitored and evaluated for their impact. CANADIAN SOCIETY OF ADDICTION MEDICINE The Canadian Society of Addiction Medicine (CSAM), which was formed in 1989, is a national organization of medical professionals and other scientists interested in the field of substance use disorders. Vision The Society shares its overall goals with many other organizations and groups in Canada; namely, the prevention of problems arising from the use of alcohol and other psychoactive substances, and the cure; improvement or stabilization of the adverse consequences associated with the use of these drugs. This Society aims to achieve these goals through the fostering and promotion of medical sciences and clinical practice in this field in Canada, particularly by: * fostering and promotion of the roles of physicians in the prevention and treatment of alcohol and drug related problems; * improvement in the quality of medical practice in the drug and alcohol field through: establishment and promotion of standards of clinical practice; fostering and promotion of research; and fostering and promotion of medical education; * promotion of professional and public awareness of the roles that physicians can play in the prevention and treatment of alcohol and drug related problems; * fostering and promotion of further development of programs for the prevention and treatment of problems of alcohol and drug use in physicians; and * contributing to professional and public examination and discussion of important issues in the drug and alcohol field. Policy Statement The CSAM National Drug Policy statement requires that: Canada must have a clear strategy for dealing with the cultivation, manufacture, importation, distribution, advertising, sale, possession and use of psychoactive substances regardless of whether they are classified as legal or illegal. Drug possession for personal use must be decriminalized and distinguished from the trafficking or illegal sale/distribution of drugs to others that must carry appropriate criminal sanctions. The individual and public health impact of substance use, substance abuse and substance dependence must be taken into account at all times. An assessment to ascertain the extent of a substance use disorder and screening for addiction must be an essential part of dealing with someone identified as an illicit drug user or possessor. Appropriate funding must be made available for supply reduction and demand reduction of various psychoactive substances that carry an abuse or addiction liability. Recommendations 1. National policies and regulations must present a comprehensive and coordinated strategy aimed at reducing the harm done to individuals, families and society by the use of all drugs of dependence regardless of the classification of "legal" or "illegal" 2. Prevention programs need to be comprehensively designed to target the entire range of dependence-producing drugs to enhance public awareness and affect social attitudes with scientific information about the pharmacology of drugs and the effects of recreational and problem use on individuals, families, communities and society. 3. Outreach, identification, referral and treatment programs for all persons with addiction need to be increased in number and type until they are available and accessible in every part of the country to all in need of such services. 4. Law enforcement measures aimed at interrupting the distribution of illicit drugs need to be balanced with evidenced based treatment and prevention programs, as well as programs to ameliorate those social factors that exacerbate addiction and its related problems. 5. Any changes in laws that would affect access to dependence-producing drugs should be carefully thought out, implemented gradually and sequentially, and scientifically evaluated at each step of implementation, including evaluating the effects on: * access to young people and prevalence of use among youth; * prevalence of use in pregnancy and effects on offspring; * prevalence rates of alcoholism and other drug dependencies; * crime, violence and incarceration rates; * law enforcement and criminal justice costs; * industrial safety and productivity; * costs to the health care system; * family and social disruption; * other human, social and economic costs. 6. CSAM opposes * any changes in law and regulation that would lead to a sudden significant increase in the availability of any dependence-producing drug (outside of a medically-prescribed setting for therapeutic indications). All changes need to be gradual and carefully monitored. * any system of distribution of dependence-producing drugs that would involve physicians in the prescription of such drugs for other than therapeutic or rehabilitative purposes. 7. CSAM supports * public policies that would offer treatment and rehabilitation in place of criminal penalties for persons with psychoactive substance dependence and whose offense is possession of a dependence-producing drug for their own use. Those who are found guilty of an offense related to Addiction, proper assessment and treatment services must be offered as part of their sentence. This goal may be attained through a variety of sentencing options, depending upon the nature of the offense. * an increase in resources devoted to basic and applied research into the causes, extent and consequences of alcohol and other drug use, problems and dependence, and into methods of prevention and treatment. RELEVANT POSITION STATEMENTS OF OTHER MEDICAL HEALTH ORGANIZATIONS The purpose of this section is to provide the Special Senate Committee on Illegal Drugs with information on the policy positions of other key medical organizations from Canada and the United States in regard to decriminalization of cannabis. Canadian Centre for Addiction and Mental Health34 The Centre for Addiction and Mental Health (CAMH) does not encourage or promote cannabis use. CAMH emphasizes that the most effective way of avoiding cannabis-related harms is through not using cannabis, and encourages people to seek treatment where its use has become a problem. Cannabis is not a benign drug. Cannabis use, and in particular frequent and long-term cannabis use, has been associated with negative health and behavioural consequences, including respiratory damage, problems with physical coordination, difficulties with memory and cognition, pre- and post-natal development problems, psychiatric effects, hormone, immune and cardio-vascular system defects, as well as poor work and school performance. The consequences of use by youth and those with a mental disorder are of particular concern. However, most cannabis use is sporadic or experimental and hence not likely to be associated with serious negative consequences. CAMH thus holds the position that the criminal justice system in general, and the Controlled Drugs and Substances Act (CDSA) specifically, under which cannabis possession is a criminal offence, has become an inappropriate control mechanism. This conclusion is based on the available scientific knowledge on the effects of cannabis use, the individual consequences of a criminal conviction, the costs of enforcement, and the limited effectiveness of the criminal control of cannabis use. CAMH thus concurs with similar recent calls from many other expert stakeholders who believe that the control of cannabis possession for personal use should be removed from the realm of the CDSA and the criminal law/criminal justice system. While harmful health consequences exist with extensive cannabis use, CAMH believes that the decriminalization of cannabis possession will not lead to its increased use, based on supporting evidence from other jurisdictions that have introduced similar controls. CAMH recommends that a more appropriate legal control framework for cannabis use be put into place that will result in a more effective and efficient control system, produce fewer negative social and individual consequences, and maintain public health and safety. An alternative legal control system for the Canadian context can be chosen from a number of options that have been tried and proven adequate in other jurisdictions. CAMH further recommends that such an alternative framework be explored on a temporary and rigorously evaluated trial basis, and that an appropriate level of funding be provided/maintained for prevention and treatment programs to minimize the prevalence of cannabis use and its associated harms. American Society of Addiction Medicine 35 The Society's 1994 policy which was updated September 2001 recommends the following: 1. National policy should present a comprehensive and coordinated strategy aimed at reducing the harm done to individuals, families and society by the use of all drugs of dependence. 2. Reliance on the distinction between "legal" and "illegal" drugs is a misleading one, since so-called "legal" drugs are illegal for persons under specified ages, or under certain circumstances. 3. Prevention programs should be comprehensively designed to target the entire range of dependence-producing drugs as well as to produce changes in social attitudes. (See ASAM Prevention Statement.) 4. Outreach, identification, referral and treatment programs for all persons suffering from drug dependencies, including alcoholism and nicotine dependence, should be increased in number and type until they are available and accessible in every part of the country to all in need of such services. 5. Persons suffering from the diseases of alcoholism and other drug dependence should be offered treatment rather than punished for their status of dependence. 6. The balance of resources devoted to combatting these problems should be shifted from a predominance of law enforcement to a greater emphasis on treatment and prevention programs, as well as programs to ameliorate those social factors that exacerbate drug dependence and its related problems. 7. Law enforcement measures aimed at interrupting the distribution of illicit drugs should be aimed with the greatest intensity at those causing the most serious acute problems to society. 8. Any changes in laws that would affect access to dependence-producing drugs should be carefully thought out, implemented gradually and sequentially, and scientifically evaluated at each step of implementation, including evaluating the effects on: a. prevalence of use in pregnancy and effects on offspring; b. prevalence rates of alcoholism and other drug dependencies; c. crime, violence and incarceration rates; d. law enforcement and criminal justice costs; e. industrial safety and productivity; f. costs to the health care system; g. family and social disruption; h. other human, social and economic costs. 9. ASAM opposes any changes in law and regulation that would lead to a sudden significant increase in the availability of any dependence-producing drug (outside of a medically-prescribed setting for therapeutic indications). Any changes should be gradual and carefully monitored. 10. ASAM opposes any system of distribution of dependence-producing drugs that would involve physicians in the prescription of such drugs for other than therapeutic or rehabilitative purposes. 11. ASAM supports public policies that would offer treatment and rehabilitation in place of criminal penalties for persons who are suffering from psychoactive substance dependence and whose only offense is possession of a dependence-producing drug for their own use. 12. ASAM supports public policies which offer appropriate treatment and rehabilitation to persons suffering from psychoactive substance dependence who are found guilty of an offense related to that dependence, as part of their sentence. This goal may be attained through a variety of sentencing options, depending upon the nature of the offense. 13. ASAM supports an increase in resources devoted to basic and applied research into the causes, extent and consequences of alcohol and other drug use, problems and dependence, and into methods of prevention and treatment. 14. In addition, scientifically sound research into public policy issues should receive increased support and be given a high priority as an aid in making such decisions. 15. Physicians and medical societies should remain active in the effort to shape national drug policy and should continue to promote a public health approach to alcoholism and other drug dependencies based on scientific understanding of the causes, development and treatment of these diseases. US Physician Leadership on National Drug Policy 32 The Physician Leadership on National Drug Policy (PLNDP) was started in 1997 when 37 senior physicians from virtually every medical society* met and agreed that the "current criminal justice driven approach is not reducing, let alone controlling drug abuse in America." Their extensive review of the literature found: * drug addiction is a chronic, relapsing disease, like diabetes or hypertension; * treatment for drug addiction works; * treating addiction saves money; * treating drug addiction restores families and communities; * prevention and education help deter youth from substance abuse, delinquency, crime and incarceration. In follow-up to an extensive review of the literature, their key policy recommendations are: * Reallocate resources toward drug treatment and prevention; * Parity in access to care, treatment benefits, and clinical outcomes; * Reduce the disabling regulation of addiction treatment programs; * Utilize effective criminal justice procedures to reduce supply and demand (e.g. community coalitions, community policing, drug courts); * Expand investments in research and training; * Eliminate the stigma associated with the diagnosis and treatment of drug problems; * Train physicians and (medical) students to be clinically competent in diagnosing and treating drug problems. REFERENCES 1 Mosher JF, Yanagisako KL. Public health, not social warfare: a public health approach to illegal drug policy. J Public Health Policy 1991; 12: 278-323. 2 Precede - proceed model of health promotion. Institute of Health Promotion Research. Available from: http://www.ihpr.ubc.ca/frameset/frset_publicat.htm. Accessed: Nov 27, 2001. 3 World Health Organization. Ottawa charter for health promotion. Ottawa: World Health Organization, 1986. 4 Dean M. UK government rejects advice to update drug laws. Lancet 2000; 355: 1341. 5 Curran WJ. Decriminalization, demythologizing, desymbolizing and deemphasizing marijuana. Am J Public Health. 1972; 62: 1151-1152. 6 Report of the Canadian Government Commission of Inquiry into the non-medical use of drugs. Ottawa, 1972. 7 Anonymous. Deglamorising cannabis. Lancet 1995; 346: 1241. (editorial) 8 Edlaf EM, Paglia A, Ivis FJ, Ialomiteanu A. Nonmedicinal drug use among adolescent students: highlights from the 1999 Ontario Student Drug Use Survey. CMAJ 2000; 162: 1677-1680. 9 Centre for Addiction and Mental Health. The 1999 Ontario Student Drug Use Survey - executive summary. Available from: http://www.camh.net/addiction/ont_study_drug_use.html. Accessed: October 15, 2001. 10 MacNeil P, Webster I. Canada's alcohol and other drugs survey 1994: a discussion of the findings. Ottawa: Health Canada, 1997. 11 Single E, Fischer B, Room R, Poulin C, Sawka E, Thompson H, Topp J. Cannabis control in Canada: options regarding possession. Ottawa, Canadian Centre on Substance Abuse, 1998. Available from: http://www.ccsa.ca/. 12 Hall W. The cannabis policy debate: finding a way forward. CMAJ 2000; 162: 1690-1692. 13 Ashton CH. Pharmacology and effects of cannabis: a brief review. Br J Psychiatr 2001; 178: 101-106. 14 Johns A. Psychiatric effects of cannabis. Br J Psychiatr 2001; 178: 116-122. 15 Farrell M, Ritson B. Br J Psychiatr 2001; 178: 98. 16 Tremblay S. Illicit drugs and crime in Canada. Juristat 1999; 19. 17 Riley D. Drugs and drug policy in Canada: a brief review and commentary. November, 1998. Available from: http://www.parl.gc.ca/37/1/parlbus/commbus/senate/com-e/ill-e/library-e/riley-e.htm. Accessed: October 15, 2001. 18 Erickson PG. The law, social control, and drug policy: models, factors, and processes. Int J Addiction 1993; 28: 1155-1176. 19 Single EW. The impact of marijuana decriminalization: an update. J Public Health Policy 1989; 10: 456-66. 20 MacCoun R. Interpreting Dutch cannabis policy: reasoning by analogy in the legalization debate. Science 1997; 278: 47-52. 