The major diseases affecting the quality and quantity of life of Canadians, which include obesity, diabetes, coronary artery disease, depression and cancer, are all linked to physical inactivity. In Canada, 69% of women and 68% of men in Canada are considered physically inactive.(1) The cost of this inactivity and obesity was estimated at $4.3 billion in 2001.(2) A 10% increase in physical activity could potentially reduce direct health care expenditures by $150 million a year. This does not include indirect costs such as lost productivity due to illness, premature death or a range of other factors, including mental illness and poor quality of life.(3)
Thus far, efforts to increase physical activity by changing the behaviour of individuals have had limited success. One reason is that many people have difficulty sustaining behaviours that involve additional time commitments. That is one reason for the increasing emphasis being placed on active transportation, which is any human-powered form of transportation, such as walking and cycling.
Walking and cycling can be efficient alternatives to automobile travel. Cycling is usually the fastest mode of travel door to door for distances under five km, and for up to 10 km in city cores. Walking is simpler and nearly as fast for distances up to two km. When travel times are similar for active and motorized transportation, physical activity is gained with no net time lost, and at much lower cost. The cost of operating a motor vehicle is typically $10,000 per year,(4) while operating costs for a bicycle are much lower.
Communities that have sidewalks, enjoyable scenery, street lights and nearby stores have improved levels of active transportation and physical activity. However, in recent decades communities have often been designed around the automobile. Street design, parking space, sidewalks and distance to retail destinations have all been planned assuming motorized transportation, and this often makes it difficult to move around communities by walking or cycling.
Although individual decision-making remains important in any strategy for increasing active transportation, there is an essential role for communities and governments to play. Major improvements in the health of Canadians in the past 200 years have been due to improved sanitation, access to clean water and injury prevention. The role of individual decision-making in effecting these changes is dwarfed by the impact of the public health measures and infrastructure involved. Just as potable tap water is a health issue, so are decisions about land use, transportation policy and infrastructure.
Community design is a major determinant of whether people use active transportation, whether they are physically active and whether they are obese. Canadians need communities that make it easy to be physically active in their daily living.
Communities can create an environment in which the physically active choice is the easy choice. They can do this via sidewalks, trails, bicycle lanes and bicycle paths, and by providing pedestrian-friendly intersections, parks and green spaces, and safe bicycle parking spaces. They can also arrange zoning so that retail destinations are within walking or cycling distance of residential areas. This process also includes dedicating a sufficient portion of their street maintenance budget (including snow clearing) to maintaining active transportation routes as well as routes for motorized vehicles. It may include redesigning intersections, giving up vehicle lanes or parking spaces, or increasing the price of parking.
Additional benefits to designing communities for pedestrians and cyclists.
* a stronger sense of community with greater civic involvement by citizens
* increased property values and retail activity
* less noise pollution
* lower crime rates
* less smog and other air pollution
* less greenhouse gas production
* decreased risk of injury to pedestrians and cyclists
* decreased costs of roadway and parking construction.
A role for everyone
Other sectors can support communities in making active transportation choices easy choices:
* Businesses can create a work environment friendly to active transportation, including a corporate culture friendly to physical activity. They can incorporate active transportation planning into building design and create an environment friendly to physical activity. These steps could include making bicycle parking, showers and lockers available, and providing stairs that are pleasant and easier to access than elevators. They can also incorporate a culture of physical activity in decisions about where and how to hold meetings, and what people are allowed to wear to work.
* School boards can develop policies to promote active transportation to and from school. These include building and maintaining secure bicycle parking, ensuring safe walking routes within communities, and assisting parents in walking their children to school.
* Citizens can use active transportation themselves and treat with respect those who are already making active transportation choices. They can also lobby governments to make their community safer and easier places for cycling and walking.
* Physicians can encourage patients to use active transportation as a way to boost their physical activity levels and improving their health. They can also lead by example and use active transportation themselves.
The CMA recommends that all sectors (government, business and the public) work together, as a matter of priority, to create a culture in their communities that supports and encourages active transportation.
The CMA urges governments to:
* Commit to long-term plans for active transportation networks that are in keeping with these goals and that include specific benchmarks to measure progress.
* Require that active transportation be part of all infrastructure renewal projects, with investment in active transportation vs. motorized transportation in proportion to targeted active transportation use. (Some cities have achieved active transportation rates of up to 15%.)
* Develop an awareness campaign to help Canadians to recognize the value of active transportation in their communities.
* Require public health impact assessments for all land-use and transportation decisions, including the impact on the chemical environment and on physical activity.
* Assess the impact that changes in the "built" environment can have on public health, and which interventions are most safe and effective.
1 Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in overweight and obesity in Canada, 1981-1996. Int J Obes Relat Metab Disord 2002;26(4):538-43.
2 Katzmarzyk PT, Janssen I. The economic costs associated with physical inactivity and obesity in Canada: an update. Can J App Phys 2004;29(1):104.
3 Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada. CMAJ 2000;163(11): 1435-40.
4 Canadian Automobile Association. Driving Costs: 2005 Edition. Available: www.carpool.ca/pdf/CAA-driving-costs-05.pdf (accessed 2007 Feb. 2).
Flexibility in Medical Training (Update 2009)
The Canadian Medical Association (CMA) believes that the medical training system must be sufficiently flexible to enable medical students to make informed career choices, accommodate resident program changes, and allow practising physicians the opportunity to re-enter training to enhance their skills and knowledge, or to enter a new sphere of practice. The system must also be able to accommodate international medical graduates (IMGs) to provide them with a reasonable opportunity to attain their postgraduate credentials and become licensed to practise in Canada. For physicians-in-training, effective career guidance and positive influences on career options (e.g., role modelling, early clinical exposure, etc.) may foster confidence with career path selection and minimize program changes during residency. A flexible and well-designed re-entry postgraduate system would be characterized by: long-term stability, sufficient and appropriate capacity, accessibility, flexibility in the workforce and accountability.
The CMA believes that, ultimately, society benefits from a flexible medical training system. These benefits may include enhanced patient care, improved access to physician services, as well as physician retention, particularly in rural and remote communities. A flexible system may also improve morale and satisfaction among students, residents and physicians, and facilitate better career choices. This policy outlines specific recommendations to help create and maintain a well-designed system for flexibility in physician training in Canada. Commitment and action by all stakeholders, including governments, medical schools, regulatory authorities and others, is required.
The CMA believes that this policy must be considered in the context of other relevant CMA policies, including but not limited to the CMA's policies on physician resource planning, physician health and well-being, physician workforce issues and others.
- Postgraduate trainee - Also known as a "resident," an individual who has received his/her MD degree and is currently enrolled in an accredited program in a Canadian school of medicine that would lead to certification by either the College of Family Physicians of Canada or the Royal College of Physicians and Surgeons of Canada.
- Medical student - An individual enrolled in an undergraduate program in a Canadian school of medicine that would lead to an MD degree.
- International medical graduate - An individual who received his/her MD degree from a training program other than from one of Canada's undergraduate schools of medicine.
- Designated positions - Postgraduate positions within the determined complement of residency positions that are identified to meet a need other than that of accommodating the annual number of new graduates of Canadian medical schools to complete the usual training for certification and licensure. Designated positions may be identified for a variety of purposes.
The need for informed career decision-making and positive influences
Choice of practice discipline as lifelong career can be one of the most difficult aspects of physician training. Exacerbating this challenge are the vast array of available specialties, timing of choices, as well as practice considerations in terms of lifestyle and physician resource needs. The rapidly changing face of medical practice as well as the limited amount of information and time available to consider options, are also contributing factors.
A number of other forces, both positive and negative, may affect students' choices of practice specialty. These can include financial considerations in light of student debt incurred by high tuition fees and insufficient financial support. 12 The biases of faculty, family and others may also impact decisions. In addition, limited training opportunities in general, as well as a lack of flexibility to switch training programs, may also restrict choice of practice specialty. While a myriad of personal factors are acknowledged to also play contributing roles in influencing program selection, these issues are too complex to discuss here. Ultimately, students need to have access to financial support so as to reduce stress and the influence of debt on specialty choice. They also need objective information and guidance and broad clinical experiences early in their medical training as this has been identified as a critical factor in making decisions about their future careers.3
The rotating internship, abolished in the early 1990s, used to permit residency selection at a later stage in medical training. The residency program match now takes place during the final year of undergraduate studies. As a consequence of this earlier timing, some students feel pressured to make their specialty choice too early in their medical education and often before their clerkship has even begun. This can include focusing research and program electives4 in one specific area, rather than sampling a broad range of disciplines, to demonstrate conviction of choice to residency program directors at the time of the match. Fifty-nine percent of respondents to the Canadian Resident Matching Service's (CaRMS) 2006 post-match survey indicated they completed more than half of their electives in their first-choice discipline.5 This, combined with the early timing of the residency match, can lead to an uninformed choice of residency program and the realization, at a later date, that a different training program would be more suitable. Eighty percent of medical leader respondents to the 2008 Core Competency Project survey indicated that timing of career choice was the biggest challenge for career decision-making.6
Those residents who wish to change to new training programs may not believe they have the opportunity to do so. Thirty-seven percent of resident respondents to the Core Competency Project survey considered switching disciplines during their residency training7 and 39% had spoken to a faculty member about switching programs.8 Others who do change programs are ultimately delayed entry into the workforce as a result of their prolonged training. This problem is exacerbated by an insufficient number of re-entry postgraduate training positions and large debt that confine trainees to a single career path.
Lack of student confidence and preparedness in choosing a postgraduate training program, or lack of success in achieving a first choice in the postgraduate match, may predict subsequent program changes. A broad range of strategies must be available to help medical students make informed career choices. These include a wider choice of electives at an earlier stage of training, positive and unbiased mentoring experiences, improved access to career information from residents, as well as career seminars and other resources.
In light of the above, the CMA recommends that:
1. the undergraduate medical school curriculum be re-designed to facilitate informed career choice and, in particular, to ensure that students enjoy a broad range of clinical experiences before they have to choose a specific discipline (i.e., via CaRMS match);
2. national career counselling curricula for both medical students and residents be developed and include the following components: national standardization; stakeholder input (students, residents and others); positive and fair role modelling by both residents and practising physicians/faculty, with appropriate professional respect among medical disciplines; and formal and informal mentorship programs;
3. a wide-range of elective opportunities be developed and communicated at a national level;
4. electives reflect a broad spectrum of experiences, including community-based opportunities;
5. clinical experiences be introduced at the earliest possible stage of undergraduate learning;
6. a national policy be implemented to ensure mandatory diversification of student elective experiences; and
7. medical schools be permitted and encouraged to model alternate systems of postgraduate learning.
The need for broad-based medical education
In order to provide medical students with the greatest options for flexibility in medical training, they should be actively encouraged to pursue a broad-based medical education. Previously, CMA advocated for a common postgraduate year (PGY1). In the 2008 Core Competency Project survey, 77% of physician respondents, 70% of medical student respondents and 67% of program director respondents expressed support for first year residents to do a broad-based common PGY1-like rotating internship.9 The rationale for and importance of ensuring flexibility has been outlined in the previous sections.
Capacity of the postgraduate training system
An essential component in ensuring flexibility within the medical training system is to establish and maintain sufficient capacity at the postgraduate training level. This is necessary for the following reasons:
* Sufficient capacity may prevent highly-skilled and well-trained Canadian physicians from being forced to seek postgraduate training in the U.S. and remain there to practise medicine.
* It is necessary to provide IMGs with a reasonable opportunity to attain their postgraduate credentials and become licensed to practise in Canada. This reflects the CMA's recognition of the important contribution that IMGs have made, and continue to make, in the provision of medical services, teaching and research in Canada. Opportunities for IMGs will also permit Canadians who study medicine abroad to pursue their medical careers in Canada.
* It is essential to provide students with sufficient choice to seek the training that best matches their skills and interests as well as societal demands.
* It is crucial to provide sufficient re-entry positions to allow practising physicians to seek training in other areas of medicine to meet the demands of their communities. [Please refer to the "Re-entry" section of this policy for more details.]
In light of the above, the CMA recommends that:
8. mechanisms be developed to permit reasonable movement of residents within the overall residency structure and career counselling supports be made available to residents considering such a change;
9. the capacity of the postgraduate training system be sufficiently large to accommodate the needs of the graduating cohort, the re-entry cohort, and the training needs of international medical graduates;
10. there be a clearly defined pool of re-entry postgraduate positions and positions for international medical graduates;
11. government match and maintain undergraduate medical enrolment with a target of at least 120 ministry-funded postgraduate training positions per 100 Canadian medical graduates, to accommodate the training needs of the graduating cohort, the re-entry cohort and international medical graduates; and
12. options be explored for influencing governments to support a flexible postgraduate medical education system that also meets societal needs.
Re-entry medical training system
Note: This section addresses only one kind of designated position, specifically, those for licensed physicians wishing to re-enter training after a period in practice (also known as "re-entry positions"). The re-entry positions addressed in this paper would require no return for service. Designated positions for training in return for service in a specified discipline and location is a separate entity from general re-entry.