21 MacCoun R, Reuter P. Evaluating alternative cannabis regimes. Br J Psychiat 2001; 178: 123-128. 22 Hall W. The recent Australian debate about the prohibition on cannabis use. Addiction 1997; 92: 1109-1115. 23 Centre for Infectious Disease Prevention and Control. HIV/AIDS among injecting drug users in Canada. May 2001. Available from: http://www.hc-sc.gc.ca/hpb/lcdc/bah/epi/idus_e.html. Accessed Oct 17, 2001. 24 Hepatitis C - prevention and control : a public health consensus. Can Communic Dis Rep 1999; 25S2. Available from: http://www.hc-sc.gc.ca/hpb/lcdc/publicat/ccdr/99vol25/25s2/index.html. Accessed: Oct 17, 2001. 25 F/P/T Advisory Committee on Population Health et al. Reducing the harm associated with injection drug use in Canada: working document for consultation. March 2001. Available from: http://www.aidslaw.ca/Maincontent/issues/druglaws.htm. Accessed: Oct 14, 2001. 26 Single E, Rehm J, Robson L, Van Truong M. The relative risks and etiologic fractions of different causes of death attributable to alcohol, tobacco and illicit drug use in Canada. CMAJ 2000: 162: 1669-1675. 27 Marwick C. Physician Leadership on National Drug Policy finds addiction treatment works. JAMA 1999; 279: 1149-1150. 28 Grinspoon L, Bakalar JB. The war on drugs - a peace proposal. N Eng J Med 1994: 330: 357-360. 29 Hankins C. Substance use: time for drug law reform. CMAJ 2000: 162: 1693-1694. 30 National Task Force on HIV, AIDS and Injection Drug Use. HIV/AIDS and injection drug use: a national action plan. Canadian Centre for Substance Abuse and Canadian Public Health Association. May 1997. Available from: http://www.ccsa.ca/docs/HIVAIDS.HTM. Accessed: Oct 15, 2001. 31 Canadian HIV/AIDS Legal Network. Injection drug use and HIV/AIDS: legal and ethical issues. Montreal: Network, 1999. 32 Physician Leadership on National Drug Policy. Position paper on drug policy. January 2000. Available from: http://center.butler.brown.edu/plndp/. Accessed: Nov 27, 2001. 33 The Fraser Institute. Sensible solutions to the urban drug problem. 2001. Available from: http://www.fraserinstitute.ca/publications/books/drug_papers/. Accessed: Nov 29, 2001. 34 Canadian Centre for Addiction and Mental Health. CAMH Position on the legal sanctions related to cannabis possession/use. April 2000. Available from: www.camh.net/position_papers/cannabis_42000.html. Accessed Oct 9, 2001. 35 American Society of Addiction Medicine. Public policy of ASAM. Adopted 1994. Updated Sept 29, 2001. Available from: www.asam.org. Accessed: Nov 27, 2001. ?? ?? ?? ?? A healthy population...a vibrant medical profession Une population en santé...une profession médicale dynamique A Public Health Perspective on Cannabis and Other Illegal Drugs Ottawa, March 11, 2002 Page 21 Canadian Medical Association
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Notes for an address by Dr. Peter Barrett, Past-President, Canadian Medical Association : Public hearings on primary care reform : Presentation to the Standing Senate Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy2011
Last Reviewed
2020-02-29
Date
2002-05-22
Topics
Health systems, system funding and performance
Health human resources
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-05-22
Topics
Health systems, system funding and performance
Health human resources
Text
On behalf of the 53,000 physician members of the CMA, we appreciate the opportunity to offer our thoughts on the issue of primary care reform and the recommendations made recently in your April 2002 report. I am very pleased to be presenting today with my CMA colleague, Dr. Susan Hutchison, Chair of our GP Forum along with Dr. Elliot Halparin and Dr. Kenneth Sky from the Ontario Medical Association. Before I begin presenting the CMA’s recommendations, I believe it’s important to make a few points clear in regard to primary care: * First, is that Canada has one of the best primary care systems in the world. (Just ask Canadians, we have. Our 2001 Report Card showed that 60% of Canadians believe that we have one of the best health care systems in the world and gave high marks for both quality of service and system access). * Second, is that primary care reform is not the panacea for all that ails Medicare. * And finally, primary care and specialty care are inextricably linked. I like to expand a bit on the last point because I think it’s an important consideration. There is a tendency to separate medical care into two areas; primary care and specialty care. However, we need to recognize that medical and health care encompasses a broad spectrum of services ranging from primary prevention to highly specialized quaternary care. Primary care and specialty care are so critically interdependent that we need to adapt an integrated approach to patient care. Now, in respect to the CMA’s recommendations on implementing changes for the delivery of primary care, we believe that government must respect the following four policy premises: 1. All Canadians should have access to a family physician. 2. To ensure comprehensive and integrated care, family physicians should remain as the central provider and coordinator of timely access to publicly-funded medical services. 3. There is no single model that will meet the primary care needs of all communities in all regions of the country. 4. Scopes of practice should be determined in a manner that serves the interests of patients and the public safely, efficiently, and competently. Access to Family Physicians A successful renewal of primary health care delivery cannot be accomplished without addressing the shortage of family physicians and general practitioners. The effects of an aging practitioners population, changes in lifestyle and productivity, along with the declining popularity of this field as the career choice of medical school graduates are all having an impact on the supply of family physician. Physician as Central Coordinator While multistakeholder teams offer the potential for providing a broader array of services to meet patients’ health care needs, it is also clear that for most Canadians, having a family doctor as the central provider for all primary medical care services is a core value. As the College of Family Physicians of Canada (CFPC) indicated in its submission to the Royal Commission on the Future of Health Care in Canada, research shows that over 90% of Canadians seek advice from a family physician as their first resource in the health care system. The CFPC also noted that a recent Ontario College of Family Physicians Decima public opinion survey found that 94% agree that it is important to have a family physician who provides the majority of care and co-ordinates the care delivered by others. i A family physician as the central coordinator of medical services ensures efficient and effective use of system resources as it allows for only one entry point into the health care system. This facilitates a continuity of care, as the family physician generally has developed an ongoing relationship with his or her patients and as a result is able to direct the patient through the system such that the patient receives the appropriate care from the appropriate provider. No Single Model for Reform In recent years, several government task force and commission reports, including the report of this Committee, have called for primary care reform. Common themes that have emerged include; 24/7 coverage; alternatives to fee-for-service payment of physicians; nurse practitioners and health promotion and disease prevention. Governments across the country have launched pilot projects of various models of primary care delivery. It is critical that these projects are evaluated before they are adopted on a grander scale. Moreover, we must take into account the range of geographical settings across the country, from isolated rural communities to the highly urbanized communities with advanced medical science centres. Scopes of Practice There is a prevailing myth that physicians are a barrier to change when in fact the progressive changes in the health care system have been more often than not physician lead. Canadian physicians are willing to work in teams and the CMA has developed a “Scopes of Practice” policy that clearly supports a collaborative and cooperative approach. A policy that has been supported in principle by the Canadian Nurses Association and the Canadian Pharmacists Association. Because of the growing complexity of care, the exponential growth of knowledge, and an increased emphasis on health promotion and disease prevention, primary care delivery will increasingly rely on multi-stakeholder teams. This is a positive development. However, expanding the primary care team to include nurses, pharmacists, dieticians, and others, while desirable, will cost the system more, not less. Therefore, we need to change our way of thinking about primary care reform. We need to think of it as an investment. We need to think of it not in terms of cost savings but as a cost-effective way to meet the emerging unmet needs of Canadians. Conclusion To conclude, there is no question that primary care delivery needs to evolve to ensure it continues to meet the needs of Canadians. But we see this as making a good system better, not fundamental reform. Thank you. i College of Family Physicians of Canada. Shaping The Future of Health Care: Submission to the Commission on the Future of Health Care in Canada. Ottawa: CFPC; Oct 25, 2001.
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Presentation to the Standing Committee on Finance Pre-Budget Consultations : Securing Our Future . . . Balancing Urgent Health Care Needs of Today With The Important Challenges of Tomorrow

https://policybase.cma.ca/en/permalink/policy2013
Last Reviewed
2020-02-29
Date
2001-11-01
Topics
Health systems, system funding and performance
Health human resources
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2001-11-01
Topics
Health systems, system funding and performance
Health human resources
Text
The Canadian Medical Association (CMA) values the open, constructive and ongoing dialogue afforded by the Standing Committee on Finance’s Pre-Budget Consultations process. As a society, it is essential that we make every effort to work together to find lasting solutions to what are a series of complex and interdependent policy issues, especially during these turbulent times. Last August, the Committee set out objectives for this year’s consultations. You asked for advice on how to ensure that Canada remains a major player in the New Economy while providing Canadians with equal opportunities to succeed and create a socio-economic environment where they can enjoy the best quality of life and standard of living. However, world events have intervened and the urgent has crowded out the important. The CMA has suspended, for the most part, what we consider important longer term issues in an effort to do our part in helping guide the government’s deliberations in this time of national need. We support the government’s commitments, to date, in response to the events of September 11 and their aftermath. We are cognizant of the economic forecasts that show a slowing economy as a result and the need to re-focus our national attention on security issues. The overriding challenge for this Committee therefore, will be to develop recommendations for the next budget that address the current and future situation with respect to national security without losing sight of internal needs such as pursuing the innovations necessary to ensure the long-term sustainability of our health care system. Indeed, we see the latter as supporting the former. The CMA is committed to working closely with the federal government to ensure that Canada’s health care system can respond to immediate health security challenges. Our members are committed to continuing to ensure that Canadians’ confidence is restored by developing and implementing policy initiatives that serve to strengthen Canadians’ access to quality health care when they need it. To this end and building on our efforts since September 11, the CMA has put together a to meet these objectives. Specifically, the CMA has examined and developed recommendations that address national preparedness in terms of security, health and capacity; the capacity of our health human workforce in addressing current and future demands; and a look beyond the urgent to the necessary, in the form of a proposed process to review tax policy in support of health policy. II. PREPAREDNESS Health and Security The events of September 11, 2001 have had a profound impact on the lives of Canadians. Anxiety over the openness of our borders, the safety of our airlines and our vulnerability to attacks filled the media and our conversations in the days following the tragedies in the United States. A Canadian Ipsos Reid Express survey taken for the Canadian Medical Association October 23-25, 2001 indicated that 31% of respondents report ongoing sadness, anger, disturbed sleep, or are overprotective of their children. 1 This confirms what our members are telling us, based on everyday practice. A GPC International survey indicates that three-quarters of Canadians have a moderate to strong fear that the US-led anti-terrorist campaign will lead to Canada being a possible terrorist target. 2 An earlier Canadian Ipsos Reid Express survey taken October 1, 2001 shows that the attacks have risen to the top of the list of issues (73%) that should receive the greatest attention among our leaders. 3 Social issues, including health, are the second rated (49%) concern among Canadians. The Canadian Medical Association’s response following the terrorist attack was immediate and is ongoing. Working through and with our provincial/territorial Divisions and Affiliates, the Association began collecting names of those physicians willing to offer assistance to US agencies dealing with the tragedy should it have been requested. As well, we spearheaded the development of the Canadian Mental Health Support Network (www.cma.ca/cmhsn), which includes Health Canada and twelve other national health associations, to help Canadians and Canada’s health professionals cope with the mental health aftermath of the attack. The work of this network continues in terms of a series of public security announcements to be released very soon and in terms of ensuring that the information available through health professionals is clear, concise and consistent. We also provided continuous updated advice to Canadian doctors about bioterrorist threats. In the early days of the anthrax scare, before Health Canada had materials available for the public, hundreds of calls for information to 1-800-OCanada were referred daily by Health Canada to the CMA. However, there is an aspect of this issue requiring urgent attention given the current environment. It is the ability of our health system to respond to a disaster, be it a terrorist attack, a natural disaster or a large scale accident. As the Canadian Medical Association and others have documented, the people and the infrastructure of our system is already stretched in its capacity to deal with everyday demands. We have seen that emergency rooms across this country can barely cope with the increased demands brought on by the annual flu season. The system is already operating at or beyond capacity. Devastation approaching the scale of September 11 has not been seen in Canada since December 6, 1917 with the Halifax explosion. While no health system can ever be fully prepared to meet such a staggering level of destruction, it must have the confidence, the resources and, the disaster planning and referral systems to rise to the challenge if Canadians are to be reassured that help will be there if and when they need it. Public Health and Safety The challenge – if and when it comes – will require a local response that is supported nationally. To appreciate the scope of the work necessary to prepare the health system for the threats brought by terrorism it will be useful to understand the challenges currently facing public health in Canada. We have long enjoyed the benefits of a solid public health system through the various health protections, health promotion, and disease prevention and control programs created to maintain and improve the health of the population. The essential role of the medical officer of health in the public health system must be acknowledged, supported, and respected. Their credibility provides the community and health care professionals, particularly physicians, with balance and specialized medical expertise on public health matters. When the board of health is performing its mandated duties successfully, few are even aware that it is at work. Yet when a public health crisis strikes, the community expects rapid, knowledgeable, expert and quality attention to matters. But it can only do that if there is a strong infrastructure in place to meet the challenge. A clear and present danger is the emergence of new diseases or the re-appearance of old ones. An editorial in the April 27, 2000 issue of the New England Journal of Medicine expresses concern about the ability of public health infrastructures to cope with this problem without the resources needed to respond. 4 Increased trade, rising migration rates, and changes in the environment have led to worries over the revival of diseases thought to be under control or near extinction (e.g., human plague, tuberculosis and malaria) and even the recognition of some new “bugs”. The need to be vigilant about the re-emergence of infectious diseases was brought home to governments with a large outbreak of human plague in India in 1994. 5 Out of 876 cases reported, characterized as presumptive plague, 56 were fatal. A large outbreak of Ebola in Zaire in 1995 led to as many as 233 people dying from the disease and further strengthened the case for devoting resources to this problem. 6 West Nile Virus The New York City area got a first-hand look at this problem in 1999 with the appearance of the West Nile virus in North America. As the New York Times reported, it may have come in the blood of a traveler returning from Africa or Europe. 7 It may have arrived in an infected bird smuggled in baggage or even in a mosquito that got onto a jet. In spite of efforts to contain the disease, it has now begun to spread through the eastern portion of the continent, as far north as southern Ontario and as deep as Florida. Tuberculosis Tuberculosis remains one of the world’s two deadliest infections and it is feared to be on the verge of a major comeback. The disease kills 1.5 million to 2 million people a year, almost as many as AIDS. Experts say that toll could increase in the coming years because TB bacteria are evolving dangerous new strains that are increasingly drug-resistant. 8 Health Canada reports that there have been some cases (and deaths) in Canada of multiple drug-resistant TB (MDR-TB) strains. 9 Only Newfoundland, PEI and the territories have not had cases of drug-resistant TB. Latvia and Russia are considered “hot spots” in the world for MDR-TB. However, one in three reported isolates in New York City in recent years was MDR-TB. As well, highly resistant strains spread from New York to Florida, Nevada, Georgia and Colorado in less than two years. Malaria The World Health Organization estimates that one million die from malaria a year and 90% of those deaths are Africans (2500 African children under five die from malaria each day). 10 The disease seems to be dying back in other continents but growing stronger across Africa. The WHO report on infectious diseases describes malaria as having the power to “overwhelm a young child causing high fever, convulsions and breathing difficulties. With the onset of cerebral malaria the child lapses into a coma and may die within 24 hours.” 11 AIDS According to the WHO, there are over 33 million people worldwide living with HIV/AIDS. 12 The hardest hit area is sub-Saharan Africa where one in four of the adult population has HIV/AIDS. In South Africa, 10% of the population is now infected with HIV. 13 The problem among pregnant women is worse, with 22% infected with HIV. In May, 2000, the US National Security Council declared that the spread of AIDS across the world is a threat to national security. 14 The concern, like many of the infectious diseases, is that eventually it will overwhelm the ability of governments to cope with the disease. The US government has sought to double to $254 million to combat AIDS overseas. Readiness Post-September 11 The tragic events of September 11 provided a grim reminder of the necessity of having a strong public health infrastructure in place at all times. As was demonstrated quite vividly that day, we do not have the luxury of time to prepare for these events. While it is not possible to plan for every contingency, certain scenarios can be sketched out and prepared for. To succeed, all communities must maintain a certain consistent level of public health infrastructure to ensure that all Canadian residents are protected from threats to their health. These are only some of the external threats. The Canadian public health system must also cope with domestic issues such as diseases created by environmental problems (e.g., asthma), sexually transmitted diseases, and influenza, among many others. Even before the spectre of bioterrorism this country’s public health experts were concerned about the infrastructure’s ability to deal with multiple crises. There are many vacancies among the public health physician and nursing staffs, particularly in rural and northern Canada as well as the First Nations units. This workforce is also aging and efforts to attract and retain staff have been lagging. The announcement of October 18, 2001 by the federal government of a $11.59 million investment was welcome news to Canadians in the aftermath of September 11. It provided for the “basics” in terms of stockpiling of necessary antibiotics, the purchase of sensor and detection equipment to help respond to radio-nuclear incidents, enhancing a laboratory network to better equip them to detect biological agents, and provide training to front-line health care professionals to help them recognize, diagnose and treat suspicious illnesses. However, far more needs to be done to improve our ability to respond to health and security contingencies of all kinds. The Walkerton water crisis is an example of the difficulties often faced by public health officials. Without the full resources (legislative, physical, financial, human) to do the job properly, the health of Canadians is potentially jeopardized. The Ontario Medical Association emphasized this point in its brief to the Walkerton Inquiry: “Unstable and insufficient resources hamper the Ontario public health system. Steps must be taken by the provincial government to enhance the ability of boards of health to deliver public health programs and services that promote and protect health and prevent disease and injury. Sufficient and reliable public health funding is critical.” 15 The CMA reinforced that message in a resolution passed at its 2001 Annual General Meeting: “That CMA recommend all levels of government across Canada urgently review legislation governing all aspects of drinking water from source to consumption to ensure that comprehensive programs are in place and being properly implemented, with effective linkages to local, provincial and territorial public health officials and Ministries of Health.” In a recent broadcast in the United States, Dr. Jeffrey Koplan, Director of the US Centers for Disease Control and Prevention laid out seven priority areas for building capacity and preparedness within a public health system: 16 * A well trained, well staffed public health workforce * Laboratory capacity to produce timely and accurate results for diagnosis and investigation * Epidemiology and surveillance to rapidly detect health threats * Secure, accessible information systems to help analyze and interpret health data * Solid communication to ensure a secure two-way flow of information * Effective policy evaluation capability * A preparedness and response capability which includes a response plan and testing and maintaining a high state of preparedness These points apply whether the threat is a natural disaster or a terrorist attack. Public health must be ready for all such threats. And, at present, we are told, that responding to a crisis like Walkerton or North Battleford, not to mention the possibility of co-ordinated bioterrorism, effectively results in public health units shutting down many core programs that are the building blocks of the health care system. As the long shadow of bioterrorism rises over Canada and menaces our health and wellbeing, these issues take on even more significance to Canadians. This Committee must do its part to provide for an “act locally by thinking nationally” with regard to public health support systems. The Current Context As noted above, prior planning and preparation is one of the keys to ameliorating the effects of such sudden and calamitous occurrences. It must be remembered that a catastrophic event of the nature that occurred on September 11 is a local event in that it happens within the jurisdiction of a specific municipality. The quality and level of the response depends on how well prepared the local authorities are for such actions. The local capacity to respond varies across Canada with some area health services (e.g., the larger urban centres) better prepared and equipped than others (there may be jurisdictions that do not have plans). Regardless of how well prepared any municipality is there is always the very strong possibility that public health officials will be overwhelmed and need to turn to the province or territory for help. It is also possible that the event is so massive that even the provincial or territorial resources are besieged and it must call on the federal government with their stockpiles of medical supplies and access to epidemiologists and laboratory services. That assumes good planning before hand between the federal and provincial/territorial governments and that is not necessarily the case. There is an important role for the federal government to urgently improve the coordination among authorities and reduce the variability among the various response plans in cooperation with provincial authorities (and assist those in preparing plans where none exist). Health Canada must help facilitate efforts to rationalize preparations and make it easier for jurisdictions to assist one another in a time of disaster. This could include measures such as transferring patients quickly to facilities outside the affected area when the immediate hospitals are full or even to transferring them to other provinces or territories if necessary. Disease surveillance is another component of these measures. To be effective there must be, at the provincial and territorial level, linked electronic surveillance mechanisms that are standardized and the staff available to analyze and report the data. At the federal level, the government must be ready to provide data in a timely fashion, especially in an emergency. However, very few of Canada’s doctors will have seen the disease entities that threaten Canadians at the moment (e.g., anthrax, smallpox). The CMA has expressed its willingness to assist Health Canada in bringing together stakeholders to develop quickly a curriculum that would train health care professionals to recognize, diagnose and treat the new threats we face as a society. The government must also aid in the development of volunteer teams of health professionals and other experts that can be mobilized rapidly in response to disasters wherever and whenever they occur. The concept would be similar to the military's Disaster Assistance Response Team (DART). 17 DART consists of medical, engineering, logistics, communications and security personnel ready to deploy at short notice to anywhere in the world from their support base at Canadian Forces Base Trenton. It is crucial, that the federal government build and maintain its supplies for emergency use, its public health laboratories for early detection, its capacity to rapidly train and inform frontline health workers of emerging threats, its ability to assist the provinces and territories, and co-ordinate provincial responses in the event of overwhelming or multiple simultaneous threats. In this area, the CMA recommends that: 1. The federal government immediately provide a minimum of $15 million for an assistance fund to municipal and provincial authorities to improve the co-ordination of their emergency responses among public health officials, police, fire and ambulance services, hospitals and other services. This fund should be over and above a similar sized investment to ensure that Health Canada’s Centre for Emergency Preparedness can function even only at a minimal level of effectiveness. The announcement of October 18 by the Minister of Health that $11.59 million would be spent to enhance our response to a potential attack is an important step toward reassuring Canadians that help will be there when they need it. However, far more must be done to further expand the federal government’s ability to assist municipalities, provinces and territories in dealing with disasters. The vital role played by disease surveillance cannot be stressed enough. In the event of an unusual or particularly feared illness, or an outbreak of a preventable disease, the public’s attention can quickly focus on the public health unit’s response. The medical officer of health communicates with physicians (specialists and, general and family practices physicians) in the community. Physicians, especially general and family practice physicians, depend upon their medical officers of health and the health units as an important resource. This includes information on contact tracing, interpretation of unusual clinical symptomatology, vaccination, communicable disease control, outbreak control, environmental health, cluster investigation, epidemiology, travel medicine etc. An effective and efficient surveillance system must be in place in order to provide this data quickly to stop the spread of a disease as fast as possible. Unfortunately, a weak link in the existing surveillance system is communications. This has had an impact on health professionals’ ability to receive timely information regarding changes in disease incidence in their community. Regional, provincial/territorial and federal authorities must work to improve the coordination of communications at all levels to protect the health and wellbeing of Canadians in times of crisis. The CMA recommends that: 2. The federal government continue to invest, at a minimum, $25 million in the coming year in the resources and infrastructure (i.e., medical supplies, equipment, laboratory facilities, and training for health care professionals), needed to anticipate and respond to disasters. The sale of Connaught Laboratories meant that Canada lost much its residual capacity to manufacture vaccines. If this were a “normal” war, Canadians would be looking to divert our manufacturing capacity toward meeting the threat. Given the biological threat, the Government of Canada should be negotiating with the pharmaceutical industry to increase our capacity to produce a secure supply of vaccine on Canadian soil. This would include the need for more than one supplier and the capacity to increase quickly the production of the vaccine. The CMA recommends that: 3. That the federal government undertake an immediate review of Canada’s self-sufficiency in terms of critical medical supplies (e.g., vaccines) required in the event of disasters with a view to short term self sufficiency. Surge Capacity Among the first points of contact with the health system for Canadians in the event of a significant attack on our population it will be the doctors offices and the emergency rooms of our hospitals. As noted earlier, we have witnessed in recent years the enormous strain these facilities can be placed under when even something quite routine like influenza strikes a community hard. The media abounded with stories of patients waiting hours to be examined, of stretchers lining corridors and of ambulances being redirected from hospital to hospital. Canadians themselves experienced first-hand how the resources of the hospitals, particularly the human resources, were stretched to the breaking point. The acute care occupancy rates of Ontario public hospitals across the Ontario Hospital Association regions in 1999-00 illustrate this point. In three of the five regions (Eastern Ontario, Central and South West) the occupancy rate ranged from 94% to 97% 18. The highest rate was found in the very heavily populated Central region. A British Medical Journal study suggests that an occupancy rate over 90% indicates that the hospital system is in a regular bed crisis 19. This problem is not unique to Ontario: “the decrease in the number of acute care beds across Canada over the past decade, coupled with an aging population and our extraordinary success in extending the survival of patients with significant chronic illness, has eliminated any cushion in bed occupancy in the hospital system.” 