Increased opportunity for exposure to the breadth of medical fields in undergraduate training, improved undergraduate career counselling and a postgraduate system that makes the changing of disciplines easier are some of the many aspects that should facilitate residents' satisfaction with career choice. There will, however, inevitably be individual cases where issues of societal need, personal health, lifestyle or personal choice necessitate a change in career direction after postgraduate training. This requires the availability of additional postgraduate positions allotted specifically to this sub-set.
A sufficient and stable supply of re-entry positions is needed within the postgraduate training system to enable practising physicians to enhance their skills or re-enter training in another discipline. While this may apply mostly to family physicians and general practitioners wishing to train in a specialty discipline, it can also include practising specialists wanting to sub-specialize or train in another area, which could be Family Medicine.
The additional or new training of primary care physicians, particularly in obstetrics, emergency medicine, anaesthesia, surgery, psychiatry and general internal medicine, will be of benefit to smaller communities lacking regular access to these specialty medical services. In addition, the availability of adequate re-entry positions may encourage new physicians to accept locum tenens, thus relieving overworked physicians in underserviced communities. Potentially, it could help to increase a community's long-term retention rate of established physicians.
The CMA believes that a well-designed re-entry system for Canadian postgraduate medical education would be characterized by an accessible national registry, long-term stability, sufficient and appropriate capacity, accessibility, flexibility in the workforce and accountability.
Medical students need reassurance that re-entry positions will be available if they wish to re-enter training after a period in practice. This will enable them to better plan their careers, reduce anxieties about career selection and ultimately help to meet the health care needs of society. For physicians re-entering the postgraduate training system, there must also be the guarantee that sufficient program funding will be available to ensure completion of training.
The CMA therefore recommends that:
13. a complement of clearly defined, permanent re-entry positions with stable funding be a basic component of the Canadian postgraduate training system and that the availability of these positions be effectively communicated to potential candidates; and
14. funding for re-entry positions be specifically allocated for the entire training period.
The CMA believes that the capacity of the postgraduate training system must be sufficiently large to accommodate the needs of the re-entry cohort and that postgraduate re-entry positions should be supernumerary to the numbers required for the graduating cohort. [Please refer to the "Capacity of the Postgraduate Training System" section of this policy for specific recommendations.]
The CMA believes that re-entry physicians should not be restricted to competing for particular disciplines for which there is an identified need in their jurisdiction. Re-entry physicians should also be able to compete for any available disciplines across all training programs. Not every discipline will be available for re-entry each year but all should be accessible over the course of a three-year period.
The CMA therefore recommends that:
15. there be accessibility within re-entry postgraduate training positions including:
* open and fair competition at the national level among all re-entry candidates for the clearly defined pool of re-entry positions,
* that the mix of positions available reflect the overall mix of positions in the postgraduate training system, and
* recognizing the limited size of the re-entry pool, access to all specialties be available over a three-year period rather than on an annual basis; and
16. access to entry should be possible through both national and regional pools of re-entry positions, with a process comparable to that currently used for the postgraduate training system.
Flexibility in the Workforce
As previously mentioned, the re-entry positions discussed in this paper would require no return for service. Designated positions for training in return for service in a specified discipline and location is a separate entity from general re-entry.
The CMA therefore recommends that:
17. physicians who have retrained through the re-entry system have the same practice opportunities as physicians entering the workforce for the first time.
The CMA recognizes the importance of public accountability and sound fiscal management and therefore recommends that:
18. there be on-going evaluation of the re-entry system in Canadian postgraduate medical education.
1 Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE & IL Johnson. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002; 166 (8): 1023-8.
2 2007 National Physician Survey Data.
3 Directions for Residency Education, 2009 - A final report of the Core Competency Project. February 2009. Royal College of Physicians and Surgeons of Canada and College of Family Physicians of Canada.
4 Ibid, page 23.
6 Ibid, page 59.
7 Ibid, page 27.
8 Ibid, page 60.
TUITION FEE ESCALATION AND DEREGULATION IN UNDERGRADUATE PROGRAMS IN MEDICINE (Update 2009)
The Canadian Medical Association (CMA) is very concerned about high and rapidly escalating, undergraduate medical school tuition fees across Canada. Ontario set a precedent for the deregulation of tuition fees in May 1998 and many provinces have since followed. This policy gives universities, including medical schools, the discretion to set fees for training in those areas that lead to professional careers, such as medicine. For the 2008-2009 academic year, first-year tuition fees at most Ontario medical schools were triple the tuition fees in 1997-1998 at an average of $16,550 per year;1 this figure does not include compulsory "other fees" that can be as much as $1,700 per year.2 Irrespective of whether tuition fees have been regulated, some medical schools outside of Ontario have doubled their tuition fees within the same time period. Decreased government funding to universities is increasing the fiscal pressures on institutions and is driving these dramatic tuition fee increases. The CMA believes that high tuition fees, coupled with insufficient financial support systems, have a significant and detrimental impact on not only current and potential medical students, but also the Canadian health care system and public access to medical services.
Broad Effects of High Tuition Fees
Lack of Diversity
Medical education in Canada has traditionally been affordable and accessible to individuals from a range of socioeconomic and ethnic groups who later serve an equally diverse population. Unfortunately, the introduction of high tuition fees may close the door to individuals who either cannot afford the high costs of a medical education or wish to avoid the prospect of significant debt load upon graduation. High tuition fees may therefore create an imbalance in admissions to medical school by favouring those who represent the affluent segment of society and not the variety of groups reflected in the Canadian population. The proportion of medical students from lower income families is already extremely low and decreasing further.3 Paradoxically, funds that should be injected to making tuition fees reasonable - and therefore more accessible by a broader range of society - may soon need to be allocated to creating career promotion and special financial support programs that target those groups that have been alienated by high tuition fees.
Influence on Practice Choice and Practice Location ("Brain Drain")
It is likely that paying off debts as quickly as possible will become a key consideration when determining practice location and specialty. For instance, more students may feel compelled to maximize their earning potential by pursuing those specialties that generate high incomes; others may choose those specialties with short training periods so they can enter the workforce and start to pay off debts sooner.
Debt load may also influence where graduating physicians choose to practise medicine. The increasing willingness of American recruiters to pay off the debts of new graduates provides tremendous incentive to practise in the U.S. and explore research opportunities; unfortunately, it only aggravates the ongoing problem of the "brain drain" of Canadian physicians.4 While we have been enjoying a net gain of physicians from the U.S., we may experience net loss with physician shortages expected in the U.S. More physician retention and recruitment initiatives are needed to encourage physicians to remain in or return to Canada. This is especially true for rural and remote communities. Urban areas are often in a better financial position to offer incentives to new graduates than rural and remote communities where physician shortages are most pronounced.
Effects on Rural and Remote Areas
The CMA believes that governments must be made aware of the potentially negative impact of high tuition fees and student debt on physician workforce supply for the rural and remote areas of Canada. Research shows that medical students from rural and remote areas have a greater likelihood of returning to these communities to practise medicine.5 Research also shows that students of rural origin have higher student debts6 and are underrepresented in Canadian medical schools.7 Students from rural and remote communities face the challenge of not being able to live at home while they attend university. They must assume high relocation expenses and travel costs, as well as separation from their families while they are away at school. Of student respondents to the 2007 National Physician Survey, 53.1% of rural students compared with 67.4% of urban medical students had no debt upon entering medical school. When asked to predict their expected debt upon completion of medical school, 33.2% of rural students compared with 23% of urban students expected their debtload to exceed $100,000.8 Unfortunately, the introduction of high tuition fees might make both the personal and financial costs of pursuing a medical education too significant for students from rural and remote areas to even consider. As a result, this may generate fewer physicians willing to practise in these areas and exacerbate the problem most rural and remote communities already face in attracting and retaining physicians. High tuition fees might also further increase the reliance on international medical graduates in rural and remote communities. While the CMA values the contributions of international medical graduates in alleviating shortages in physician supply, it believes that Canadian governments must adopt the guiding principle of self-sufficiency in the production and retention of physicians to meet population needs.
Effects on New and Potential Medical Students
Medical students affected by high and escalating tuition fees will graduate with unprecedented debt loads. Enormous education costs, already a reality in some provinces, are a growing trend. In 2007, over one third (36%) of students said they expected debtloads of $80,000 or more upon completion of medical school.9
A number of factors, as highlighted below, contribute to students' financial burden and may affect their ability to pay off debts and meet financial obligations. This, in turn, may influence their choice of medical discipline and practice location. Exorbitant education costs may also result in students considering dropping out of, or taking longer to complete, their medical studies because they cannot afford the ongoing costs, or are too overwhelmed with the combined stress of their medical studies and trying to make financial ends meet. The CMA is very concerned that excessive debt loads will exacerbate the stress already experienced by medical students during their training and will have a significant and negative impact on their health and well-being.
Previous Education Debt and Accumulative Debt
Most Canadian medical schools make an undergraduate degree a prerequisite to application. As such, by the time most students are accepted into medical school, they may have already accumulated debt from a previous undergraduate degree. Many students have also completed postgraduate degrees before entering medical school.10 This debt continues to accumulate during the undergraduate years of medical school and into the postgraduate training period, which is anywhere from two years to seven years in duration. This does not include additional time spent doing fellowships. It may be very useful to establish a national clearinghouse of public and private financial assistance programs to help students in their search for financial support.
Limited or No Employment Opportunities during Undergraduate Training
Tuition fees, along with ongoing increases in living expenses, are already making it very difficult for some students to make ends meet. It makes matters worse that there are limited or no opportunities to generate income through employment during the academic year and the summer months. Given the intensity of the medical school program, some schools strongly advise against working part time. To further compound the problem, some schools have very short summer breaks. For those schools that do provide summer holidays, the holidays often start later than other university programs, by which time employment opportunities are scarce or low paying. There is also the common expectation that medical students will undertake unpaid clinical or research elective experiences during the summer to enhance their desirability for postgraduate medical programs.
Limited or No Remuneration for the Clinical Clerkship
During the clerkship years, there are no summertime breaks because students spend these years working in hospitals and other clinical settings. All Canadian medical students (outside of Québec) receive a relatively small stipend during their clerkship varying from $2,808 to $6,000;11 however, the stipend had previously been abolished in medical schools in Ontario and Québec in the early 1990s. Fortunately Ontario reinstated the stipend as the Final Year Medical Student Bursary in 2004.12
In addition to very limited or no opportunities to generate employment income, medical students must bear a number of unique and significant costs. These include very high textbook and instrument costs, as well as a variety of expenses associated with their clerkship, such as travel to and from the clinical setting and the need for professional attire. The introduction of distributed medical education including satellite campuses, co-campuses and rural learning sites has increased the amount of travel required of medical students as well as the associated costs.
Off-site electives also generate many additional expenses, including the cost for travel to the site - which may be in a different province - as well as accommodation and other living expenses. A 1999 survey of graduating medical students revealed that more than half took an off-site elective at a specific institution in order to increase their chances of being matched to that site.13 As postgraduate training becomes even more competitive, the number of students taking off-site electives may increase and so will the number of students who are adding this expense to their overall debt load.
Medical students must also assume considerable costs related to interviews for residency training, including the high costs for travel to various interview sites, accommodation expenses, application fees for the resident matching service and other miscellaneous expenses. There is also a considerable fee for the qualifying examination that is written at the end of medical school.
Insufficient Public Funding and Increasing Reliance on Bank Loans
Government financial support programs (bursaries and loans) are not increasing to meet students' needs due to rising tuition costs and living expenses. As a consequence, the number of students who must rely on interest-bearing bank loans to help support themselves while they are in school may increase. Unlike some government programs, repayment of bank loans often cannot be postponed until after graduation and interest payment is required during the course of study; this further exacerbates students' financial stress.
Upon graduation from medical school, students must pursue two to seven years of postgraduate training to obtain a licence to practise medicine. This training period is marked with fees for examinations as well as an annual tuition and/or registration fee. During 2008-2009, the tuition fee was as much as $3,900 in some provinces.14 Residents are also required to work long hours in hospitals and other clinical settings and have frequent on-call responsibilities. Although residents do receive a salary for this work, the remuneration is relatively modest when these factors and debt servicing payments are considered. In fact, mandatory debt maintenance can consume a very significant proportion of a resident's pay.15 The CMA opposes tuition fees for residents. While the CMA's opposition to residency tuition is based on a number of factors not limited to its financial impact, clearly, tuition fees exacerbate debt.
High Practice Start-up Costs and Decreased Pay Potential
Licensed physicians wanting to establish a clinical practice currently face start-up costs estimated between $30,000 and $50,000, depending on their practice specialty and type (e.g., solo versus group practice).16 Some specialties require capital investment over and above the basic start-up costs. These expenses will add to the significant debt that new physicians will bear in the next few years.