20 With this in mind, picture a catastrophe similar in scale to the destruction seen in New York or Washington D.C. occurring in downtown Toronto, Vancouver or Montréal; or perhaps the release of smallpox or botulism over Fredericton or Winnipeg. As noted earlier, the public health system and medical diagnostic and treatment systems in the community and hospitals could become overwhelmed very quickly without the ability to absorb the extra caseload. Like our hydro system, that is why surge capacity must be built into the system nationally to enable hospitals to open beds, purchase more supplies, and bring in the health care professionals it requires to meet the need. An element of surge capacity that is seriously lacking is the federal government’s contribution to emergency bed space. With the closure of most of the Canadian Force’s hospitals and the severe loss of experienced health professionals in the military, the government’s ability to assist local and provincial/territorial civilian authorities should their systems become overwhelmed is limited. Currently the National Emergency Stockpile System can supply up to 40,000 cots, as well as medical supplies and relatively rudimentary hospital equipment. Reports indicate, however, that much of the equipment is decades old, and that protocols for logistical management (e.g., transport and rapid deployment) are outdated. There is an urgent need to reassess and reaffirm capacity in this context. The CMA is in close contact with the American Medical Association as they advise their government on coordinating the use of civilian and federal facilities in an emergency. Most hospitals work on a just-in-time inventory basis for the purchase of drugs. Without some sort of plan to quickly re-supply their pharmacies and expand their capacity, patient care will suffer. The federal government must assure Canadians that municipal and provincial plans are in place with an overarching national plan to support these jurisdictions if their service capacities are overwhelmed. As mentioned earlier, the announcement by the federal government of the $11.59 million investment to enhance our response to a potential attack is a good step. But the government must help further by making available an emergency fund that would enable hospitals to plan and organize their surge capacity. The CMA recommends: 4. The federal government provide, in the coming year, $25 million in specific earmarked funding to the provinces and territories to enable health care facilities to plan, build and maintain surge capacity (e.g., open more beds, purchase emergency supplies) into their systems. The purpose of having such elaborate response plans and stockpiles of supplies and equipment is to be ready for the possibility that, in spite of all efforts to prevent a catastrophe from occurring, it nevertheless happens. That is when responsibility for dealing with the aftermath of the event falls largely to the public health system where a strong and viable infrastructure must already be in place to meet the challenge. Without the resources and the preparations, the crisis might well deteriorate and spread beyond “ground-zero.” That notion is often very difficult for non-health sector agencies and organizations to appreciate and can be an impediment to improving our capacity to help Canadians in times of disaster. No one can be completely prepared but you can prepare for certain scenarios. That is where the federal government can facilitate the health system’s readiness and reassure Canadians that help will be there when they need it. The federal government has taken several steps to reassure Canadians that their physical safety is enhanced. This includes the introduction of the Anti-Terrorism Act and the development of an Anti-Terrorism Plan. As well, there is increased funding to the Canadian Security and Intelligence Service and the Communications Security Establishment to help those agencies do their jobs more effectively. The health system must be considered an integral component of any plan to combat terrorism. It too requires assistance, especially the public health infrastructure, in strengthening its ability to counter the effects of an attack, whomever or whatever is responsible. III. THE CAPACITY OF OUR HEALTH HUMAN WORKFORCE Although the right mix of physical infrastructure and sustainable, long-term funding is necessary, in and of itself, it is not sufficient to ensure that all Canadians have timely access to quality medical services. We must also have an adequate supply of physicians and other health personnel or the system will not have the flexibility or adaptability to respond to basic societal needs or a crisis in times of disaster. We believe that the health workforce in general is facing a major sustainability challenge, and as such, this section of the brief proposes initiatives that are not solely focused on physicians but the entire health human workforce. Reports produced by several health professional organizations show that although overall numbers may be increasing, it is not sufficient to meet future demands. In 2000, there was a moderate 1.7% increase in the nurse population 21; however, a 1997 Canadian Nurses Association report projected that the supply of nurses must grow by 2.1% per year to meet future demand. 22 Similarly, the number of physicians per 100,000 population appears to be increasing slightly each year (187 in 2000), but it remains below the 1993 level of 191 per 100,000 population. The physician to population ratio can be misleading in that it does not necessarily represent full time physicians. CMA figures show that a larger proportion of physicians fall into the older age groups and may not be working full time or indeed may not be providing patient care at all. Also, one needs to factor in the demographics of the current physician workforce. Female physicians, who tend to work fewer hours per week than their male colleagues, now represent 30% of the practising pool. This means that more physicians will be needed to provide the same number of services. But this may not be possible, as approximately two-thirds of all family physicians are no longer routinely accepting new patients. 23 This is placing considerable pressure on those currently working within the health care system with little hope for relief. For example, data gathered through the CMA’s annual Physician Resource Questionnaire (PRQ) substantiates anecdotal evidence that physicians are working harder. Over half the respondents to the 2001 PRQ (53.7%) indicated that their workload had increased over the past year. Looking at specific areas that have caused physicians the greatest degree of stress, 63.7% indicated that their workload is heavier than they would like (up from 62% in 1998), while 58.1% felt that their family and personal life had suffered from choosing medicine as a profession (up from 55% in 1998). There are a number of short-term and longer term initiatives that can be implemented to reverse the shortage in our health care personnel and alleviate the stress they are feeling from trying to keep the system operating as best it can. What follows is a description of the short-term initiative the CMA is proposing for consideration by the Standing Committee. For a detailed description of the longer term initiatives and recommendations, please refer to Appendix A. What Can be Done Today? Given the immediate need for more physicians and other health professionals in Canada and the time lag involved in training, especially for physicians, the CMA proposes that a variation on the strategy adopted by the Canadian Forces (CF) 24 be used to repatriate physicians and other professionals. The CF announced the implementation of a Medical and Dental Direct Entry Officer Recruitment Allowance effective April 1, 1999 to recruit licensed family physicians, general practitioners and dentists. Recruitment incentives involve a lump-sum signing bonus/recruitment allowance of $80,000 per direct entry medical officer and $25,000 per direct entry dental officer after a successful completion of 3 months of basic officer training. The commitment is for a duration of 4 years and retention incentives involve an adjustment to medical and dental rates of pay that are competitive with private sector net earnings. The CMA concurs with the concept of an incentive program as proposed by the CF and suggests that a similar approach be implemented for recruiting and retaining Canadian physicians and other health care professionals currently practising outside of Canada. Presently there are some 10,500 Canadian physicians practicing in the US as well as tens of thousands of Canadian nurses. Of these physicians, close to 1,000 are considered active physicians both in Canada and the US. 25 Some of these physicians are no doubt practising in border towns where dual licensure is common, but many may be expatriates who have maintained their licensure in Canada hopefully with plans to either return or at least leave their future options open. Rather than proposing a lump sum approach as an incentive the CMA proposes that the incentive come through graduated federal income tax relief by reducing federal income tax payable by 50% for 3 years for Canadian physicians and health care professionals who return to practice in Canada. Such an approach provides direct relief and over a period of 3 years would provide incentives similar in size to those proposed by the CF in their recruitment and retention program. It is estimated that such a program would cost approximately $45 million over 3 years to repatriate an estimated 5% or 500 physicians back to Canada. If repatriation of other health care providers were included then it is estimated that the total cost of such an initiative could increase to $85 million over 3 years. The CMA therefore recommends: 5. That the federal government seriously consider implementing a 3-year graduated tax relief and re-allocation policy to encourage expatriate physicians and other health professionals to return to Canada. IV. TAX POLICY IN SUPPORT OF HEALTH POLICY The federal government has played a key role in the development of our health care system, primarily through a variety of measures or policy levers such as: spending; taxation; regulation; and information. Up until now, Canada’s health care system has made extensive use of only two federal policy levers, namely spending, in the form of cost-sharing arrangements between the federal and provincial/territorial governments; and by regulation, through the Canada Health Act. However, the degree to which the government can continue to rely on these levers must be examined. In the not-too-distant future, our health care system will face a number of pressures that will challenge its sustainability. Namely, an aging and more demanding population in terms of the specialty care services and technology they will seek; the cry for expanding the scope of medicare coverage to include homecare and pharmacare; and a shortage of health personnel. Several national health care studies, namely the Prime Minister’s Forum on Health and more recently, the Senate Standing Committee on Social Affairs, Science and Technology’s Study of the Health Care System have raised the need to look at alternative health care funding sources. We can not and should not wait any longer to explore and act upon the options available to us. Looking at Alternatives One of the lesser-explored options has been the strategic use of Canada’s taxation system. A public discussion of tax policy has not been seen in Canada since at least 1966. 26 Nor have we seen a major assessment of tax policy in relation to social policy since the 1980’s Macdonald Commission. In fact, the last major overall tax policy review was that of Benson in 1971. There is an urgent need to more fully consider the role that the tax system can play in supporting the health care system. Several proposals have been put forward over time in this areas, such as earmarked taxes for health; health-related excise taxes; input tax credits for health care services; medical savings accounts; saving for long-term care; social insurance; and refundable tax credits. This list is not exhaustive. In fact, the CMA has done some preliminary work in this area by commissioning a discussion paper on taxation and health policy. 27 In the paper, the author puts forth 10 “real world” proposals where the tax system can be used to support health policy. The CMA has initiated detailed discussion with Health Canada, Statistics Canada and others to model some of the possible scenarios. Of course, some of these are more promising than others. It is for this reason that the CMA is recommending the federal government to establish a National Task Force to review the tax system with the purpose of developing innovative tax-based mechanisms that better synchronize tax policy with health policy. In this area, the CMA recommends: 6. That the Federal Government establish a blue ribbon National Task Force to study the development of innovative tax-based mechanisms to better synchronize tax policy and health policy. First and foremost this Task Force would study: a) increasing the reach of the medical expense deduction (i.e., increasing the threshold from the current 3% of taxable expenditures) b) extending the medical expense deduction from a non-refundable tax credit to a refundable tax credit so that those not having income tax payable are afforded easier access to those services not covered under universal health “programs” c) dealing with the untoward inequities arising out of the application of the GST. The CMA envisions the mandate of the Task Force as being – to conduct a thorough policy and costing analysis of all potential tax-based mechanisms (not limited to those outlined in the above recommendations) that can be developed to assist in the financing and management of the health care system. The Task Force would be comprised of representatives from government, the health care system, private sector, and the public and it would issue its findings and recommendations within 2 years of its conception. V. SUMMARY OF RECOMMENDATIONS In closing, the CMA has offered a powerful and strategic combination of policy initiatives designed to re-vitalize Canada’s health care system as well as to restore Canadians’ confidence that they will be taken care of in times of disaster. The proposals are realistic and practical. They give the provinces and territories full flexibility in terms of policy implementation while ensuring full recognition to the federal government for its essential investments. These proposals emphasize the need for the federal government to continue its leadership to ensure that our health care system, Canada’s most cherished social program, is available to meet the health care needs of all Canadians. No one group can address all of the issues and challenges facing the health care system. The CMA reiterates its commitment to work with the federal government and others to ensure that our health care system will be there for all Canadians in the future and in times of crisis. The Summary of Recommendations is as follows: 1. The federal government immediately provide a minimum of $15 million for an assistance fund to municipal and provincial authorities to improve the co-ordination of their emergency responses among public health officials, police, fire and ambulance services, hospitals and other services. 2. The federal government continue to invest, at a minimum, $25 million in the coming year in the resources and infrastructure (i.e., medical supplies, equipment, laboratory facilities, and training for health care professionals), needed to anticipate and respond to disasters. 