In addition to significantly higher debt load than the previous generation of new physicians, a number of factors may influence the net income of physicians and their ability to pay off debts. These include billing caps, stagnant fees for services, high malpractice insurance fees, overhead expenses and increasing non-remunerative administrative responsibilities.
In summary, the CMA believes that high tuition fees, coupled with insufficient financial support systems, have a significant impact on not only current and potential medical students, but also the Canadian health care system and public access to medical services. This impact includes:
* creating socioeconomic barriers to application to medical school and threatening the diversity of future physicians serving the public
* exacerbating the physician brain drain to the U.S. where new physicians can pay off their huge debts more quickly
* generating fewer physicians available or interested in practising in rural and remote areas of Canada
In response to its concerns regarding the deregulation of tuition fees and high tuition fee increases, the CMA recommends that:
1 governments increase funding to medical schools to alleviate the pressures driving tuition increases
2 any tuition increase should be regulated and reasonable
3 financial support systems for students be developed concomitantly or in advance of any tuition increase, be in direct proportion to the tuition fee increase and provided at levels that meet the needs of students.
Glossary of Terms
Undergraduate Program in Medicine, also known as "Medical School"
Medical school is the period of study, usually four years in duration that leads to the doctor of medicine or "MD" degree upon graduation. Most Canadian universities require applicants to the undergraduate medicine program to have at least a three-year degree (e.g., Bachelor of Science degree) before they are eligible to apply. Although the title "Doctor" is conferred upon successful completion of the undergraduate program, an additional two to seven years or more of residency training is required before these individuals can apply for a licence to practise medicine in Canada.
The clerkship is the period during the last one to two years of undergraduate studies in medicine during which medical students work in hospitals, clinics and physicians' offices.
Many students take off-site electives during their clerkship. An "elective" is a course or training that is not mandatory to the curriculum, but may be elected or chosen by the student. An "off-site" elective means that the training is being provided at a location different from the medical school where the student is enrolled; for example, the elective may be in a different city, province, or even a different country.
During the last year of undergraduate training, most graduating medical students participate in a national process that matches them with available residency training positions in Canada.
Residency/Postgraduate Training Period
After earning his/her MD degree and receiving the title "Doctor," additional training is required in a specific area before an individual may practise medicine in Canada. This period of training is referred to as "residency" or "postgraduate training;" the individuals undergoing the training are called "residents." Residents usually work in hospitals (also called "teaching hospitals") under the supervision of a licensed physician. Depending on the field of study, residency training may range from two to seven years or longer if subspecialty training is pursued (e.g., pediatric cardiology). At the end of residency training, individuals must pass a number of examinations to practise medicine in Canada.
A fellowship is training sought by individuals who wish to obtain expertise in a specific area of medicine above and beyond basic residency requirements.
1 Tuition Fees in Canadian Faculties of Medicine: Session Commencing Fall 2008. Office of Research and Information Services, Association of Faculties of Medicine of Canada, November 2008.
3 Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE & IL Johnson. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002; 166 (8): 1023-8.
4 "Are We Losing Our Minds? Trends, Determinants and the Role of Taxation in Brain Drain to the United States," The Conference Board of Canada, July 1999.
5 Advisory Panel Report on the Provision of Medical Services in Underserviced Regions. Canadian Medical Association, 1992.
6 2007 National Physician Survey.
7 Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL, et al. Characteristics of first-year students in Canadian medical schools. CMAJ 2002;166(8):1029-35. 
8 2007 National Physician Survey.
9 2007 National Physician Survey.
10 "Educational Attainment at Time of Application of Registered and Not Registered Applicants to Canadian Faculties of Medicine - 2006-2007 (Table 105)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p154.
11 "Duration of Clinical Clerkship and Amount of Stipend in Canadian Faculties of Medicine 2008-2009 (Table 7)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p9.
12 Clinical Clerkship Stipends by Faculty of Medicine, 1995-1996 to 1999-2000, Canadian Medical Association Research Directorate, January 2000.
13 Results of the Post-Match Survey of Students Graduating 1999, Canadian Resident Matching Service.
14 "Post-MD Clinical Trainee Fees in Canadian Faculties of Medicine - 2008-2009 (Table 6)." 2008 Canadian Medical Education Statistics. Association of Faculties of Medicine of Canada, Volume 30, p8.
15 2007 National Physician Survey.
16 Practice Management, MD Management Ltd.
Health equity is created when individuals have the opportunity to achieve their full health potential; equity is undermined when preventable and avoidable systematic conditions constrain life choices.1 These conditions are known as the social determinants of health. The World Health Organization (WHO) defines the social determinants of health as the circumstances in which people are born, develop, live and age.2 In 2002, researchers and policy experts at a York University conference identified the following list: income and income distribution; early life; education; housing; food security; employment and working conditions; unemployment and job security; social safety net; social inclusion/exclusion; and health services. 3
Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.4 Any actions to improve health and tackle health inequity must address the social determinants and their impact on daily life.5
THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH STATUS
Social status is one of the strongest predictors of health at the population level. There is a social gradient of health such that those with higher social status experience greater health than those with lower social status. The social gradient is evident not only when comparing the most disadvantaged to the most advantaged; within each strata, even among those holding stable middle-class jobs, those at the lowest end fare less well than those at the higher end. The Whitehall study of civil servants in the United Kingdom found that lower ranking staff have a greater disease burden and shorter life expectancy than higher-ranking staff.6 Differences in medical care did not account for the differences in mortality.7 This gradient has been demonstrated for just about any health condition.8
Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.9 In 2001, people in the neighbourhoods with the highest 20% income lived about three years longer than those in the poorest 20% neighbourhoods (four years for men; two years for women).10 Dietary deficiencies, common in food insecure households, can lead to an increased chance of chronic disease and greater difficulty in disease management. It is estimated that about 1.1 million households in Canada experience food insecurity, with the risk increasing in single-parent households and in families on social assistance.11
Studies suggest that adverse socio-economic conditions in childhood can be a greater predictor of cardiovascular disease and diabetes in adults than later life circumstances and behavioural choices.12 Effective early childhood development offers the best opportunity to reduce the social gradient and improve the social determinants of health,13 and offers the greatest return on investment.14
Low income contributes not only to material deprivation but social isolation as well. Without financial resources, it is more difficult for individuals to participate in cultural, educational and recreational activities or to benefit from tax incentives. Suicide rates in the lowest income neighbourhoods are almost twice as high as in the wealthiest neighbourhoods.15 This social isolation and its effects are most striking in Canada's homeless population. Being homeless is correlated with higher rates of physical and mental illness. In Canada, premature death is eight to 10 times higher among the homeless.16
The gradient in other social determinants can have an adverse impact as well. A study conducted in the Netherlands estimated that average morbidity and mortality in the overall population could be reduced 25-50% if men with lower levels of education had the same mortality and morbidity levels as those men with a university education.17 Employment status also follows this gradient, such that having a job is better than being unemployed. 18 Unemployment is correlated with increased blood pressure, self-reported ill health, drug abuse, and reductions in normal activity due to illness or injury.19 Unemployment is associated with increases in domestic violence, family breakups and crime. Finally, job security is relevant.20 Mortality rates are higher among temporary rather than permanent workers.21
Canada's Aboriginal people face the greatest health consequences as a result of the social determinants of health. Poverty, inadequate or substandard housing, unemployment, lack of access to health services, and low levels of education characterize a disproportionately large number of Aboriginal peoples.22 The crude mortality rate for First Nations is higher and life expectancy lower than the Canadian average.23 Aboriginal peoples experience higher rates of chronic disease, addictions, mental illness and childhood abuse.24 Aboriginal peoples have higher rates of suicide, with suicide being the leading cause of potential years of life lost in both the First Nations and Inuit populations.25
THE SOCIAL DETERMINANTS OF HEALTH AND CANADA'S HEALTH SYSTEM
These differences in health outcomes have an impact on the health care system. Most major diseases including heart disease and mental illness follow a social gradient with those in lowest socio-economic groups having the greatest burden of illness.26 Those within the lowest socio-economic status are 1.4 times more likely to have a chronic disease, and 1.9 times more likely to be hospitalized for care of that disease.27 Chronic diseases such as diabetes account for 67% of direct health care costs and 60% indirect costs.28
Research has shown that Canadians with low incomes are higher users of general practitioner, mental health, and hospital services.29 People in the lowest income group were almost twice as likely as those in the highest income group to visit the emergency department for treatment. 30 Part of this may be caused by differences in access to care. Low-income Canadians are more likely to report that they have not received needed health care in the past 12 months.31 Those in the lowest income groups are 50% less likely than those in the highest income group to see a specialist or get care in the evenings or on weekends, and 40% more likely to wait more than five days for a doctor's appointment.32
Barriers to health care access are not the only issue. Research in the U.K.33 and U.S.34 has found that compliance with medical treatment tends to be lower in disadvantaged groups, leading to pain, missed appointments, increased use of family practice services and increased emergency department visits, and corresponding increases in cost. In the U.S., non-adherence has been attributed to 100,000 deaths annually.35 Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.36
These differences have financial costs. In Manitoba for example, research conducted in 1994 showed that those in the lowest income decile used services totaling $216 million (12.2%). In the same year, those in the highest income decile consumed $97 million (5.5%) of expenditures. If expenditures for the bottom half of the population by income had been the same as the median, Manitoba would have saved $319 million or 23.1% of their health care budget. 37 According to a 2011 report, low-income residents in Saskatoon consume an additional $179 million in health care costs than middle income earners.38
To reduce the burden of illness and therefore system costs, Canada needs to improve the underlying social and economic determinants of health of Canadians. However, until these changes have time to improve the health status of the population, there will still be a large burden of illness correlated to these underlying deficiencies. As a result, the health system will need to be adequately resourced to address the consequences of the social determinants of health.
AREAS FOR ACTION
The WHO Commission on the Social Determinants of Health identified four categories through which actions on social determinants can be taken. These include:
* reducing social stratification by reducing inequalities in power, prestige, and income linked to socio-economic position;
* decreasing the exposure of individuals and populations to the health-damaging factors they may face;
* reducing the vulnerability of people to the health damaging conditions they face; and
* intervening through health care to reduce the consequences of ill health caused by the underlying determinants.39
All of these areas offer possibilities for action by the physician community. The following section provides suggestions for action by the medical profession through: CMA and national level initiatives; medical education; leadership and research; and clinical practice.
CMA and national level initiatives
Despite the strong relationship between the social determinants of health and health, little in the way of effective action has resulted. CMA and its partners can and should, advocate for research and push for informed healthy public policy, including health impact assessments for government policies. Additionally, targeted population health programs aimed at addressing the underlying determinants should be supported.
All Canadians need a better understanding of the health trends and the impacts of various social and economic indicators. Information about the differences in specific health indicators, collected over time,40 is essential to the task of describing underlying health trends and the impacts of social and economic interventions. Data within primary care practices could be assembled into (anonymous) community-wide health information databases, to address this need.
CMA recommends that:
1. The federal government recognize the relationship of the social determinants of health on the demands of the health care system and that it implement a requirement for all cabinet decision-making to include a Health Impact Assessment.
2. Options be examined for minimizing financial barriers to necessary medical care including pharmaceuticals and medical devices necessary for health.
3. Federal and provincial/territorial governments examine ways to improve the social and economic circumstances of all Canadians.
4. Efforts be made to educate the public about the effect of social determinants on individual and population health.
5. Appropriate data be collected and reported on annually. This data should be locally usable, nationally comparable and based on milestones across the life course.
Medical education is an effective means to provide physicians with the information and tools they require to understand the impact of social determinants on the health of their patients and deal with them accordingly.41 In 2001, Health Canada published a report in which they stated that the primary goal of medical education should be the preparation of graduates who know how to reduce the burden of illness and improve the health of the communities in which they practice.42 Among the report's recommendations was a call for greater integration of the social determinants in medical curricula.43 Although the CanMEDS framework has been a part of the Royal College of Physicians and Surgeons of Canada's accreditation process since 2005, challenges to the integration of these competencies remain.44
The report called for a greater emphasis on providing medical students with firsthand experiences in the community and with distinct populations (service learning),45 which addresses the difficulties in teaching the social aspects of medicine within a traditional classroom or hospital setting.46 Many such programs exist across the country.47 However, these programs are still limited and there is a need to increase the availability of longitudinal programs which allow students to build on the skills they develop throughout medical school.
Increasingly residency programs which focus on the social determinants of health are being offered.48 These programs are a means of providing physicians with the proper tools to communicate with patients from diverse backgrounds49 and reduce behaviours that marginalized patients have identified as barriers to health services.50 It also provides residents with physician role models who are active in the community. However, medical residents note a lack of opportunities to participate in advocacy during residency.51 Further, while experiential programs are effective in helping to reduce barriers between physicians and patients from disadvantaged backgrounds, greater recruitment of medical students from these marginalized populations should also be explored and encouraged.
Finally, physicians in practice need to be kept up to date on new literature and interventions regarding the social determinants. Innovations which help address health equity in practice should be shared with interested physicians. In particular, there is a need for accredited continuing medical education (CME) and a means to encourage uptake.52
CMA recommends that:
6. Greater integration of information on the social determinants and health inequity be provided in medical school to support the CanMEDS health advocate role
7. All medical schools and residency programs offer service learning programs, to provide students with an opportunity to work with diverse populations in inner city, rural and remote settings, and to improve their skills in managing the impact of the social determinants on their patients.
8. CME on the social determinants of health and the physician role in health equity be offered and incentivized for practising physicians.
Leadership and research
Within many communities in Canada, there are physicians who are working to address social determinants and health equity within the patient populations they serve. This is done in many cases through collaboration with partners within and outside of the health care system. Providing these local physician leaders with the tools they need to build these partnerships, and influence the policies and programs that affect their communities is a strategy that needs to be explored.
Evidence-based research about health equity, the clinical setting and the role of physicians is underdeveloped. Interested physicians may wish to participate in research about practice level innovations, as a means of contributing to the evidence base for 'health equity' interventions or simply to share best practices with interested colleagues. Further, physicians can provide the medical support to encourage the adoption of early childhood development practices for example, which support later adult health. In time, research will contribute to training, continuing medical education and potentially to clinical practice guidelines.
Physicians can provide leadership in health impact assessments and equity audits within the health care system as well. Data is essential to identify health equity challenges within a program, to propose and test measures that address the issues underlying the disparities. Formal audits and good measurement are essential to develop evidence-based policy improvements.53 Innovative programs such as those within the Saskatoon Health Region and the Centre for Addiction and Mental Health in Toronto are examples of using these tools to improve access and reduce inequities.
CMA recommends that:
9. Physicians who undertake leadership and advocacy roles should be protected from repercussions in the workplace, e.g., the loss of hospital privileges.
10. Physician leaders explore opportunities to strengthen the primary care public health interface within their communities by working with existing agencies and community resources.
11. Physician leaders work with their local health organizations and systems to conduct health equity impact assessments in order to identify challenges and find solutions to improve access and quality of care.
12. Physicians be encouraged to participate in or support research on best practices for the social determinants of health and health equity. Once identified, information sharing should be established in Canada and internationally.
In consultation with identified health equity physician champions, a number of clinical interventions have been identified which are being undertaken by physicians across the country. These interventions could be undertaken in many practice settings given the right supports, and could be carried out by various members of the collaborative care team.1
First, a comprehensive social history is essential to understand how to provide care for each patient in the context of their life.54 There are a number of tools that can be used for such a consultation and more are in development.55 However, consolidation of the best ideas into a tool that is suitable for the majority of health care settings is needed. There is some concern that asking these questions is outside of the physician role. The CanMEDS health advocate role clearly sees these types of activities as part of the physician role.56 The 'Four Principles of Family Medicine' defined by the College of Family Physicians of Canada, affirms this role for physicians as well.57
Community knowledge was identified as a strategy for helping patients. Physicians who were aware of community programs and services were able to refer patients if/when social issues arose.58 Many communities and some health providers have developed community resource guides.59 For some physicians, developing a network of community resources was the best way to understand the supports available.
As a corollary, physicians noted their work in helping their patients become aware of and apply for the various social programs to which they are entitled. The programs vary by community and province/territory, and include disability, nutritional supports and many others. Most if not all of these programs require physicians to complete a form in order for the individual to qualify. Resources are available for some of these programs,60 but more centralized supports for physicians regardless of practice location or province/territory are needed.
Physicians advocate on behalf of their patients by writing letters confirming the medical limitations of various health conditions or the medical harm of certain exposures.61 For example, a letter confirming the role of mold in triggering asthma may lead to improvements in the community housing of an asthmatic. Additionally, letters might help patients get the health care services and referrals that they require. As identified leaders within the community, support from a physician may be a 'game-changer' for patients.
Finally, the design of the clinic, such as hours of operation or location, will influence the ability of people to reach care.62
CMA recommends that:
13. Tools be provided for physicians to assess their patients for social and economic causes of ill health and to determine the impact of these factors on treatment design.
14. Local databases of community services and programs (health and social) be developed and provided to physicians. Where possible, targeted guides should be developed for the health sector.
15. Collaborative team-based practice be supported and encouraged.
16. Resources or services be made available to physicians so that they can help their patients identify the provincial/territorial and federal programs for which they may qualify.
17. Physicians be cognizant of equity considerations when considering their practice design and patient resources.
18. All patients be treated equitably and have reasonable access to appropriate care, regardless of the funding model of their physician.
Socio-economic factors play a larger role in creating (or damaging) health than either biological factors or the health care system. Health equity is increasingly recognized as a necessary means by which we will make gains in the health status of all Canadians and retain a sustainable publicly funded health care system. Addressing inequalities in health is a pillar of CMA's Health Care Transformation initiative. Physicians as clinicians, learners, teachers, leaders and as a profession can take steps to address the problems on behalf of their patients.
1 A full review of the consultations is provided in the companion paper The Physician and Health Equity: Opportunities in Practice.
1 Khalema, N. Ernest (2005) Who's Healthy? Who's Not? A Social Justice Perspective on Health Inequities. Available at: http://www.uofaweb.ualberta.ca/chps/crosslinks_march05.cfm
2 World Health Organization (2008) Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Available at: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf
3 Public Health Agency of Canada (N.D.) The Social Determinants of Health: An Overview of the Implications for Policy and the Role of the Health Sector. Available at: http://www.phac-aspc.gc.ca/ph-sp/oi-ar/pdf/01_overview_e.pdf
4 Keon, Wilbert J. & Lucie Pépin (2008) Population Health Policy: Issues and Options. Available at: http://www.parl.gc.ca/Content/SEN/Committee/392/soci/rep/rep10apr08-e.pdf
5 Friel, Sharon (2009) Health equity in Australia: A policy framework based on action on the social determinants of obesity, alcohol and tobacco. The National Preventative Health Taskforce. Available at: http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/0FBE203C1C547A82CA257529000231BF/$File/commpaper-hlth-equity-friel.pdf
6 Wilkinson, Richard & Michael Marmot eds. (2003) Social Determinants of Health: The Solid Facts: Second Edition. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf
7 Khalema, N. Ernest (2005) Who's Healthy?...
8 Dunn, James R. (2002) The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Available at: http://www.opha.on.ca/our_voice/collaborations/makeconnxn/HDP-proj-full.pdf
10 Wilkins, Russ; Berthelot, Jean-Marie; and Ng E. . Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996. Health Reports 13 [Supplement]: pp. 45-71
11 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health: The Canadian Facts. Available at: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf
12 Raphael, Dennis (2003) "Addressing The Social Determinants of Health In Canada: Bridging The Gap Between Research Findings and Public Policy." Policy Options. March 2003 pp.35-40.
13 World Health Organization (2008) Closing the gap in a generation...
14 Hay, David I. (2006) Economic Arguments for Action on the Social Determinants of Health. Canadian Policy Research Networks. Available at: http://www.cprn.org/documents/46128_en.pdf
15 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
17 Whitehead, Margaret & Goran Dahlgren (2006) Concepts and principles for tackling social inequities in health: Levelling up Part 1. World Health Organization Europe. Available at: http://www.euro.who.int/__data/assets/pdf_file/0010/74737/E89383.pdf
18 Wilkinson, Richard & Michael Marmot eds. (2003) "Social Determinants of Health...
19 Ferrie, Jane E. (1999) "Health consequences of job insecurity." In Labour Market Changes and Job Security: A Challenge for Social Welfare and Health Promotion. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98411/E66205.pdf
20 Marmot, Michael (2010) Fair Society Healthy Lives: The Marmot Review: Executive Summary. Available at: http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLivesExecSummary.pdf
21 World Health Organization (2008) Closing the gap in a generation...
22 Aboriginal Healing Foundation, Frequently Asked Questions (Ottawa: Canadian Government Publishing Directorate, 2009) Available at: http://www.ahf.ca/faq
23Health Council of Canada, "The Health Status Of Canada's First Nations, Métis And Inuit Peoples", 2005, Available at:http://healthcouncilcanada.ca.c9.previewyoursite.com/docs/papers/2005/BkgrdHealthyCdnsENG.pdf
24 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
25Health Council of Canada, (2005)"The Health Status Of Canada's First Nations, Métis And Inuit Peoples...
26 Dunn, James R. (2002) The Health Determinants Partnership...
27 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions. http://secure.cihi.ca/cihiweb/products/PHC_Experiences_AiB2012_E.pdf
28 Munro, Daniel (2008) "Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health." The Conference Board of Canada. Available at: http://www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb
29 Williamson, Deanna L. et.al. (2006) "Low-income Canadians' experiences with health-related services: Implications for health care reform." Health Policy. 76(2006) pp. 106-121.
30 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians...
31 Williamson, Deanna L. et.al. (2006) "Low-income Canadians'...
32 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
33 Neal, Richard D. et.al. (2001) "Missed appointments in general practice: retrospective data analysis from four practices." British Journal of General Practice. 51 pp.830-832.
34 Kennedy, Jae & Christopher Erb (2002) "Prescription Noncompliance due to Cost Among Adults with Disabilities in the United States." American Journal of Public Health. Vol.92 No.7 pp. 1120-1124.
35 Bibbins-Domingo, Kirsten & M. Robin DiMatteo. Chapter 8: Assessing and Promoting Medication Adherence. pp. 81-90 in King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients...
36 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
37 Dunn, James R. (2002) The Health Determinants Partnership...
38 Saskatoon Poverty Reduction Partnership (2011) from poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Available at: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf
39 World Health Organization (2005) Action On The Social Determinants Of Health: Learning From Previous Experiences. Available at: http://www.who.int/social_determinants/resources/action_sd.pdf
40 Braveman, Paula (2003) "Monitoring Equity in Health and Healthcare: A Conceptual Framework."Journal of Health, Population and Nutrition. Sep;21(3):181-192.
41 Royal College of Physicians (2010) How doctors can close the gap: Tackling the social determinants of health through culture change, advocacy and education. Available at: http://www.marmotreview.org/AssetLibrary/resources/new%20external%20reports/RCP-report-how-doctors-can-close-the-gap.pdf
42 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools. Available at: http://www.medicine.usask.ca/leadership/social-accountability/pdfs%20and%20powerpoint/SA%20-%20A%20vision%20for%20Canadian%20Medical%20Schools%20-%20Health%20Canada.pdf
44 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate: Translating the Quest for Social Responsibility into Medical Education and Practice." Academic Medicine. Vol.86 No.9 pp.1108-1113.
45 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools...
46 Meili, Ryan; Fuller, Daniel; & Jessica Lydiate. (2011) "Teaching social accountability by making the links: Qualitative evaluation of student experiences in a service-learning project." Medical Teacher. 33; 659-666.
47 Ford-Jones, Lee; Levin, Leo; Schneider, Rayfel; & Denis Daneman (2012) "A New Social Pediatrics Elective-A Tool for Moving to Life Course Developmental Health." The Journal of Pediatrics. V.160 Iss. 3 pp.357-358; Meili, Ryan; Ganem-Cuenca, Alejandra; Wing-sea Leung, Jannie; & Donna Zaleschuk (2011) "The CARE Model of Social Accountability: Promoting Cultural Change." Academic Medicine. Vol.86 No.9 pp.1114-1119.
48 Cuthbertson, Lana "U of A helps doctors understand way of life in the inner city." Edmonton Journal Dec 22, 2010. Available at: http://www2.canada.com/edmontonjournal/news/cityplus/story.html?id=943d7dc3-927b-4429-878b-09b6e00595e1
49 Willems, S.; Maesschalck De, S.; Deveugele, M.; Derese, A. & J. De Maeseneer (2005) "Socio-economic status of the patient and doctor-patient communication: does it make a difference?" Patient Education and Counseling. 56 pp. 139-146.
50 Bloch, Gary; Rozmovits, Linda & Broden Giambone (2011) "Barriers to primary care responsiveness to poverty as a risk factor for health." BioMed Central Family Practice. Available at: http://www.biomedcentral.com/content/pdf/1471-2296-12-62.pdf; Schillinger, Dean; Villela, Theresa J. & George William Saba. Chapter 6: Creating a Context for Effective Intervention in the Clinical Care of Vulnerable Patients. pp.59-67. In King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients.
51 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate...