3. That the federal government undertake an immediate review of Canada’s self-sufficiency in terms of critical medical supplies (e.g., vaccines) required in the event of disasters with a view to short term self sufficiency. 4. The federal government provide, in the coming year, $25 million in specific earmarked funding to the provinces and territories to enable health care facilities to plan, build and maintain surge capacity (e.g., open more beds, purchase emergency supplies) into their systems. 5. That the federal government seriously consider implementing a 3-year graduated tax relief and re-allocation policy to encourage expatriate physicians and other health professionals to return to Canada. 6. That the Federal Government establish a blue ribbon National Task Force to study the development of innovative tax-based mechanisms to better synchronize tax policy and health policy. First and foremost this Task Force would study: a) increasing the reach of the medical expense deduction (i.e., increasing the threshold from the current 3% of taxable expenditures) b) extending the medical expense deduction from a non-refundable tax credit to a refundable tax credit so that those not having income tax payable are afforded easier access to those services not covered under universal health “programs” c) dealing with the untoward inequities arising out of the application of the GST. APPENDIX A The Capacity of Our Health Human Workforce Looking to the Future There are some signs that governments have begun to acknowledge that we are in a sustained shortage situation. In November 1999, several health ministers met with members of the Canadian Medical Forum Task Force on Physician Supply in Canada which recommended 2000 first year medical school places for 2000. Since then, governments have been very active in committing to increases in both undergraduate and postgraduate medical training. Enrolment of new medical students in 2000/2001 reached 1763 for an increase of 12% since 1997/98. This closely matches the promised increases to undergraduate enrolment made by governments. Approximately 140 more positions have been promised for the school years beginning 2001 and 2002. In this area, the CMA recommends that: 7. That the federal government immediately establish a Health Human Resources Education and Training Fund in the amount of $500 million per year for 5 years to fund: (1) increased enrolment in undergraduate and postgraduate education; and (2) the expanded infrastructure (both human and physical resources) required at Canada’s 16 health science centres as a result of increased enrolment. While the outlook for the future supply of physicians in Canada seems brighter, it will be quite a few years before we can benefit from the current increases in undergraduate enrolment. These initiatives must not only continue, but be enhanced to ensure that our health care system is sustainable into the future. However, there is one factor that may keep us from attaining the optimal level of medical school enrolment – high and rising medical school tuition fees. In August 2000, at the Conference of Premiers, Prime Minister Chretien said, “It is indeed important in the new knowledge-based economy that Canadians … have access to high quality post-secondary education without excessive debt loads, and that every child get the best possible start in life. This is all part of the Canadian competitive advantage.” 28 This sounds well and good, but the facts tell us otherwise. Since 1980, medical school tuition costs have increased by almost 880%, or more than twice as fast as the general cost of living. 29 The average tuition for students entering first year medical school in September 2001 was $12,840, a 158% increase over the 1997 average fee of $4,977. This means that over the course of four years, an undergraduate medical student is likely to spend approximately $110,000 in tuition, academic and living expenses. 30 Many students have had to resort to bank loans to cover the shortfall from their government-sponsored student loan, but the growing amount of debt accumulating for medical students is starting to worry the banks. The CIBC says that rising medical education costs have resulted in debt loads growing much faster than medical students’ potential income and so, it will no longer grant medical students preferred lending rates. The CIBC sets limits on the amount of debt that they feel students can repay in the years following their training. Unfortunately, medical students are now reaching these limits – which are in the $100,000 - $130,000 range. 31 Unlike the government-sponsored loans, interest on bank loans begin accruing immediately, up to a decade before a medical student starts earning a full income. This trend raises serious concerns that access to medical education will be restricted solely on the basis of personal financial resources. High debt loads will discourage capable and qualified students – particularly those from modest financial backgrounds – from applying to medical school. Canada’s health care system needs individuals from different socio-economic, cultural, rural and urban backgrounds to serve an equally diverse population of patients. First and foremost, the government must address the situation concerning the high and rising tuition fees and the insufficient financial support systems available to medical students. It must also consider purchasing additional training positions in Canada’s medical schools specifically targeted for groups, such as Aboriginal, Indian and Inuit populations. These measures will foster the education and training of a diverse population of health care givers, and will support the culturally and socially sensitive health care needs of all Canadians. The CMA sees a strong role for the federal government in ensuring that medicine remains a rewarding and affordable career accessible to students based on their passion and academic performance, not their financial status. The CMA therefore recommends: 8. That, in order to alleviate some of the pressures driving tuition fee increases, the federal government increase transfer payments to the provinces/territories with targeted amounts for post-secondary education. 9. That the federal government create and fund a national health services student bursary program to encourage students who have limited financial resources to apply for an education in health care services. 10. That the federal government develop financial support systems for health services students that are: (a) non-coercive; (b) developed concomitantly or in advance of any tuition increase; (c) in direct proportion to any tuition fee increase; and (d) provided at levels that meet the needs of the students. 11. That the federal government purchase additional training slots in Canadian medical schools for particular segments of our population, such as aboriginals. REFERENCES 1 Canadian Ipsos Reid Express. Terrorist Effect. October 23-25, 2001. 2 GPC International. Canadians split on the best response to the terrorist attacks and fear reprisals at home. Media Release October 18, 2001. www.gpcinternational.com/media/releases/20011018.html 3 Canadian Ipsos Reid Express. The Public Agenda Post September 11, 2001. October 1, 2001 4 Osterholm M. Emerging infections – another warning. NEJM 2000; 342(17) http://www.nejm.org/content/2000/0342/0017/1280.asp. 5 World Health Organization. Plague Manual – Epidemiology, Distribution, Surveillance and Control. The Organization: 1999. http://www.who.int/emc-documents/plague/docs/whocdscsredc992a.pdf 6 Sanchez A. et al. Reemergence of Ebola virus in Africa. Emerging Infectious Diseases Vol. 1(3); July-September 1995. http://www.cdc.gov/ncidod/eid/vol1no3/sanchez.htm. 7 Revkin A. Mosquito virus exposes the hole in the safety net. New York Times Oct. 4, 1999. http://www.nytimes.com/library/national/regional/100499ny-pest.html 8Okie S. Tuberculosis is threatening to make a comeback. International Herald Tribune Aug. 11, 1999. http://www.iht.com/IHT/TODAY/WED/IN/tb.2.htm 9 Health Canada. When anti-tuberculosis drugs don’t work. Tuberculosis Epi Update January 2000. http://www.hc-sc.gc.ca/hpb/lcdc/bah/epi/tbdrug_e.html. 10 BBC News Online. Africa confronts malaria. Apr. 25, 2000. http://www.bbc.co.uk/hi/english/world/africa/newsid_724000/724445.stm 11World Health Organization. World Health Organization Report on Infectious Diseases – Removing Obstacles to Healthy Development. Geneva: The Organization, 1999. http://www.who.int/infectious-disease-report/pages/textonly.html 12 Ibid. 13 BBC News Online. South Africa AIDS crisis worsens. Apr. 19, 2000. http://www.bbc.co.uk/hi/english/health/newsid_719000/719183.stm 14 Richwine L. US declares AIDS a threat to security. National Post May 1, 2000 A1. 15 Ontario Medical Association. Ontario Medical Association Input to Walkerton Inquiry Part II: Protecting the Public’s Health. Toronto. April 2001 16 Koplan JP. Building Infrastructure to Protect the Public’s Health. Public Health Training Network Broadcast September 21, 2001 (Downloaded from Web: October 19, 2001 www.phppo.cdc.gov/documents/KoplanASTHO.pdf ) 17 Dept. of National Defence. Canadian Forces Disaster Assistance Relief Team. BG-99-051 (Amended) October 10, 2001. (Downloaded from Web: October 25, 2001 [www.dnd.ca/eng/archive/2001/oct01/28DART_b_e.htm] 18 Ontario Hospital Reporting System, 2001. Acute Care Occupancy Rates, Ontario Public Hospitals by OHA region, 1999/00. Ontario Ministry of Health and Long Term Care. 19 Bagust A, Place M, Posnett J. Dynamics of bed use in accommodating emergency admissions: stochastic simulation model. BMJ; 319: 155-158 July 17, 1999. 20 Nicolle L. Viruses without borders. Can J Infect Dis Vol. 11, Issue 3, May/June 2000 (Downloaded from Web: October 23, 2001: www.pulsus.com/Infdis/11_03/nico_ed.htm) 21 CIHI. Canadian Institute for Health Information Reports Moderate Rise in Register Nurses Workforce, Fewer RNs Working on Casual Basis, More Working Full-time, Media Release, May 23, 2001. 22 Canadian Medical Association. Specialty Care In Canada: Issue Identification and Policy Challenges, October 2001. 23 Canadian NewsWire. Not enough family-physicians to meet patient needs, October 25, 2001 [www.cnw.ca/releases/October2001/25/c0304.html] 24 Incentive Programs for the Recruitment and Retention of Medical and Dental Officers, http://www.dnd.ca/eng/archive/1999/jul99/05DocIncen_b_e.htm 25 Based on a linkage done by Canadian Institute for Health Information of data from Southam Medical Data Base and the America Medical Association’s Masterfile. 26 Carter K. Royal Commission on Taxation, Canada, 1966. 27 Thompson A. Taxation and Health Policy: A Discussion Paper, August 2001. 28 Letter from Prime Minister Jean Chretien to the Honorable Gary Doer, Premier of Manitoba, Chair, Conference of Premiers, August 4, 2000. 29 Ontario Medical Association. Medical Education Fact Sheet, 2001. 30 Admissions/Student and Equity Affairs, Faculty of Medicine, University of Western Ontario. Budgeting Guide for Medical Students: 1999-2000. 31 Banks no longer banking on earning potential of medical students, Canadian Medical Association Journal, June 12, 2001; 164(12) 1735
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Scopes of practice

https://policybase.cma.ca/en/permalink/policy1237
Last Reviewed
2019-03-03
Date
2002-01-22
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2002-01-22
Topics
Health human resources
Text
SCOPES OF PRACTICE Purpose This policy outlines the principles and criteria that are important for physicians to consider when they are involved in the determination of the scopes of practice of physicians and other health care providers, whether regulated or unregulated, in all settings. The primary purposes of scopes of practice determinations are to meet the health care needs and to serve the interests of patients and the public safely, efficiently, and competently. Background There are many factors impacting the scopes of practice of health providers: broadening definition of health, emerging use of alternative therapies, increasing patient consumerism, advances in technology and in treatment and diagnostic modalities, information technology, legislation, changing demographics, increasing health care costs, and the shortage of physicians, nurses and other providers. Scopes of practice must reflect these changes in societal needs (including the need of the public for access to services), societal expectations, and preferences of patients and the public for certain types of health care providers to fulfill particular roles and functions, while at the same time reflecting economic realities. These factors and related issues (e.g., access, availability and cost) are influencing governments and other stakeholders to consider new roles and expanded scopes of practice for health care providers. There is a need to define principles and criteria for understanding and articulating scopes of practice that ensure public safety and appropriate utilization of provider skills. Principles for determining scopes of practice Focus: Scopes of practice statements should promote safe, ethical, high-quality care that responds to the needs of patients and the public in a timely manner, is affordable and is provided by competent health care providers. Flexibility: A flexible approach is required that enables providers to practise to the extent of their education, training, skills, knowledge, experience, competence and judgment while being responsive to the needs of patients and the public. Collaboration and cooperation: In order to support interdisciplinary approaches to patient care and good health outcomes, physicians engage in collaborative and cooperative practice with other health care providers who are qualified and appropriately trained and who use, wherever possible, an evidence-based approach. Good communication is essential to collaboration and cooperation. Coordination: A qualified health care provider should coordinate individual patient care. Patient choice: Scopes of practice should take into account patients' choice of health care provider. Criteria for determining scopes of practice Accountability: Scopes of practice should reflect the degree of accountability, responsibility and authority that the health care provider assumes for the outcome of his or her practice. Education: Scopes of practice should reflect the breadth, depth and relevance of the training and education of the health care provider. This includes consideration of the extent of the accredited or approved educational program(s), certification of the provider and maintenance of competency. Competencies and practice standards: Scopes of practice should reflect the degree of knowledge, values, attitudes and skills (i.e., clinical expertise and judgment, critical thinking, analysis, problem solving, decision making, leadership) of the provider group. Quality assurance and improvement: Scopes of practice should reflect measures of quality assurance and improvement that have been implemented for the protection of patients and the public. Risk assessment: Scopes of practice should take into consideration risk to patients. Evidence-based practices: Scopes of practice should reflect the degree to which the provider group practices are based on valid scientific evidence where available. Setting and culture: Scopes of practice should be sensitive to the place, context and culture in which the practice occurs. Legal liability and insurance: Scopes of practice should reflect case law and the legal liability assumed by the health care provider including mutual professional malpractice protection or liability insurance coverage. Regulation: Scopes of practice should reflect the legislative and regulatory authority, where applicable, of the health care provider. Conclusion Principles and criteria to ensure safe, competent and ethical patient care should guide the development of scopes of practice of health care providers. To this end, the CMA has developed these principles and criteria to assist physicians and medical organizations when they are involved in the determination of scopes of practice. The CMA welcomes opportunities to dialogue with others on how scopes of practice can be improved for the benefit of patients and society in general.