52 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
53 Meili, Ryan (2012) A Healthy Society: How A Focus On Health Can Revive Canadian Democracy. Saskatoon: Canada. Purich Publishing Limited. pp.36
54 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
55 Bloch, Gary (2011) "Poverty: A clinical tool for primary care "Family & Community Medicine, University of Toronto. Available at: http://www.healthprovidersagainstpoverty.ca/system/files/Poverty%20A%20Clinical%20Tool%20for%20Primary%20Care%20%28version%20with%20References%29_0.pdf ; Bricic, Vanessa; Eberdt, Caroline & Janusz Kaczorowski (2011) "Development of a Tool to Identify Poverty in a Family Practice Setting: A Pilot Study." International Journal of Family Medicine. Available at: http://www.hindawi.com/journals/ijfm/2011/812182/ ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, female health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, male health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders
56 Frank, Dr. Jason R. ed. (2005) "The CanMEDS 2005 Physician Competency Framework: Better standards. Better physicians. Better Care." Office of Education: The Royal College of Physicians and Surgeons of Canada. Available at: http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf
57 Tannenbaum, David et.al. (2011) "Triple C Competency-based Curriculum: Report of the Working Group on Postgraduate Curriculum Review-Part 1
58 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
59 Doyle-Trace L, Labuda S. Community Resources in Cote-des-Neiges. Montreal: St Mary's Hospital Family Medicine Centre, 2011. (This guide was developed by medical residents Lara Doyle-Trace and Suzan Labuda at McGill University.); Mobile Outreach Street Health (N.D.) Pocket MOSH: a little MOSH for your pocket: A Practitioners Guide to MOSH and the Community We Serve. Available at: http://www.cdha.nshealth.ca/mobile-outreach-street-health
60 Health Providers Against Poverty (N.D.) Tools and Resources. Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders
61 Meili, Ryan (2012) A Healthy Society: How A Focus...pp.61; UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
62 Rachlis, Michael (2008) Operationalizing Health Equity: How Ontario's Health Services Can Contribute to Reducing Health Disparities. Wellesley Institute. Available at: http://wellesleyinstitute.com/files/OperationalizingHealthEquity.pdf
Restricting Marketing of Unhealthy Foods and Beverages to Children and Youth in Canada: A Canadian Health Care and Scientific Organization Policy Consensus Statement
Federal government to immediately
begin a legislative process to restrict all
marketing targeted to children under the
age of 13 of foods and beverages high in
saturated fats, trans-fatty acids, free
sugars or sodium and that in the interim
the food industry immediately ceases
marketing of such food to children.
PURPOSE OF STATEMENT
This policy consensus statement was developed to
reflect the growing body of evidence linking the
promotion and consumption of diets high in
saturated fats, trans-fatty acids, free sugars or
sodium1 to cardiovascular and chronic disease
(hypertension, dyslipidemia, diabetes mellitus,
obesity, cancer, and heart disease and stroke)—
leading preventable risk factors and causes of death
and disability within Canada and worldwide. (1-3)
(1) For the remainder of the document, reference to foods
high in saturated fats, trans-fatty acids, free sugars or
sodium will be framed as foods high in fats, sugars or
The current generation of Canadian children is
expected to live shorter, less healthy lives as a
result of unhealthy eating. (4) Canadians’
overconsumption of fat, sodium and sugar, rising
rates of childhood obesity, growing numbers of
people with cancer, heart disease and stroke, and
the combined strain they exert on the health care
system and quality of life for Canadians necessitates
immediate action for Canadian governments and
policy-makers. Restricting the marketing of
unhealthy foods and beverages directed at children
is gaining increasing international attention as a
cost-effective, population-based intervention to
reduce the prevalence and the burden of chronic
and cardiovascular diseases through reducing
children’s exposure to, and consumption of,
disease-causing foods. (2,5,6)
In May 2010, the World Health Organization (WHO
released a set of recommendations on the
marketing of foods and non-alcoholic beverages to
children (5) and called on governments worldwide
to reduce the exposure of children to advertising
messages that promote foods high in saturated fats,
trans-fatty acids, free sugars or sodium and to
reduce the use of powerful marketing techniques. In
June 2012, the follow-up document, A Framework
for Implementing the Set of Recommendations on
the Marketing of Foods and Non-Alcoholic
Beverages to Children, (7) was released.
The policy aim should be to reduce the impact
on children of marketing of foods high in
saturated fats, trans-fatty acids, free sugars,
WHO (2010): Recommendation 1
What this policy consensus statement offers is the
perspective of many major national health care
professional and scientific organizations to guide
Canadian governments and non-government
organizations on actions that need to be taken to
protect the health of our future generations, in part
by restricting the adverse influence of marketing of
foods high in fat, sugar or sodium to Canadian
children and youth.
SUMMARY OF EVIDENCE AND RATIONALE
-Young children lack the cognitive ability to
understand the persuasive intent of marketing
or assess commercial claims critically. (8) in
1989 the Supreme Court of Canada ruled that
“advertisers should not be able to capitalize
upon children’s credulity” and “advertising
directed at young children is per se
-The marketing and advertising of information or
products known to be injurious to children’s
health and wellbeing is unethical and infringes
on the UN Convention on the Rights of the Child
which stipulates that, “In all actions concerning
children … the best interests of the child shall
be a primary consideration.” (9)
- Unhealthy food advertising during children’s
television programs in Canada is higher than in
many countries, with children being exposed to
advertisements for unhealthy foods and
beverages up to 6 times per hour. (10)
- Unhealthy food and beverage advertising
influences children’s food preferences,
purchase requests and consumption patterns
and has been shown to be a probable cause of
childhood overweight and obesity by the WHO.
- The vast majority of Canadians (82%) want
government intervention to place limits on
advertising unhealthy foods and beverages to
- The regulation of food marketing to children is
an effective and cost-saving population-based
intervention to improve health and prevent
- Several bills have been introduced into the
House of Commons to amend the Competition
Act and the Food and Drug Act to restrict
commercial advertising, including food, to
children under 13 years of age. None have yet
been passed. (15)
- Canada’s current approach to restricting
advertising to children is not effective and is not
in line with the 2010 WHO recommendations on
the marketing of foods and beverages to
children, nor is it keeping pace with the direction
of policies being adopted internationally, which
ban or restrict unhealthy food and beverage
marketing targeted to children. (16,17)
The Supreme Court of Canada concluded
that “advertising directed at young
children is per se manipulative”
Irwin Toy Ltd. v. Québec (AG), 1989
FOOD MARKETING TO CHILDREN: A TIMELY
OPPORTUNITY FOR CANADA
Childhood obesity and chronic disease prevention
are collective priorities for action of federal,
provincial and territorial (F/P/T) governments.
Strategy 2.3b of the 2011 Federal, Provincial and
Territorial Framework for Action to Promote Healthy
Weights stipulates “looking at ways to decrease the
marketing of foods and beverages high in fat, sugar
and/or sodium to children. “(5, p. 31)
The 2010 Sodium Reduction Strategy for Canada
has also identified the need to “continue to explore
options to reduce the exposure of children to
marketing for foods that are high in sodium" as a
key activity for F/P/T governments to consider. (19,
In their 2010 set of recommendations, the WHO
stipulated that governments are best positioned to
lead and ensure effective policy development,
implementation and evaluation. (6)
To date, there has been no substantive movement
by the federal government to develop coordinated
national-level policies that change the way
unhealthy foods and beverages are produced,
marketed and sold. Current federal, provincial and
industry-led self-regulatory codes are inconsistent
in their scope and remain ineffective in their ability
to sufficiently reduce children’s exposure to
unhealthy food marketing, nor have they been
adequately updated to address the influx of new
marketing mediums to which children and youth in
Canada are increasingly subjected.
Quebec implemented regulations in 1980 restricting
all commercial advertising. (20) Although the ban
has received international recognition and is viewed
as world leading, several limitations remain, in part
due exposure of Quebec children to marketing from
outside Quebec, weak enforcement of the
regulations and narrow application of its provisions.
Accordingly, the undersigned are calling on the
federal government to provide strong leadership
and establish a legislative process for the
development of regulations that restrict all
commercial marketing of foods and beverages high
in saturated fats, trans-fatty acids, free sugars or
sodium to children.
Strong federal government action and commitment
are required to change the trajectory of chronic
diseases in Canada and institute lasting changes in
public health. Specifically:
Efforts must be made to ensure that
children…are protected against the impact
of marketing [of foods with a high content
of fat, sugar and sodium] and given the
opportunity to grow and develop in an
enabling food environment — one that
fosters and encourages healthy dietary
choices and promotes the maintenance of
healthy weight. (7, p. 6)
Such efforts to protect the health of children must
go beyond the realm of federal responsibility and
involve engagement, dialogue, leadership and
advocacy by all relevant stakeholders, including all
elected officials, the food and marketing sector,
public health, health care professional and scientific
organizations, and most importantly civil society.
The undersigned support the development of
policies that are regulatory in nature to create
national and/or regional uniformity in
implementation and compliance by industry.
“Realizing the responsibility of governments
both to protect the health of children and to
set definitions in policy according to public
health goals and challenges — as well as to
ensure policy is legally enforced — statutory
regulation has the greatest potential to achieve
the intended or desired policy impact.”
WHO (2012), p. 33
The following outline key definitions and
components of an effective and comprehensive
policy on unhealthy food and beverage marketing
to children and should be used to guide national
policy scope and impact.
- Age of Child: In the context of broadcast
regulations, the definition of “age of child”
typically ranges from under 13 years to under
16 years. In Canada, Quebec’s Consumer
Protection Act (20) applies to children under
13 years of age. Consistent with existing
legislation, this report recommends that policies
restricting marketing of unhealthy foods and
beverages be directed to children less than
13 years of age at a minimum.
While the science on the impact of marketing on
children over 13 is less extensive, emerging
research reveals that older children still require
protection and may be more vulnerable to newer
forms of marketing (i.e., digital media ), in which
food and beverage companies are playing an
increasingly prominent role. (21-23) Strong
consideration should be given to extending the
age of restricting the marketing of unhealthy
food and beverage to age 16.
- Unhealthy Food and Beverages: In the absence
of a national standardized definition for “healthy”
or “unhealthy” foods, this document defines
unhealthy foods broadly as foods with a high
content of saturated fats, trans-fatty acids, free
sugars or sodium, as per the WHO
recommendations. (5) It is recommended that a
robust and comprehensive definition be
developed by an interdisciplinary stakeholder
- Focus on Marketing: Marketing is more than
advertising and involves:
…any form of commercial communication or
message that is designed to, or has the
effect of, increasing the recognition, appeal
and/ or consumption of particular products
and services. It comprises anything that acts
to advertise or otherwise promote a product
or service. (6, p. 9)
This definition goes beyond the current legal
definition of advertisement outlined in the Food
and Drug Act as “any representation by any
means whatever for the purpose of promoting
directly or indirectly the sale or disposal of any
food, drug, cosmetic or device.” (24)
- Marketing Techniques, Communication Channels
and Locations: Legislation restricting unhealthy
food marketing needs to be sufficiently
comprehensive to address the broad scope of
marketing and advertising techniques that have a
particularly powerful effect on children and
youth. This includes, but is not limited to, the
. Direct electronic marketing (email, SMS)
. Mobile phones
. Video and adver-games
. Characters, brand mascots and/or celebrities,
including those that are advertiser-generated
. Product placement
. Point-of-purchase displays
. Cinemas and theatres
. Competitions and premiums (free toys)
. Children’s institutions, services, events and
activities (schools, event sponsorship)
. “Viral and buzz marketing” (25,26)
. Directed to Children: The criteria used by the
Quebec Consumer Protection Act (20) to
determine whether an advertisement is “directed
at children” offers a starting point in developing
national legislation regarding child-directed
media. The loopholes in the Quebec Consumer
Protection Act criteria, namely allowing
advertising of unhealthy foods and beverages
directed at adults during children’s programming,
will necessitate the development of an
alternative approach or set of criteria that
reflects the range of media to which children are
exposed and when they are exposed, in addition
to the proportion of the audience that is made up
Quebec Consumer Protection Act
To determine whether or not an
advertisement is directed at persons under
thirteen years of age, account must be taken
of the context of its presentation, and in
a)the nature and intended purpose of the
b)the manner of presenting such
c)the time and place it is shown.
1. Federal Government Leadership
1.1 Immediately and publicly operationalize the
WHO set of recommendations on the marketing
of foods and non-alcoholic beverages to
In working toward the implementation of the
WHO recommendations, the federal
government is strongly urged to accelerate
implementation of the WHO Framework for
Implementing the Set of Recommendations on
the Marketing of Foods and Beverages to
Children. To this end, the Government of
Canada is urged to:
1.2 Convene a Federal, Provincial and Territorial
Working Group on Food Marketing to Children
to develop, implement and monitor policies to
restrict unhealthy food and beverage marketing
to children. As stipulated within the WHO
The government-led working group should
ultimately reach consensus on the priorities
for intervention, identify the available policy
measures and decide how they best can be
implemented. (7, p.13)
1.3 In developing policies, it is recommended that
the working group:
- Develop standardized criteria and an
operational definition to distinguish and
classify “unhealthy” foods. Definitions
should be developed using objective,
evidence-based methods and should be
developed and approved independent of
- Develop a set of definitions/specifications
that will guide policy scope and
implementation. Consistent with the WHO
recommendations, the working group is
encouraged to apply the policy
specifications identified above.