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Rural and remote health in Canada : Presentation to the Standing Senate Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy2017
Last Reviewed
2019-03-03
Date
2001-05-31
Topics
Health human resources
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2001-05-31
Topics
Health human resources
Text
As Secretary General and Chief Executive Officer of the Canadian Medical Association (CMA), I am here today representing our members, more than 50,000 physicians from across Canada. The Association has a two-fold mission, namely to provide leadership for physicians and to promote the highest standards of health and health care for Canadians. The CMA wants to expand significantly on part of its May 16th presentation to this Committee on health human resources. The issue of rural and remote health is of concern to the CMA and we commend the Committee for tackling this complex and very important aspect of Canada's health care system. Our presentation will focus primarily on physician workforce issues in rural and remote practice locations. Most would agree that the health care infrastructure and level of professional support in rural and remote areas of Canada are insufficient to provide appropriate care, and contribute significantly to the difficulty in recruiting and retaining qualified physicians in sufficient numbers (relative to community needs). I will address the following elements: 1. the distribution of physicians practising in rural and remote Canada; 2. their practice profile; 3. what rural physicians are telling us; 4. the CMA Policy on Rural and Remote Practice Issues; and 5. the role for the Federal Government in ensuring reasonable access to health care in these parts of the country. 1. Distribution of physicians practising in rural and remote Canada As you know, Statistics Canada informs us that approximately 25% of Canadians live in rural areas. This number varies from 15% in British Columbia and Ontario to 45% in Atlantic Canada and as high as 60% in the territories. The distribution of physicians is somewhat different. The following data are derived from the CMA physician resources database: * Approximately 10% of Canadian physicians practise outside census metropolitan areas or census agglomerations. This roughly translates to communities of 10,000 or less and for research purposes we consider this cohort to be rural physicians. * There are about 5,700 rural physicians, 87% of which are family physicians. The male/female split is similar to the overall physician pool in Canada but, among those under 35 years of age, half are female. This reflects the current breakdown of the postgraduate output and implies that females are just as likely to seek out rural practice as males. * While Quebec and Ontario are home to almost half of all rural physicians in Canada, Newfoundland has the highest proportion of rural doctors (31%) followed by New Brunswick at 23% and Nova Scotia at 21%. The territories are considered separately since one could argue that even those physicians living in northern cities would be considered to be practising in a remote area. * The majority of rural physicians are graduates of Canadian medical schools (72%) but it varies greatly by region. In Newfoundland, one in three rural physicians is a Canadian graduate; in Saskatchewan, it is only one in five. In contrast, 95% of Quebec rural physicians were trained in this country. 2. Practice profile The CMA routinely surveys the Canadian physician population. Response rates for the surveys mentioned in this brief are shown in Table 1. The following data from CMA's 2000 Physician Resource Questionnaire will be of interest to the Committee: * rural physicians are more likely to be in group practice than urban physicians (68% vs. 58%); * 78% of rural physicians take call (compared to 75% of urban physicians); * excluding their on-call time commitments, rural physicians report spending the same number of hours on direct patient care as urban physicians; * however, rural physicians are on-call for more hours in a month than their urban colleagues; not only do they see more patients while on-call but they also spend more hours providing services; * rural physicians are more likely to be compensated for being on-call, whether it is for carrying a phone or pager (37% are compensated vs 10% of urban physicians) or being available on-site (60% are compensated vs 31% of urban physicians); * while more than half of rural physicians are paid primarily on a fee-for-service basis, proportionately fewer physicians are remunerated this way (53%) compared with 63% of urban physicians. Rural physicians are more likely than their city colleagues to be paid with a salary or some type of blended arrangement. When asked how they would prefer to be paid, 40% selected blended compared to 30% of urban doctors. Less than a third (31%) preferred fee-for-service. Please see Table 2 for an overview of these results. 3. What rural physicians are telling us In the last ten years, in addition to CMA's annual general physician resource questionnaire, two surveys (in 1991 and 1999) were specifically designed to address issues pertaining to physicians practising in rural and remote areas of Canada. I would like to highlight some results from both these surveys. 1991 Survey * Over half of the survey respondents selected desire for rural practice as a very important factor in the decision to locate in a rural area (Figure 1). Only 11% reported financial incentives as being very important. * The physicians who moved from a rural to an urban area were asked about the importance of selected professional considerations (Figure 2). Hours of work was by far the most frequently cited as very important (39%), followed by the need for professional backup (28%) and access to specialty services (24%). * The physicians who moved from a rural to an urban area were asked about the importance of selected personal considerations (Figure 3). Children's educational opportunities was the most frequently cited (by 36%) as very important among the personal considerations, followed by career opportunities for their spouse. * The physicians who moved from a rural to an urban area indicated that there were a number of professional factors that might have influenced them to stay (Figure 4). These factors include additional colleagues (56%), locum tenens (48%), opportunity for group practice (41%) and specialist services (36%). 1999 Survey * In a tracking question from the survey conducted eight years previously, the 1999 survey found that, while rural physicians' level of personal satisfaction with their choice to practise and live in rural communities has remained constant, their level of professional satisfaction - i.e., how they are able to meet the health care needs of their patients - fell significantly since the early 1990s. In a striking example, only 17% reported being very satisfied with the availability of hospital services in 1999 compared to 40% in 1991. * Rural physicians identified the following five factors as being most important in defining their practice community as rural: (1) a high level of on-call duty; (2) the long distance to a community health centre or hospital; (3) lack of services from medical specialists; (4) an insufficient number of family physicians or general practitioners; and (5) the long distance to a teaching hospital (tertiary health care centre). CMA's findings were supported by the 1999 report from Barer and colleagues 1 that identified the following barriers to recruiting and retaining physicians in underserviced communities in Canada: (1) lack of adequate training for the unique circumstances associated with practising medicine in rural environments; (2) remuneration issues; (3) onerous on-call duties and, more generally, heavy workload leading to burnout; (4) professional isolation; (5) lack of spousal employment opportunities; (6) children's education and extracurricular opportunities; (7) climate, recreational and cultural opportunities; and (8) distance from family and friends. CMA 2001 Physician Resource Questionnaire To illustrate some of these findings and highlight some of the positive events, the following quotes are taken from CMA's most recent survey of physicians (the response rate is unavailable for this survey which is still in the field): I know one of the biggest problems my rural colleagues suffer from is lack of locums and difficulty replacing doctors in the community leading to heavier patient loads and responsibilities. This has particularly become worse since medical students have had to choose earlier about specialties with less options to return later. Somehow students and residents should be exposed to more rural medicine. Rural surgical specialists have onerous responsibilities placed upon them with little backup, expectations for 24/7 call coverage ad no financial compensation or recognition for their unwavering devotion to their communities and their profession. My colleagues and I are a dying breed and do not expect that we will be replaced. There is little incentive to practise in a rural environment yet the need continues to grow. Although Fort Frances is rural/remote, we have managed to recruit and retain excellent physicians. We service a catchment area of 22,000 and have 10 MD's on the call rotation. We are an example of how you can live rural/remote, practise interesting medicine and have great quality of life. Most people would think we are over-doctored here but it is the only way we can sustain a healthy lifestyle. Nonetheless the lifestyle of on-call, long irregular hours, and a physician spouse has been hard on the family and relationship. I dream of having regular hours and never having to answer the phone in the middle of the night. 4. CMA Policy on Rural and Remote Practice Issues In October of last year, the CMA released its Policy on Rural and Remote Practice Issues. A copy of this policy is appended to this presentation. The policy contains 28 specific recommendations in the three key areas of training requirements for physicians practising (or wanting to practise) in rural and remote Canada, compensation, and work and lifestyle support issues. The policy illustrates the breadth of issues that need to be addressed before we can hope to alleviate the shortage of the rural physician workforce. The CMA believes that strategies developed to recruit and retain physicians to rural and remote Canada must be comprehensive, flexible and varied to meet and respond to local needs and interests; they must also include, from the outset, community and physician input. The CMA also believes that, as a general rule, these strategies should not be coercive in nature, for example mandatory return-in-service contracts with new medical students. However, this is not to say that strong, positive incentive programs would not work. The Nova Scotia Department of Health, for example, developed a successful incentive program for physicians (including a guaranteed minimum income, a signing bonus and moving expenses, among others) and, importantly, hired a full-time recruiter to implement it. Under this program, 52 physicians were recruited in 1999, 50 in 2000 and 15 so far in 2001; none of these physicians were actively recruited from other Atlantic Canada provinces. There are also examples from the international scene. In Australia, the National Rural Health Strategy involved funding a rural incentives program and the creation of the Australian Rural Health Research Institute (a consortium of five universities with rural campuses). The Australian Journal of Rural Health was also funded through this strategy. The incentive program included relocation grants, grants for continuing medical education and funding for temporary replacements (locums). While this strategy has been well received, there are still many problems of reasonable access to primary care in many parts of rural Australia. In the United States, a financial incentive program, with its roots in the HMO act of 1973, uses an index of medical underservice to determine which areas receive the most funding. The CMA developed an index of rurality in 1999 which could be used in a similar fashion should the federal government decide to become involved in a similar program. 5. Role for the Federal Government The CMA and others have identified a number of issues that need to be addressed to increase physician recruitment and retention in rural and remote Canada. While our presentation appropriately focuses on the physician workforce issue, this situation applies to other health care professions as well. On this note, the CMA has recently embarked on a study, in collaboration with the Society of Rural Physicians of Canada and the Canadian Nurses Association, that will examine the rural workforce of a number of health care professions. We understand that, constitutionally, it is the role and responsibility of the provincial and territorial governments to oversee the provision of health care within their respective jurisdictions. Nonetheless, the CMA has identified five major leadership opportunities for the Federal Government in ensuring that Canadians who live in rural and remote areas have access to appropriate health care. These opportunities are in delivery, evaluation, immigration, planning and funding. Allow me to expand on each of these: i) Delivery: the Federal Government already has a health care delivery role in rural and remote Canada through the Indian and Northern Health Services Directorate of Health Canada. It would be important and valuable to identify lessons learned from this role and share this knowledge with all jurisdictions and players (for example, how physicians can best work with out-post nurses). ii) Evaluation: the CMA applauds the creation of the federal Office of Rural Health within Health Canada. We encourage the Federal Government to expand the role of this office so it can carry out an ongoing evaluation and roll-up of rural health and workforce status; this would become a reliable source of information for researchers, planners and decision-makers. iii) Immigration: in order to meet the short-term health care needs of Canadians, the CMA encourages the Federal Government, through Bill C-11, to develop an immigration policy that is friendly towards qualified international medical graduates. At the same time, any such policy must recognize the need for Canada to strive for reasonable self-sufficiency in the production of physicians. iv) Planning: we need a national planning approach for the short, medium and long term. Again, the CMA encourages the Federal Government to expand the role of its Office of Rural Health, with adequate support and funding, to carry out a comprehensive workforce needs assessment in rural and remote Canada. This information is critical to a successful planning process. v) Funding: finally, there is a role for the Federal Government in funding a mechanism whereby physicians and other health care professionals who want to prepare for practice in rural and remote Canada can obtain the appropriate training and experience. This is one of the main identified barriers to recruitment and retention in rural and remote areas. There is a precedent for the Federal Government in providing one time only funding to create capacity: this was in the 1966 Health Resources Fund Act, whereby the Federal Government funded the creation of new medical schools and the expansion of existing ones. The Federal Government could do the same thing now for the rural and remote workforce capacity. As you know, the Government of Ontario has recently announced the creation of its Northern Ontario Rural Medical School. This begs the question about the rest of the country and opens the door to the Federal Government to work with the Association of Canadian Medical Colleges, the CMA and other relevant medical education organizations to address this issue on a national scale. I want to thank the Committee for inviting us to appear today and we trust that we will have further opportunities to appear before this Committee and work with you during the course of this study. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1 - Response Rates of CMA Surveys to Rural Physicians Year Response rate Sample size of respondents Accuracy level (19 times out of 20) 1991 CMA survey Rural cohort Rural to urban cohort 55% 49% n = 1320 n = 196 +/- 2.7% +/- 7.0% 1999 CMA Rural survey 31% n = 1658 +/- 2.5% 2000 CMA Physician Resource Questionnaire 40% (rural respondents) n = 253 rural respondents +/- 6.2% [TABLE END] [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 2 - Results of the CMA 2000 Physician Resource Questionnaire Rural Urban Take call 78.3% 75.4% Hours of shared call per month 175 hrs/month 139 hrs/month Patients attended while on call 73 per month 41 per month Hours spent providing service while on call 56 hrs/month 34 hrs/month Group Practice 68.4% 58.2% Remuneration 90%+ professional income from fee-for-service Preference for fee-for-service mode Preference for blended mode 52.6% 30.8% 40.3% 63.0% 38.1% 29.7% [TABLE END] 1 Barer M. et al. Toward Improved Access to Medical Services for Relatively Underserved Populations: Canadian Approaches, Foreign Lessons. Centre for Health Services and Policy Research, University of British Columbia, May 1999.