- Set measurable outcomes, targets and
timelines for achievement of targets for
industry and broadcasters to restrict
unhealthy food marketing to children in all
forms and settings. It is recommended that
policies be implemented as soon as possible
and within a 3-year time frame.
- Establish mechanisms for close monitoring
and enforcement through defined rewards
and/or penalties by an independent
regulatory agency that has the power and
infrastructure to evaluate questionable
advertisements and enforce penalties for
(2) Such an infrastructure could be supported
though the Canadian Radio-television and
Telecommunications Commission (CRTC), similar
to the authority of the US Federal Trade
Commission (FTC), the Canadian Food
Inspection Agency or the Food and Drug Act via
the development of an advertising investigation
The nature and extent of penalties imposed should be sufficiently
stringent to deter violations. Enforcement
mechanisms should be explicit, and infringing
companies should be exposed publicly.
- Develop evaluation mechanisms to assess
process, impact and outcomes of food
marketing restriction policies. Components
should include scheduled reviews (5 years or
as agreed upon) to update policies and/or
strategies. To showcase accountability,
evaluation findings should be publicly
1.4 Provide adequate funding to support the
successful implementation and monitoring of
the food marketing restriction policies.
1.5 Collaborate with the Canadian Institutes of
Health Research and other granting councils to
fund research to generate baseline data and
address gaps related to the impact of marketing
in all media on children and how to most
effectively restrict advertising unhealthy foods
to children. (27)
1.6 Fund and commission a Canadian economic
modeling study to assess the cost-effectiveness
and the relative strength of the effect of
marketing in comparison to other influences on
children’s diets and diet-related health
outcomes. Similar studies have been
undertaken elsewhere and highlight cost–
benefit savings from restricting unhealthy food
1.7 Call on industry to immediately stop marketing
foods to children that are high in fats, sugar or
2. Provincial, Territorial and Municipal
2.1 Wherever possible, incorporate strategies to
reduce the impact of unhealthy food and
beverage marketing to children into provincial
and local (public) health or related strategic
action plans, and consider all settings that are
frequented by children.
2.2 Pass and/or amend policies and legislation
restricting unhealthy food and beverage
marketing to children that go beyond
limitations stipulated in federal legislation and
regulations and industry voluntary codes.
2.3 Until federal legislation is in place, strike a P/T
Steering Committee on Unhealthy Food
Marketing to Children to establish
interprovincial consistency related to key
definitions and criteria and mechanisms for
enforcement, as proposed above.
2.4 Collaborate with local health authorities, non-
governmental organizations and other
stakeholders to develop and implement
education and awareness programs on the
harmful impacts of marketing, including but not
limited to unhealthy food and beverage
2.5 Call on industry to immediately stop marketing
foods to children that are high in fats, sugar or
3. Non-governmental Organizations
(NGOs), Health Care Organizations,
Health Care Professionals
3.1 Publicly endorse this position statement and
advocate to all Canadian governments to
restrict marketing of unhealthy foods to
children and youth in Canada.
3.2 Collaborate with governments at all levels to
facilitate implementation and enforcement of
federal/provincial/municipal regulations or
3.3 Wherever possible, incorporate and address
the need for restrictions on unhealthy food
and beverage marketing to children into
position papers, strategic plans, conferences,
programs and other communication mediums.
3.4 Support, fund and/or commission research to
address identified research gaps, including the
changing contexts and modes of marketing
and their implications on the nutritional status,
health and well-being of children and youth
3.5 Call on industry to immediately stop the
marketing of foods high in fat, sugar or
4. Marketing and Commercial Industry
4.1 Immediately cease marketing foods high in fats,
sugar or sodium.
4.2 Amend the Canadian Children’s Food and
Beverage Advertising Initiative (CAI) nutrition
criteria used to re-define “better-for-you
products” to be consistent with currently
available international standards that are
healthier and with Canadian nutrient profiling
standards, once developed.
BACKGROUND AND EVIDENCE BASE
Non-communicable diseases (diabetes, stroke,
heart attack, cancer, chronic respiratory disease)
are a leading cause of death worldwide and are
linked by several common risk factors including high
blood pressure, high blood cholesterol, obesity,
unhealthy diets and physical inactivity. (1,2,3 28)
The WHO has predicted that premature death from
chronic disease will increase by 17% over the next
decade if the roots of the problem are not
Diet-related chronic disease risk stems from long-
term dietary patterns which start in childhood
(8,28). Canadian statistics reveal children, consume
too much fat, sodium and sugars (foods that cause
chronic disease) and eat too little fiber, fruits and
vegetables (foods that prevent chronic disease). (3)
There is evidence that (television) advertising of
foods high in fat, sugar or sodium is associated with
childhood overweight and obesity. (6,11) Children
and youth in Canada are exposed to a barrage of
marketing and promotion of unhealthy foods and
beverages through a variety of channels and
techniques – tactics which undermine and
contradict government, health care professional
and scientific recommendations for healthy eating.
Available research indicates that food marketing to
children influences their food preferences, beliefs,
purchase requests and food consumption patterns.
(8,29) A US study showed that children who were
exposed to food and beverage advertisements
consumed 45% more snacks than their unexposed
counterparts. (30) Similarly, preschoolers who were
exposed to commercials for vegetables (broccoli
and carrots) had a significantly higher preference
for these vegetables after multiple exposures (n=4)
compared to the control group. (31)
Economic modeling studies have shown that
restricting children’s exposure to food and beverage
advertising is a cost effective population based
approach to childhood obesity prevention, with the
largest overall gain in disability adjusted life years.
(13,14). Canada has yet to conduct a comparable
Marketing and Ethics
Foods and beverages high in fats, sugars or sodium
is one of many health compromising products
marketed to children. It has been argued that policy
approaches ought to extend beyond marketing of
unhealthy foods and beverages to one that restricts
marketing of all products to children, as practiced in
Quebec (7,26,32). Article 36 of the Convention on
the Rights of the Child, to which Canada is a
signatory, states that, “children should be protected
from any activity that takes advantage of them or
could harm their welfare and development.” (9)
Restricting marketing of all products has been
argued to be the most comprehensive policy option
in that it aims to protect children from any
commercial interest and is grounded in the
argument that children have the right to a
commercial-free childhood (7, 25,26,32). The focus
on restricting unhealthy food and beverage
marketing was based in consultations with national
health organizations whose mandates, at the time
of writing, were more aligned with a focus on
unhealthy foods and beverages.
This policy statement is not opposed to, and does
not preclude further policy enhancements to
protect children from all commercial marketing, and
therefore encourages further advocacy in this area.
In order to inform the debate and help underpin
future policy direction, further research is needed.
Canada’s Food and Beverage Marketing
Television remains a primary medium for children’s
exposure to advertising, with Canadian children
aged 2–11 watching an average of 18 hours of
television per week. (26) In the past two decades,
the food marketing and promotion environment has
expanded to include Internet marketing, product
placement in television programs, films and DVDs,
computer and video games, peer-to-peer or viral
marketing, supermarket sales promotions, cross-
promotions between films and television programs,
use of licensed characters and spokes-characters,
celebrity endorsements, advertising in children’s
magazines, outdoor advertising, print marketing,
sponsorship of school and sporting activities,
advertising on mobile phones, and branding on toys
and clothing. (25,26)
A systematic review of 41 international studies
looking at the content analysis of children’s food
commercials found that the majority advertised
unhealthy foods, namely pre-sugared cereals, soft
drinks, confectionary and savoury snacks and fast
food restaurants. (33) In an analysis of food
advertising on children’s television channels across
11 countries, Canada (Alberta sample) had the
second-highest rate of food and beverage
advertising (7 advertisements per hour), 80% of
which were for unhealthy foods and beverages
defined as “high in undesirable nutrients and/or
Illustrating the influence of food packaging in
supermarkets, two Canadian studies found that for
six food product categories 75% of the products
were directed solely at children through use of
colour, cartoon mascots, pointed appeals to parents
and/or cross-merchandising claims, games or
activities. Of the 63% of products with nutrition
claims, 89% were classified as being “of poor
nutritional quality” due to high levels of sugar, fat,
or sodium when judged against US-based nutrition
criteria. Less than 1% of food messages specifically
targeted to children were for fruits and vegetables.
Food is also unhealthily marketed in schools. A
recent study of 4,936 Canadian students from
grades 7 to 10 found that 62% reported the
presence of snack-vending machines in their
schools, and that this presence was associated with
students’ frequency of consuming vended goods.
(36) In another Canadian analysis, 28% of
elementary schools reported the presence of some
form of advertising in the school and 19% had an
exclusive marketing arrangement with Coke or
Pepsi. (37) Given children’s vulnerability, a key
tenant of the WHO recommendations on marketing
to children is that “settings where children gather
should be free from all forms of marketing of foods
high in saturated fats, trans-fatty acids, and free
sugars or sodium.” (6, p.9) and need to be included
in development of food marketing policies directed
The Canadian public wants government oversight in
restricting unhealthy food marketing to children. A
nation-wide survey of over 1200 Canadian adults
found 82% want limits placed on unhealthy food
and beverage advertising to children; 53% support
restricting all marketing of high-fat, high-sugar or
high-sodium foods aimed directly at children and
Canada’s Commercial Advertising Environment
Internationally, 26 countries have made explicit
statements on food marketing to children and 20
have, or are in the process of, developing policies in
the form of statutory measures, official guidelines
or approved forms of self-regulation. (38) The
differences in the nature and degree of these
restrictions is considerable, with significant
variation regarding definition of child, products
covered, communication and marketing strategies
permitted and expectations regarding
implementation, monitoring and evaluation. (38,39)
With the exception of Quebec, Canada’s advertising
policy environment is restricted to self-regulated
rather than legislative measures with little
monitoring and oversight in terms of measuring the
impact of regulations on the intensity and
frequency of advertising unhealthy foods and
beverages to children. (39)
Nationally, the Food and Drug Act and the
Competition Act provide overarching rules on
commercial advertising and (loosely) prohibit selling
or advertising in a manner that is considered false,
misleading or deceptive to consumers. These laws,
however, contain no provisions dealing specifically
with unhealthy food advertising or marketing to
children and youth. (26) The Consumer Package
and Labeling Act outlines federal requirements
concerning the packaging, labeling, sale,
importation and advertising of prepackaged non-
food consumer products. Packaging and labels,
however, are not included under the scope of
advertising and therefore not subject to the
administration and enforcement of the Act and
Such loopholes have prompted the introduction of
three private member's bills into the House of
Commons to amend both the Competition Act and
the Food and Drugs Act. Tabled in 2007, 2009 and
2012, respectively, none of the bills have, to date,
advanced past the First Reading. (15)
The Canadian Code of Advertising Standards (Code)
and the Broadcast Code for Advertising to Children
(BCAC) together cover Canadian broadcast and non-
broadcast advertising. (23) While both have explicit
provisions/clauses to cover advertising directed to
children (12 years and younger), neither address or
explicitly cover unhealthy food and beverage
advertising. Further excluded are other heavily
used and persuasive forms of marketing directed to
children, including in-store promotions, packaging,
logos, and advertising in schools or at events, as
well as foreign media. (40)
Formed in 2008, the Canadian Children’s Food and
Beverage Advertising Initiative (CAI) defines
marketing standards and criteria to identify the
products that are appropriate or not to advertise to
children under 12 years old. Under this initiative,
participating food companies (N=19) are
encouraged to direct 100% of their advertising to
children under 12 to “better-for-you” products. (41)
In 2010, the scope of CAI was expanded to include
other media forms, namely video games, child-
directed DVDs and mobile media.
Despite reportedly high compliance by CAI
participants, (41) several fundamental loopholes
undermine its level of protection and effectiveness,
- Participation is voluntary, exempting non-
participators such as President’s Choice,
Wendy’s and A&W, from committing to CAI core
- Companies are allowed to create their own
nutrient criteria for defining “better-for-you” or
“healthier dietary choice” products. (32) A 2010
analysis revealed that up to 62% of these
products would not be acceptable to promote to
children by other countries’ advertising nutrition
- Companies are able to adopt their own
definition of what constitutes “directed at
children” under 12 years. (32) Participants'
definitions of child audience composition
percentage range from 25% to 50%, significantly
more lenient than current Quebec legislation
and other international regulatory systems.