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Drug testing in the workplace (Update 2001)

https://policybase.cma.ca/en/permalink/policy194
Last Reviewed
2018-03-03
Date
2001-05-28
Topics
Ethics and medical professionalism
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2001-05-28
Replaces
Drug testing in the workplace (1992)
Topics
Ethics and medical professionalism
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Health and safety in the workplace continue to be areas of concern to the CMA. The CMA recommends that educational programs on the risks of drug-related impairment to health and safety in the workplace be directed toward labour, management and the public in general. Occupations for which impairment resulting from drug use may constitute a serious hazard should be identified and designated as such. The association recommends that supervisors be trained to refer a worker in a safety-sensitive job for a health assessment if the supervisor has reasonable grounds to suspect impairment of the worker. Workers holding safety-sensitive jobs should be educated to report any departure from their usual state of health as well as any drugs (prescribed or otherwise) being taken to the occupational health physician or, in the absence of such, to the physician of the worker's choice. The CMA is opposed to routine pre-employment drug testing. It recommends that random drug testing among employees be restricted to safety-sensitive positions and undertaken only when measures of performance and effective peer or supervisory observation are unavailable. Drug testing should always be conducted in such a way as to protect confidentiality and should be undertaken with the subject's informed consent (except when otherwise required by law). The idea of drug testing among workers has developed from society's concern over the relation between drug use and impairment, with resultant risks to the worker, fellow workers and the public. Education: Since prevention is the principal and ultimate objective the association recommends that educational programs on the risks of impairment to health and safety in the workplace be directed toward labour, management and the public in general. Illicit drugs are not the only ones that may cause impairment. Certain prescription drugs and even some over-the-counter medications may affect a person's ability to carry out professional functions safely; such effects may vary considerably from one person to another. Alcohol is by far the most common impairing drug implicated in accidents; in addition, the scientific literature contains a growing body of information on impairment and dangers resulting from the use and misuse of various therapeutic medications. Far less is documented or known about the role of illicit drugs in work-related accidents. Safety-sensitive occupations: In most workplaces there are occupations for which impairment may constitute a serious hazard. Such occupations should be identified and designated as such. Workers who hold such safety-sensitive jobs must accept the fact that other workers and the public need to be protected from the hazards of impairment, whether from physical or psychologic ill health or from the use of drugs (over-the-counter, prescription or illicit). Performance assessment of safety-sensitive occupations: The CMA recommends that supervisors be trained to refer a worker in a safety-sensitive job for a health assessment if the supervisor has reasonable grounds (e.g., unsatisfactory performance or observed unusual behaviour) to suspect impairment of the worker. The examining physician may recommend that some tests (including tests for the presence of certain drugs) be carried out under pre-agreed protocols. Workers holding safety-sensitive jobs must be educated to report any departure from their usual state of health as well as any drugs (prescribed or otherwise) they may be taking to the occupational health physician or, in the absence of such, to the physician of the worker's choice. Testing: Any discussion of drug testing must take the following into account: If a quantitative test is to be used to determine impairment a limit must be established beyond which a person is deemed to be impaired. However, since the threshold of impairment varies from one person to another this variation should be taken into account when a worker is being assessed. The tests must be valid and reliable. They must be performed only in laboratories accredited for drug testing. The tests must provide results rapidly enough to be useful in deciding whether the person should continue to work. If different testing procedures are available and the differences between the validity and reliability are not significant the least intrusive alternative should be chosen. The test should be conducted in such a way as to ensure confidentiality and should be undertaken with the subject's informed consent (except when otherwise required by law). Pre-employment testing: The CMA opposes routine pre-employment drug testing for the following reasons: Routine pre-employment drug screening may not objectively identify those people who constitute a risk to society. The mass, low-cost screening tests may not be reliable or valid. The circumstances may not justify possible human rights violations. Random testing: The CMA believes that random drug testing among employees has a limited role, if any, in the workplace. Such testing should be restricted to employees in safety-sensitive positions and undertaken only when measures of performance and effective peer or supervisory observation are unavailable. Role of occupational health services: Occupational health physicians must not be involved in a policing or disciplinary role with respect to employee testing. CMA recommends that employers provide a safe environment for all workers. With the help of experts such as those from national and provincial agencies dedicated to dealing with substance abuse occupational health departments should develop lists of drugs known to cause short-term or long-term impairment, including alcohol. These lists should be posted prominently in the workplace, and workers should be advised that in the event of obvious impairment those involved in safety-sensitive occupations will be asked to undergo medical assessment. If testing for drugs is indicated refusal to submit to testing may result in a presumption of noncompliance with the health requirements of the job. Alcohol impairment should not be tolerated, and legislation should be considered that would set a legal blood alcohol level for safety-sensitive occupations. Breathalyzers or other detection methods could be used if alcohol impairment is suspected in a person holding safety-sensitive occupation. As stated previously, refusal to submit to testing may result in a presumption of noncompliance with the health requirements of the job. These measures should be discussed with labour and management. Labour should be expected to recognize drug-related impairment as a serious health and safety issue, and management should demonstrate its concern by ensuring access to treatment, prevention and educational programs such as employee assistance programs.
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Physician mental health and wellness

https://policybase.cma.ca/en/permalink/policy37
Last Reviewed
2016-05-20
Date
2002-08-21
Topics
Health human resources
Resolution
GC02-50
That Canadian Medical Association promote awareness of physician mental health and wellness issues and reduction of the stigma associated with the need to seek personal assistance for these issues
  1 document  
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2002-08-21
Topics
Health human resources
Resolution
GC02-50
That Canadian Medical Association promote awareness of physician mental health and wellness issues and reduction of the stigma associated with the need to seek personal assistance for these issues
Text
That Canadian Medical Association promote awareness of physician mental health and wellness issues and reduction of the stigma associated with the need to seek personal assistance for these issues
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Aboriginal physicians

https://policybase.cma.ca/en/permalink/policy53
Last Reviewed
2016-05-20
Date
2002-08-21
Topics
Health human resources
Resolution
GC02-66
That Canadian Medical Association work with others to develop a health human resource strategy aimed at improving: Recruitment, training, retention of Aboriginal physicians and other health care workers; Integrated, holistic primary care service delivery relevant to the needs of the Aboriginal community and under community control.
  1 document  
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2002-08-21
Topics
Health human resources
Resolution
GC02-66
That Canadian Medical Association work with others to develop a health human resource strategy aimed at improving: Recruitment, training, retention of Aboriginal physicians and other health care workers; Integrated, holistic primary care service delivery relevant to the needs of the Aboriginal community and under community control.
Text
That Canadian Medical Association work with others to develop a health human resource strategy aimed at improving: Recruitment, training, retention of Aboriginal physicians and other health care workers; Integrated, holistic primary care service delivery relevant to the needs of the Aboriginal community and under community control.
Documents
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Last Reviewed
2016-05-20
Date
2002-08-21
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC02-67
That Canadian Medical Association support the concept that liability for individual practitioner actions in any collaborative care model must be clearly delineated and appropriately insured.
  1 document  
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2002-08-21
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC02-67
That Canadian Medical Association support the concept that liability for individual practitioner actions in any collaborative care model must be clearly delineated and appropriately insured.
Text
That Canadian Medical Association support the concept that liability for individual practitioner actions in any collaborative care model must be clearly delineated and appropriately insured.
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Safety in emergency rooms

https://policybase.cma.ca/en/permalink/policy59
Last Reviewed
2016-05-20
Date
2002-08-21
Topics
Health human resources
Resolution
GC02-72
That Canadian Medical Association and its divisions advocate for the promotion of the safety of all health professionals working in emergency rooms.
  1 document  
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2002-08-21
Topics
Health human resources
Resolution
GC02-72
That Canadian Medical Association and its divisions advocate for the promotion of the safety of all health professionals working in emergency rooms.
Text
That Canadian Medical Association and its divisions advocate for the promotion of the safety of all health professionals working in emergency rooms.
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Programs to provide skills in health system governance

https://policybase.cma.ca/en/permalink/policy79
Last Reviewed
2016-05-20
Date
2002-08-21
Topics
Health human resources
Resolution
GC02-95
That Canadian Medical Association, divisions and affiliates maintain, enhance and improve access to their continuing professional development programs to provide physicians with the skills needed to participate fully in the management and governance of health care.
  1 document  
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2002-08-21
Topics
Health human resources
Resolution
GC02-95
That Canadian Medical Association, divisions and affiliates maintain, enhance and improve access to their continuing professional development programs to provide physicians with the skills needed to participate fully in the management and governance of health care.
Text
That Canadian Medical Association, divisions and affiliates maintain, enhance and improve access to their continuing professional development programs to provide physicians with the skills needed to participate fully in the management and governance of health care.
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Physicians and health policy

https://policybase.cma.ca/en/permalink/policy82
Last Reviewed
2016-05-20
Date
2002-08-21
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC02-117
That Canadian Medical Association, divisions and affiliates urge governments to meet regularly with physicians in leadership roles and other health professionals when developing implementation plans for the recommendations of federal, provincial and territorial commission and task force reports pertaining to health policy.
  1 document  
Policy Type
Policy resolution
Last Reviewed
2016-05-20
Date
2002-08-21
Topics
Health systems, system funding and performance
Health human resources
Resolution
GC02-117
That Canadian Medical Association, divisions and affiliates urge governments to meet regularly with physicians in leadership roles and other health professionals when developing implementation plans for the recommendations of federal, provincial and territorial commission and task force reports pertaining to health policy.
Text
That Canadian Medical Association, divisions and affiliates urge governments to meet regularly with physicians in leadership roles and other health professionals when developing implementation plans for the recommendations of federal, provincial and territorial commission and task force reports pertaining to health policy.