- The initiative excludes a number of marketing
and advertising techniques primarily directed at
children, namely advertiser-generated
characters (e.g., Tony the Tiger), product
packaging, displays of food and beverage
products, fundraising, public service messaging
and educational programs. (26,27)
The Quebec Consumer Protection Act states that
“no person may make use of commercial
advertising directed at persons under thirteen years
of age.” (26) Despite its merits, the effectiveness of
the Quebec ban has been compromised. In its
current form, the ban does not protect children
from cross-border leakage of child-directed
advertisements from other provinces. (40) One
study found that while the ban reduced fast food
consumption by US$88 million per year and
decreased purchase propensity by 13% per week,
the outcomes primarily affected French-speaking
households with children, not their English-speaking
counterparts. (44) A more recent study looking at
the ban’s impact on television advertising arrived at
similar conclusions and found that Quebec French
subjects were exposed to significantly fewer candy
and snack promotions (25.4%, p<0.001) compared
to the Ontario English (33.7%) and Quebec English
(39.8%) groups. (40)
The ban has further been criticized for having a
weak definition of “advertisement”, which allows
adult-targeted advertisements for unhealthy foods
during children’s programming (37) and having
weak regulatory and monitoring structures. (37,40)
In assessing the effectiveness of Quebec’s
legislation in reducing children’s exposure to
unhealthy food advertising, it is important to note
that the ban was not developed to target or reduce
the marketing of foods and beverages specifically,
but rather to reduce the commercialization of
Public Policy: The Way Forward
Several legislative approaches have been
undertaken internationally to restrict unhealthy
food and beverage marketing. (7,43,45) While
more research is needed with regards to the impact
of restricting unhealthy food and beverage
marketing on child health outcomes (i.e., obesity), a
US study estimated that between 14-33% of
instances of childhood obesity could be prevented
by eliminating television advertising for unhealthy
food. (46) An Australian study found that a
restriction on non-core-food advertisement
between 7am and 8:30pm could reduce children’s
exposure to unhealthy food advertising by almost
80%. (47) An evaluation of the UK regulations
which restricts television advertising of all foods
high in fat, sugar and sodium found that since its
introduction there has been a 37% reduction in
unhealthy food advertisement seen by children.
Restrictions on food marketing are being
increasingly advocated internationally. A 2011
International Policy Consensus Conference
identified regulating marketing to children as a key
policy strategy to prevent childhood obesity. (48) A
similar recommendation was made at the
September 2011 United Nations high-level meeting
on the prevention and control of non-
communicable diseases. Restrictions on television
advertising for less healthful foods has also been
identified as an effective (Class I; Grade B)
population-based strategy to improve dietary
behaviors in children by the American Heart
Within Canada, non-governmental and other health
organizations are assuming an equally active role.
Among others, the Chronic Disease Prevention
Alliance of Canada, the Dietitians of Canada, the
Alberta Policy Coalition for Chronic Disease
Prevention, the Simcoe Board of Health, the
Thunder Bay and District Board of Health and the
Kingston, Frontenac, Lennox and Addington Board
of Health have issued position papers or statements
urging the federal government to implement more
stringent regulations on food and beverage
marketing to children. (26,42,48)
The current voluntary, industry self-regulated and
ineffective system of restricting the marketing and
advertising of foods and beverages fails to protect
Canadian Children and thereby contributes to the
rising rates of childhood obesity and the likelihood
of premature death and disability in our children’s
and future generations. Strong federal government
leadership and nationwide action from other levels
of government and other key stakeholders are
needed. Regulation restricting unhealthy food
advertising is internationally supported, with a
growing evidence base for expanding such
regulation to all forms of food marketing.
This policy statement offer an integrated, pragmatic
and timely response to the national stated priorities
of childhood obesity and chronic disease prevention
in Canada and supports the F/P/T vision of making
Canada, “…a country that creates and maintains the
conditions for healthy weights so that children can
have the healthiest possible lives.” (4)
This policy statement was funded by The Heart and Stroke
Foundation of Canada (HSFC) and the Institute of
Circulatory and Respiratory Health (CIHR) Chair in
Hypertension Prevention and Control, prepared with the
assistance of an ad hoc Expert Scientific Working Group,
reviewed and approved by the Hypertension Advisory
Committee and endorsed by the undersigned national
HYPERTENSION ADVISORY COMMITTEE
Manuel Arango, Heart and Stroke Foundation of Canada
Norm Campbell, Canadian Society of Internal Medicine
Judi Farrell, Hypertension Canada
Mark Gelfer, College of Family Physicians of Canada
Dorothy Morris, Canadian Council of Cardiovascular Nurses
Rosana Pellizzari, Public Health Physicians of Canada
Andrew Pipe, Canadian Cardiovascular Society
Maura Rickets, Canadian Medical Association
Ross Tsuyuki, Canadian Pharmacists Association
Kevin Willis, Canadian Stroke Network
Norm Campbell, HSFC/CIHR Chair in Hypertension
Prevention and Control, Chair
Tara Duhaney, Policy Director, Hypertension Advisory
1. World Health Organization. Diet, Nutrition, and the
Prevention of Chronic Diseases. WHO Technical
Report Series No. 916. Geneva, WHO; 2003.
http://www.who.int/hpr/NPH/docs/who_fao_expert_report.pdf. Accessed December 2011
2. World Health Organization. 2008-2013 Action Plan
for the Global Strategy for the Prevention and
Control of Noncommunicable Diseases. Geneva:
WHO; 2008. Available at:
2008.pdf. Accessed December 2011
3. Public Health Agency of Canada. Tracking Heart
Disease and Stroke in Canada. Ottawa, 2009.
Available at: http://www.phac-
eng.pdf. Accessed January 2012
4. Olshansky SJ, Passaro DJ, Hershow RC et al. A
potential decline in life expectancy in the United
States in the 21st century. N Engl J Med. 2005;
5. Public Health Agency of Canada. Curbing Childhood
Obesity: A Federal, Provincial and Territorial
Framework for Action to Promote Healthy Weights.
Ottawa, PHAC; 2011 Available at: http://www.phac-
Accessed January 2012
6. World Health Organization. Set of recommendations
on the marketing of foods and non-alcoholic
beverages to children. Geneva: WHO; 2010.
http://www.who.int/dietphysicalactivity/publications/recsmarketing/en/index.html. Accessed December 2011
7. World Health Organization. A Framework for
Implementing the Set of Recommendations on the
Marketing of Foods and Non-Alcoholic Beverages to
Children. Geveva: WHO; 2012. Available at:
http://www.who.int/dietphysicalactivity/MarketingFramework2012.pdf. Accessed June 2012
8. Kunkel D, Wilcox B, Cantor J, Palmer E, Linn S,
Dowrick P. Report of the APA Taskforce on
Advertising and Children. Washington: American
Psychological Association; 2004. Available at:
http://www.apa.org/pi/families/resources/advertising-children.pdf. Accessed January 2012
9. United Nations. Convention on the Rights of the
Child. Geneva: United Nations, 2009 Available at:
Accessed February, 2012
10. Kelly B, Halford JCG, Boyland E, Chapman K, Bautista-
Castaño I, Berg C, et al. Television food advertising to
children: A global perspective. Am J Public Health.
2010;100:1730-5. Available at:
11. McGinnis JM, Gootman JA, Kraak VI (Eds.) Food
Marketing to Children and Youth: Threat or
Opportunity? Committee on Food Marketing and the
Diets of Children and Youth. Washington, DC: IOM;
12. Ipsos Reid. Canadians’ Perceptions of, and Support
for, Potential Measures to Prevent and Reduce
Childhood Obesity. Prepared for the Public Health
Agency of Canada. Ottawa, November 2011.
http://www.sportmatters.ca/files/Reports/Ipsos%20Obesity%202011.pdf. Accessed February 2012
13. Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-
Barron V, Chisholm D. Tackling of Unhealthy Diets,
physical inactivity, and obesity: Health effects and
cost-effectiveness. Lancet 2010; 376 (9754): 1775-
84 Available at:
14. Magnus A, Habby MM, Carter R, Swinburn B. The
cost-effectiveness of removing television advertising
of high fat and/or high sugar food and beverages to
Australian children. Int J Obes.2009; 33: 1094-1102.
15. Parliament of Canada. Private Member’s Bills.
Accessed April 2012
16. Conrad S. Innovations in Policy Evaluation:
Examining the food and beverages included in the
Canadian Children’s Food and Beverage Advertising
Initiative. Ottawa: Public Health Agency of Canada;
17. Alberta Policy Coalition for Cancer Prevention. Using
Public Policy to Promote Healthy Weights for
Canadian Children. Submission to the “Our Health,
Our Future – National Dialogue on Healthy Weights”
18. Public Health Agency of Canada. The integrated pan-
Canadian healthy living strategy. 2005. Available at:
strat/pdf/hls_e.pdf. Accessed January 2012
19. Health Canada. Sodium Reduction Strategy for
Canada: Recommendations of the Sodium Working
Group. Ottawa, Ontario, July 2010. Available at:
http://publications.gc.ca/collections/collection_2010/sc-hc/H164-121-2010-eng.pdf. Accessed December
20. Quebec Consumer Protection Office. The Consumer
Protection Act: Application Guide for Sections 248
and 249. Quebec, 1980
21. Montgomery K, Chester J. Interactive Food and
Beverage Marketing: Targeting Adolescents in the
Digital Age. J Adolesc Health. 2009: S18-S29.
22. Harris JL, Brownell KD, Bargh JA. The Food Marketing
Defense Model: Integrating Psychological Research
to Protect Youth and Inform Public Policy. Soc Issues
Policy Rev. 2009; 3(1): 211-271. Available at:
23. Pechman C, Levine L, Loughlin S, Leslie F. Impulsive
and Self-Conscious: Adolescents' Vulnerability to
Advertising and Promotion. Journal of Public Policy
and Marketing. 2005; 24 (2): 202-221. Available at:
24. Health Canada. Food and Drugs Act . R.S., c. F-27.
Ottawa: Health Canada; 1985. Available at:
Accessed February 2012
25. Mackay S, Antonopoulos N, Martin J, Swinburn B. A
comprehensive approach to protecting children from
unhealthy food advertising. Melbourne, Australia:
Obesity Policy Coalition; 2011. Available at:
email1%20final%2013.04.11.pdf. Accessed January
26. Cook B. Policy Options to Improve the Children’s
Advertising Environment in Canada. Report for the
Public Health Agency of Canada Health Portfolio Task
Group on Obesity and Marketing. Toronto; 2009.
27. Toronto Board of Health. Food and Beverage
Marketing to Children. Staff Report to the Board of
Health. Toronto: Board of Health; 2008. Available at:
http://www.toronto.ca/legdocs/mmis/2008/hl/bgrd/backgroundfile-11151.pdf. Accessed January 2012
28. The Conference Board of Canada. Improving Health
Outcomes: The Role of Food in Addressing Chronic
Diseases. Conference Board of Canada, 2010.
177_FoodandChronicDisease.pdf. Accessed June 2012
29. Cairns G, Angus K, Hastings G, Caraher M.
Systematic reviews of the evidence on the nature,
extent and effects of food marketing to children. A
retrospective summary. Appetite. 2012 (in press).
30. Harris JL, Bargh JA, Brownell KD. Priming Effects of
Television Food Advertising on Eating Behavior.
Health Psychol. 2009; 28(4):404-13. Available at:
31. Nicklas TA, Goh ET, Goodell LS et al. Impact of
commercials on food preferences of low-income,
minority preschoolers. J Nutr Educ Behav. 2011;
32. Elliott C. Marketing Foods to Children: Are We
Asking the Right Questions. Child Obes. 2012; 8(3):
33. Hastings G, Stead M, McDermott L, Forsyth A,
Mackintosh AM, Rayner M, Godfrey C, Caraher M,
Angus K. Review of research on the effects of food
promotion to children. Final Report to the UK Food
Standards Agency. Glasgow, Scotland: University of
Strathclyde Centre for Social Marketing; 2003.
http://www.food.gov.uk/multimedia/pdfs/promofoodchildrenexec.pdf. Accessed February 2012
34. Elliott C. Marketing fun foods: A profile and analysis
of supermarket food messages targeted at children.
Can Public Policy. 2008; 34:259-73
35. Elliott C. Assessing fun foods: Nutritional content
and analysis of supermarket foods targeted at
children. Obes Rev. 2008; 9: 368-377. Available at:
36. Minaker LM, Storey KE, Raine KD, Spence JC, Forbes
LE, Plotnikoff RC, McCargar LJ. Associations between
the perceived presence of vending machines and
food and beverage logos in schools and adolescents'
diet and weight status. Public Health Nutr. 2011;
37. Cook B. Marketing to Children in Canada: Summary
of Key Issues. Report for the Public Health Agency of
Canada. 2007. Available at:
Accessed January 2012
38. Hawkes C, Lobstein T. Regulating the
commercial promotion of food to children: a
survey of actions worldwide. Int J Pediatr
Obes. 2011; 6(2):83-94.
39. Hawkes C, Harris J. An analysis of the content of
food industry pledges on marketing to children.
Public Health Nutr. 2011; 14:1403-1414. Available
40. Potvin-Kent M, Dubois, L, Wanless A. Food
marketing on children's television in two
different policy environments. Int J of Pediatr
Obes. 2011; 6(2): e433-e441. Available at:
41. Advertising Standards Canada. Canadian children’s
food and beverage advertising initiative: 2010
compliance report. Available at:
2010ComplianceReport.pdf. Accessed March 2012
42. Dietitians of Canada. Advertising of Food and
Beverage to Children. Position of Dietitians of
Canada. 2010. Available at:
paper.aspx. Accessed January 2012
43. Hawkes C. Marketing food to children: a global
regulatory environment. World Health Organization.