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A Prescription for SUFA : CMA Submission to the F/P/T Ministerial Council on Social Policy Renewal

https://policybase.cma.ca/en/permalink/policy1961
Last Reviewed
2010-02-27
Date
2002-10-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2010-02-27
Date
2002-10-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health systems, system funding and performance
Text
It has been over three years since the Social Union Framework Agreement (SUFA) was signed by the federal and provincial/territorial governments, with the exception of Quebec. At the time, it was heralded as an important breakthrough in federal-provincial relations that would clear the way for greater intergovernmental cooperation on pressing social policy issues such as health care renewal. Functional federalism is essential to achieving social policy objectives that will be of benefit to Canadians from coast to coast. While SUFA may not be perfect, it is better than the alternative of federal-provincial paralysis and dysfunction. And as SUFA acknowledges, Canada’s social union is about more that how governments relate to each other: it is about how governments can and should work with external stakeholders and individual Canadians to improve the social policies and programs. The health sector is an important test case for SUFA. It is the most cherished of Canada’s social programs. Canadians want and expect their governments to work together to improve the health care system and ensure its future sustainability. Ironically, it is also the area where government intergovernmental discord has been the greatest. On the eve of the final report of the Commission on the Future of Health Care in Canada, it is timely to reflect on SUFA and its role in the renewal of Canada’s health system. SUFA and the Health Sector – Strengths and Weaknesses The attached table provides a summary of the key elements of SUFA and the CMA’s assessment of how well SUFA provisions have been applied in the health sector. On the positive side, the health sector has fared relatively well in the area of mobility within Canada. Physicians and other regulated health care providers generally enjoy a high degree of mobility. Portability of hospital and medical benefits is largely ensured through interprovincial eligibility and portability agreements. There are, however, two areas of concern. First, there is the longstanding failure to resolve the non-portability of medical benefits for Quebec residents. Second, there is growing disparity in coverage for services that are currently not subject to national standards under the Canada Health Act, particularly prescription drugs and home care. In the area of dispute avoidance and resolution, governments have agreed to a formal process to address concerns with the Canada Health Act. This is a positive step, though few details have been made public. The real test will be whether this new process accelerates the resolution of non-compliance issues (most of which, as the Auditor-General recently pointed out, have remained unresolved for five years or longer), and whether the federal government will have the political will to levy discretionary penalties for non-compliance. There has also been progress on public accountability and transparency as governments have begun reporting results in 14 health indicator areas pursuant to the September 2000 health accord. The CMA is disappointed, however, that governments did not fulfil their pledge to involve stakeholders at all levels in the development of these indicators. Moreover, governments have short-changed Canadians by not providing them with a national roll-up of indicators that would facilitate comparisons across jurisdictions. Looking to the future, it will be critical to put in place a process that moves from benchmarks (indicators) to the bedside (best practices, better outcomes). This must be done in collaboration with health care researchers, providers and health managers—those individuals who understand the importance of taking research and importing it into practice. Clinical researchers across the country are doing this work and must to be supported. Overshadowing these relative successes in the first three years of the Social Union Framework Agreement are three key challenges that must be addressed: * inadequate institutional mechanisms to improve accountability across the system * failure to reduce uncertainty about what the health system will deliver, now and into the future * resistance on the part of governments to engage stakeholders in a true partnership for health system renewal The CMA is concerned that if these fundamental weaknesses are not addressed, they will undermine future attempts to renew Canada’s health system. Improving accountability With the adoption of SUFA, governments have significantly increased emphasis on performance measurement and public reporting. While this is a positive development, it also has the potential to lead towards information overload and paralysis, unless two critical elements are addressed. First, there is a need for a clear accountability framework that sets out the roles, rights and responsibilities of all key players in Canada’s health system: patients, health care providers and governments. This, in turn, requires the creation of a credible arm’s length institution to monitor compliance with this framework and rise above the fray to give Canadians the straight goods on health care. One has to look no further that the recent rekindling of the so-called “shares debate” between the federal and provincial governments as an example of why these changes are necessary. Reducing uncertainty Over the past decade, Canada’s health system has been plagued by an escalating crisis of uncertainty. Patients have faced increasing uncertainty about the accessibility and timeliness of essential health care services. Health care providers have seen working conditions deteriorate. Employers and private insurers have seen their contribution to funding health services increase unpredictably as governments have scaled back their funding commitments. Furthermore, provincial and territorial governments have had to contend with an unstable federal funding partner. Canadians deserve better. They need more certainty that their public health system will care for them when they need it most. They need more transparency from governments about “what’s in” and “what’s out” in terms of public or private coverage. They need their governments to act on their SUFA undertaking to make service commitments for social programs publicly available such as establishing standards for acceptable waiting times for health care. And they need governments to follow through with their SUFA commitment to ensure stable and adequate funding for the health system and other social programs. Fostering real partnerships In the health care field, deliberations and agreements have taken place behind closed doors and governments have discounted the role that non-governmental organizations and citizens should play in decision-making. It is these very providers and patients who are expected to implement and live with the results of such cloistered decision-making. The consequences of this systematic exclusion are all too evident in the current critical and growing shortages of physicians, nurses and other health professionals. If we are to achieve the vision of a sustainable Medicare program, it is critical that governments come clean on their SUFA commitment to work in partnership with stakeholders and ensure opportunities for meaningful input into social policies and programs. CMA’s Prescription for Sustainability – Building on SUFA The Social Union Framework Agreement has created the necessary, but not sufficient, conditions for health system renewal. It has codified the emerging consensus on federal-provincial relations and has clarified the "rules of the game". However, it is an enabling framework that is of limited value in the health sector unless it is given life through institutional mechanisms that establish enduring partnerships not just between governments, but between governments health care providers, and patients. In its final submission to the Commission on the Future of Health Care in Canada entitled “Prescription for Sustainability”, the CMA proposes the implementation of three integrated “pillars of sustainability” that together would improve accountability and transparency in the system: a Canadian Health Charter, a Canadian Health Commission, and federal legislative renewal. Canadian Health Charter A Canadian Health Charter would clearly articulate a national health policy that sets out our collective understanding of Medicare and the rights and mutual obligations of individual Canadians, health care providers, and governments. It would also underline governments’ shared commitment to ensuring that Canadians will have access to quality health care within an acceptable time frame. The existence of such a Charter would ensure that a rational, evidence-based, and collaborative approach to managing and modernizing Canada’s health system is being followed. Canadian Health Commission In conjunction with the Canadian Health Charter, a permanent, independent Canadian Health Commission would be created to promote accountability and transparency within the system. It would have a mandate to monitor compliance with and measure progress towards Charter provisions, report to Canadians on the performance of the health care system, and provide ongoing advice and guidance to the Conference on Federal-Provincial-Territorial ministers on key national health care issues. Recognizing the shared federal and provincial/territorial obligations to the health care system, one of the main purposes of the Canadian Health Charter is to reinforce the national character of the health system. Federal legislative renewal Finally, the CMA’s prescription calls for the federal government to make significant commitments in three areas: 1) a review of the Canada Health Act, 2) changes to the federal transfers to provinces and territories to provide increased and more targeted support for health care, and 3) a review of federal tax legislation to realign tax instruments with health policy goals. While these three “pillars” will address the broader structural and procedural problems facing Canada’s health care system, there is many other changes required to meet specific needs within the system in the short to medium term. The CMA’s Prescription for Sustainability provides specific recommendations in the following key areas: * Defining the publicly-funded health system (e.g. a more rational and transparent approach to defining core services, a “safety valve” if the public system fails to deliver, and increased attention to public health and Aboriginal health) * Investing in the health care system (e.g. human resources, capital infrastructure, surge capacity to deal with emergencies, information technology, and research and innovation) * Organization and delivery of services (e.g. consideration of the full continuum of care, physician compensation, rural health, and the role of the private sector, the voluntary sector and informal caregivers) Conclusion On balance, the Social Union Framework Agreement has been a positive step forward for social policy in Canada, though its potential is far from being fully realized. The CMA’s proposal for a Canadian Health Charter, a Canadian Health Commission and federal legislative review entail significant changes to the governance of Canada’s health system. These changes would be consistent with the Social Union Framework Agreement and would help “turn the corner” from debate to action on health system renewal. The early, ongoing and meaningful engagement of health care providers is the sine qua non of securing the long-term sustainability of Canada’s health system. Canada’s health professionals, who have the most to contribute, and next to patients – who have the most at stake – must be at the table when the future of health and health care is being discussed. The CMA’s Assessment of the Social Union Framework Agreement ANNEX [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] SUFA provisions CMA assessment Principles 1. All Canadians to be treated with fairness and equity 2. Promote equality of opportunity for all Canadians 3. Respect for the equality, rights and dignity of all Canadian women and men and their diverse needs 4. Ensure access for all Canadians to essential social programs and services of reasonably comparable quality 5. Provide appropriate assistance to those in need 6. Respect the principles of Medicare: comprehensiveness, universality, portability, public administration and accessibility 7. Promote the full and active participation of all Canadians in Canada’s economic and social life 8. Work in partnership with stakeholders and ensure opportunities for meaningful input into social policies and programs 9. Ensure adequate, affordable, stable and sustainable funding for social programs 10. Respect Aboriginal treaties and rights [#4] Progress towards the objective of ensuring access to essential health services of reasonably comparable quality is difficult to assess. First, there is no agreed-upon definition of essential health services. Second there the development of indicators and benchmarks of health care quality is still in its infancy. However, the CMA is very concerned that the system is not headed in the right direction, with growing shortages of physicians, nurses and other health care providers. According to Statistics Canada’s recently released survey on access to health care services, an estimated 4.3 million Canadians reported difficulties accessing first contact services and approximately 1.4 million Canadians reported difficulties accessing specialized services. [#6]Although there is broad support for the five principles of Medicare, there continue to be a number of longstanding violations of Canada Health Act that are not being addressed, including the portability of medical benefits for Quebec residents. The emergence of privately-owned clinics that charge patients for medically-necessary MRI scans is also cause for concern. [#8] There is no formal, ongoing mechanism for input from stakeholders and the individual Canadians in debates about national health policy issues. (See also #17 below). [#9] Ensuring adequate, affordable, and stable funding for Canada’s health system is essential to its long-term sustainability. During the 1990s, billions of dollars were siphoned out of the system to eliminate government deficits. To put Medicare back on a sustainable path, governments must make long-term funding commitments to meet the health care needs of Canadians. The CMA has recommended that the federal government should significantly increase its financial contribution to restore the federal-provincial partnership in health care, and increase accountability and transparency through a new earmarked health transfer. Mobility within Canada 11. Removal of residency-based policies governing access to social services 12. Compliance with the mobility provisions of the Agreement on Internal Trade [#11] Residency-based policies are generally not an issue for physician and hospital services, where inter-provincial portability is guaranteed through reciprocal billing arrangements. As noted above, however, the portability of medical benefits for many Quebec residents is limited because the province only reimburses out-of-province services at home-province (as opposed to host-province) rates. [#12] Regulatory authorities initiated work towards meeting the obligations of the Labour Mobility Chapter of the Agreement on Internal Trade in fall 1999. A Mutual Recognition Agreement has been developed and endorsed by all physician licensing authorities. Public accountability & transparency 13. Performance measurement and public reporting 14. Development of comparable indicators to measure progress 15. Public recognition of roles and contributions of governments 16. Use funds transferred from another order of government for purposes agreed and pass on increases to residents 17. Ensure effective mechanisms for Canadians to participate in developing social priorities and reviewing outcomes 18. Make eligibility criteria and service commitments for social programs publicly available 19. Have mechanisms in place to appeal unfair administrative practices 20. Report publicly on appeals and complaints [#13-14] Pursuant to the September 2000 Health Accord, the federal government and provinces have developed common health indicators in 14 areas and have released a first slate of reports. However, the usefulness of these reports is hampered by missing data elements on quality of care (access and waiting times in particular) and the absence of a national roll-up to facilitate inter-provincial comparisons. [#15] Continuing federal-provincial bickering about shares of health funding makes it clear that this provision is not being met. [#16] The CMA’s analysis of the Medical Equipment Fund found that incremental spending by provinces on medical technology accounted for only 60% of the $500 million transferred by the federal government for this purpose. [#17] There is no mechanism in place to ensure ongoing input from Canadians and health care providers in national health policy development. The CMA has recommended the creation of a Canadian Health Commission, with representation from the public and stakeholders to provide advice and input to governments on key national health policy issues. [#18] Although there have been proposals to this effect in a couple of provinces, governments currently do not make explicit commitments about the quality and accessibility of health services. In order to reduce the uncertainty Canadians are feeling with respect to Medicare, the CMA has recommended the creation of a Canadian Health Charter that would set out the rights and responsibilities of patients, health care providers and governments. In particular, the health charter would require all governments to set out care guarantees for timely access to health services based on the best available evidence. [#19-20] The Auditor-General recently reported that Health Canada provides inadequate reporting on the extent of compliance with the Canada Health Act. Governments working in partnership 21. Governments to undertake joint planning and information sharing, and work together to identify priorities for collaborative action 22. Governments to collaborate on implementation of joint priorities when this would result in more effective and efficient service to Canadians. 23. Advance notice prior to implementation of a major policy or program change that will substantially affect another government 24. Offer to consult prior to implementing new social policies and programs that are likely to substantially affect other governments. 25. For any new Canada-wide social initiative, arrangements made with one province/territory will be made available to all provinces/territories. 26. Governments will work with the Aboriginal peoples of Canada to find practical solutions to address their pressing needs [#21-25] The requirement for governments to work together collaboratively is perhaps the most important part of SUFA, yet there it is impossible for organizations and individuals outside of government to assess the degree to which these provisions have been met. This so-called “black box of executive federalism” is not serving Canadians well. In the health sector, there are too many examples of governments developing policy and making decisions with little or no input from those who will ultimately have to implement change. To achieve a true social union, the tenets of good collaborative working relationships – joint planning, advance notice and consultation prior to implementation – must be extended beyond the ambit of federal-provincial decision-making. The CMA’s proposal for a Canadian Health Commission would go some distance in addressing these concerns. A key part of its mandate would be to bring the perspective of health providers and patients into national health policy deliberations and decision-making. Federal spending power 27. Federal government to consult with P/T governments at least one year prior to renewal or significant funding changes in social transfers 28. New Canada-wide initiatives supported by transfers to provinces subject to: a) collaborative approach to identify Canada wide objectives and priorities b) Agreement of a majority of provincial governments c) Provincial discretion to determine detailed design to meet agreed objectives d) Provincial freedom to reinvest funding in related area if objectives are already met e) Jointly developed accountability framework 29. For new Canada-wide initiatives funded through direct transfers to individuals or organizations, federal government to provide 3-months notice and offer to consult [#27-28] There have been three new Canada-wide health initiatives supported by the federal spending power: the $500M Medical Equipment Fund, the $800 Primary Health Care Transition Fund and the $500M fund for health information technology. The Medical Equipment Fund was created to respond to a genuine need for more modern diagnostic and treatment equipment. However, objectives were vague, money was transferred with no strings attached, and there was no accountability framework. The result, as the CMA’s analysis has shown, is that a significant portion of the funding did not reach its destination. The jury is still out in the case of the Primary Care Transition Fund. Delivery of this program through normal government machinery will entail a higher degree of accountability than in the case of the Medical Equipment Fund. However, objectives of this initiative may be too broad to have a significant steering effect on the system as a whole. Canada Infoway Inc. is an arm’s length body created by the federal government to disburse the $500M in health information technology funding. While this model has the advantage of being less politicized than government-run programs; accountability to Parliament and to Canadians is weaker. Dispute avoidance & resolution 30. Governments committed to working together and avoiding disputes 31. Sector negotiations to resolve disputes based on joint fact-finding, including the use of a third party 32. Any government can require a decision to be reviewed one year after it enters into effect 33. Governments will report publicly on an annual basis on the nature of intergovernmental disputes and their resolution [#30-33] Federal and provincial governments have agreed to a formal dispute avoidance and resolution process under the Canada Health Act. The Canadian Health Commission recommended by the CMA could play a useful role as an independent fact-finder. Review of SUFA 34. By the end of the 3rd year, governments will jointly undertake a full review of the Agreement and its implementation. This review will ensure significant opportunities for input and feedback from Canadians and all interested parties, including social policy experts, the private sector and voluntary organizations. [#34] Governments have taken a minimalist approach to the SUFA review by opting for an internet-based consultation and closed meetings with invited external representatives. This approach is not sufficient. Future reviews should be more inclusive of all stakeholders. [TABLE END]
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