2004(b). Available at:
http://whqlibdoc.who.int/publications/2004/9241591579.pdf. Accessed February 2012
44. Dhar T, Baylis K. Fast-food Consumption and the Ban
on Advertising Targeting Children: The Quebec
Experience. Journal of Marketing Research. 2011; 48
(5): 799-813. Available at:
45. World Health Organization. Marketing of Food and
Non-Alcoholic Beverages of Children. Report of a
WHO Forum and Technical Meeting. Geneva: WHO;
2006. Available at:
pdf. Accessed January 2012
46. Veerman JL, Van Beeck, Barendregt JJ, Mackenbach
JP. By how much would limiting TV food advertising
reduce childhood obesity? Eur J Public Health. 2009;
19(4): 365-9. Available at:
47. Kelly B, King L, Mauman A, Smith BJ, Flood V. The
effects of different regulation systems on television
food advertising to children. Aust N Z J Public
Health. 2007; 31(4): 340-343.
48. Alberta Policy Coalition for Chronic Disease
Prevention. Canadian Obesity Network -
International Consensus: Take Action to Prevent
Childhood Obesity (Press Release). 2011. Available
49. Mozaffarian D, Afshin A, Benowitz NL et al.
Population Approaches to Improve Diet, Physical
Activity, and Smoking Habits: A Scientific Statement
From the American Heart Association. Circulation.
This paper discusses the current state of the professional relationship between physicians and the health care system. A review of the concept of medical professionalism, and the tensions that can arise between the care of individual patients and a consideration of the broader needs of society, provides some basic groundwork. Our understanding of what it means to be a physician has evolved significantly over the years, and the medical profession is now being challenged to clarify the role it is willing to play in order to achieve transformation of our health care system.
We have arrived at this point due to a convergence of several factors. Regionalization of health care has led to a change in the leadership roles played by practising physicians and to the opportunities they have for meaningful input into system change. Physicians are now also less likely to be involved in hospital-based care, which has resulted in a loss of collegiality and interactions with peers. Changing models of physician engagement status and changing physician demographics have also presented new and unique issues and challenges over the past few years.
The Canadian Medical Association (CMA) suggests that its physician members and other stakeholders employ a "AAA" lens to examine the challenges and opportunities currently facing Canadian physicians as they attempt to engage with the health care system: Autonomy, Advocacy and Accountability. These important concepts are all underpinned by strong physician leadership. Leadership skills are fundamentally necessary to allow physicians to be able to participate actively in conversations aimed at meaningful system transformation.
KEY CMA RECOMMENDATIONS ARE AS FOLLOWS:
Physicians should be provided with the leadership tools they need, and the support required, to enable them to participate individually and collectively in discussions on the transformation of Canada's health care system.
Physicians need to be provided with meaningful opportunities for input at all levels of decision-making, with committed and reliable partners, and must be included as valued collaborators in the decision-making process.
Physicians have to recognize and acknowledge their individual and collective obligations (as one member of the health care team and as members of a profession) and accountabilities to their patients, to their colleagues and to the health care system and society.
Physicians must be able to freely advocate when necessary on behalf of their patients in a way that respects the views of others and is likely to bring about meaningful change that will benefit their patients and the health care system.
Physicians should participate on a regular and ongoing basis in well-designed and validated quality improvement initiatives that are educational in nature and will provide them with the feedback and skills they need to optimize patient care and outcomes.
Patient care should be team based and interdisciplinary with smooth transition from one care setting to the next and funding and other models need to be in place to allow physicians and other health care providers to practise within the full scope of their professional activities.
The concept of medical professionalism, at its core, has always been defined by the nature and primacy of the individual doctor-patient relationship, and the fiduciary obligation of physicians within this relationship. The central obligation of the physician is succinctly stated in the first tenet of the CMA Code of Ethics:
Consider first the well-being of the patient.1
Since the latter half of the 20th century, however, there has been a growing emphasis on the need for physicians to also consider the collective needs of society, in addition to those of their individual patients. As stated in the CMA Code of Ethics:
Consider the well-being of society in matters affecting health.
This shift in thinking has happened for at least two reasons. First, there have been tremendous advances in medical science that now enable physicians to do much more to extend the length and quality of life of their patients, but these advances inevitably come at a cost which is ultimately borne by society as a whole. Second, since World War II, Canadian governments have been increasingly involved in the financing of health care through taxation revenues. As a result, there have been growing calls for physicians to be prudent in their use of health care resources, and to be increasingly accountable in the way these resources are employed.
The 2002 American Board of Internal Medicine (ABIM) Foundation Charter on Medical Professionalism calls for physician commitment to a just distribution of finite resources: "While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources."2 This has also been described as civic professionalism.
Lesser et al have put forward a systems view of professionalism that radiates out from the patient-physician relationship to broader interactions with members of the health care team, the training environment and to the external environment, dealing with payers and regulators and also addressing the socio-economic determinants of health.3 Understandably, given that the resources available for health care are finite, tensions will arise between the care of individual patients and the collective needs of society, and these tensions can at times be very difficult to resolve for individual medical practitioners.
As stated in the CMA policy Medical Professionalism (Update 2005):
Medical professionalism includes both the relationship between a physician and a patient and a social contract between physicians and society. Society grants the profession privileges, including exclusive or primary responsibility for the provision of certain services and a high degree of self-regulation. In return, the profession agrees to use these privileges primarily for the benefit of others and only secondarily for its own benefit. 4
Over time the delivery, management and governance of health care have become more complex, and as a result the health care sector now accounts for roughly one in 10 jobs in Canada. There are more than two dozen regulated health professions across Canada, as well as numerous professional managers employed in various capacities, many of whom have had little or no exposure to the everyday realities of the practice of clinical medicine. Notwithstanding the acknowledgement of the very real and important need for inter-professional collaboration and teamwork, inevitably this creates competition for influence in the health care system.
The CMA 2005 update of its policy on medical professionalism acknowledges the need for change.
While maintaining responsibility for care of the patient as a whole, physicians must be able to interact constructively with other health care providers within an interdisciplinary team setting. The relationship of physicians with their colleagues must be strengthened and reinforced. Patient care benefits when all health care practitioners work together towards a common goal, in an atmosphere of support and collegiality.
Now, physicians are being challenged to clarify exactly what it is that they are prepared to do in order to advance the much-needed transformation of our health care system, and how they will partner with patients, other care providers and the system in order to achieve this common goal. This provides a significant opportunity for physicians to continue their leadership role in the health care transformation initiative in the interests of their patients, while at the same time redefining their relationship with the system (understood in this context as health care administrators, governments and their representatives, health districts, health care facilities and similar organizations) in order to ensure that they have a meaningful and valued seat at the decision-making table, now and in the future.
The common refrain among health administrators, health ministry officials and health policy analysts for the past decade and longer has been that physicians are "not part of the health care system", that they are independent contractors and not employees, and that they are too often part of the problem and not the solution.
Over this period of time, several developments have resulted in a diminished role of physicians in clinical governance in Canada and have, to varying degrees, transformed the professional and collegial relationship between physicians and their health regions, health care facilities and communities to one that is increasingly governed by legislative fiat or regulation.
Beginning with New Brunswick in 1992, all jurisdictions except Ontario, the Yukon Territory and Nunavut have adopted a regional governance model. This change has eliminated all hospital and community services boards within a geographic region and replaced them with a single regional board. Clinical governance is now administered through a regional medical advisory committee (MAC). Some provinces such as Saskatchewan recognize the role of the district (regional) medical staff association. This has had a profound impact in reducing the number of physicians engaged in the clinical governance of health care institutions.
Another by-product of regionalization is that in virtually all jurisdictions, physicians no longer sit on governing boards. While physicians continue to serve as department heads and section chiefs within regions and/or individual hospital facilities, the level of support and financial compensation to do so varies greatly, particularly outside major regions and institutions, and there has been a lack of physician interest in such positions in some places.
In addition to a diminished presence in clinical governance, physicians are less likely to be actively involved in hospitals than they were previously. Anecdotally, many physicians, particularly in larger urban communities, describe having been "pushed out" of the hospital setting, and of feeling increasingly marginalized from the decision-making process in these institutions. Another result of the diminished engagement with hospitals has been the loss of the professional collegiality that used to be fostered through interaction in the medical staff lounge or through informal corridor consultations.
In the community setting, there have been some positive developments in terms of physician leadership and clinical governance. Ontario and Alberta have implemented new primary care funding and delivery models that promote physician leadership of multidisciplinary teams, and at least two-thirds of the family physicians in each of these jurisdictions have signed on. British Columbia has established Divisions of Family Practice, an initiative of the General Practice Services Committee (a joint committee of the BC Ministry of Health and the BC Medical Association), in which groups of family physicians organize at the local and regional levels and work in partnership with the Health Authority and the Ministry of Health to address common health care goals.
Looking ahead, regionalization is also likely to affect physicians in community-based practice. There is a clear trend across Canada to require all physicians within a region to have an appointment with the health region if they want to access public resources such as laboratory and radiology services. In the future this may also result in actions such as mandated quality improvement activities which may be of variable effectiveness and will not necessarily be aligned with the learning needs of physicians.
Physician engagement status
Traditionally physicians have interfaced with hospitals through a privileges model. This model, which has generally worked well, aims to provide the physician with the freedom to reasonably advocate for the interests of the patient.5 In this model, legislation and regulations also require that there are minimum procedures in place for renewing, restricting, and terminating privileges, and that procedures are set out to ensure that this takes place within a fair and structured framework. The hospital's MAC generally reviews physician privileges applications and recommends appointment and reappointment. The MAC thus plays an integral role in ensuring the safety of care within the region or hospital.5
There has been increasing attention recently on engaging in other types of physician-hospital relationships, including employment or contractual arrangements. This type of arrangement can vary from an employment contract, similar to that used by other professional staff such as nurses and therapists, to a services agreement whereby the physician provides medical services to the hospital as an independent contractor.5 However, there are concerns, expressed by the Canadian Medical Protective Association (CMPA) and others, that many of the procedural frameworks and safeguards found in hospital bylaws pertaining to the privileges model may not necessarily extend to other arrangements, and that physicians entering into these contractual agreements may, in some cases, find their appointment at the hospital or facility terminated without recourse. Under such arrangements the procedural fairness and the right of appeal available under the privilege model may not be available to physicians.
One relatively new approach is the appointment model, which aims to combine many of the protections associated with the privileges model with the advantages of predictability and specificity of the employment model. It generally applies the processes used to grant or renew privileges to the resolution of physician performance-related issues.5
It has been argued that changes in appointment status and relationship models can have a detrimental impact on the relationship between practitioners and health care facilities.6 While this has been reported specifically within the context of Diagnostic Imaging, the same may hold true for other specialties as well.
It should also be noted that the issues raised in this paper are applicable to all members of the profession, regardless of their current or future practice arrangements or locations.
Changing physician demographics and practice patterns
It is well recognized that physician demographics and practice patterns have changed significantly over the past several years. Much has been written about the potential impact of these changes on medicine, and their impact on patient care, on waiting lists and on the ability of patients to access clinical services.7 It is also acknowledged that "lifestyle factors," that is to say the attempt by many physicians to achieve a healthier work-life balance, may play a role in determining the type and nature of clinical practice chosen by new medical graduates, the hours they will work and the number of patients they will see.
All of these changes mean that clinical practices may have smaller numbers of patients and may be open shorter hours than in the past. Physicians are being increasingly challenged to outline their understanding of their commitment to ensuring that all patients have timely access to high quality health care within the Canadian public system, while balancing this with their ability to make personal choices that are in their best interests.
Put another way, how can we assist physicians in adjusting their clinical practices, at least to some extent, based on the needs of the population?
While there are clearly challenges and barriers to physician participation in meaningful transformation of the health care system, there are also opportunities for engagement and dialogue, particularly when the doctors of Canada show themselves to be willing and committed partners in the process. Health care transformation cannot be deferred just because it involves difficult decisions and changes to the status quo. Regardless of how we have reached the current situation, relationships between physicians and other parties must evolve to meet future needs. Physicians need to be assisted in their efforts in this regard, both by local health boards and facilities, and by organizations such as the CMA and its provincial and territorial counterparts.
Physicians, individually and collectively, need to demonstrate what they are willing to do to assist in the process and what they are willing to contribute as we move forward, and they need to commit to having the medical profession be an important part of the solution to the challenges currently facing the Canadian system.
We examine some of these challenges through the "AAA" lens of Autonomy, Advocacy and Accountability, which are underpinned by the concept of Physician Leadership.
To a large extent, physicians continue to enjoy a significant degree of what is commonly termed clinical or professional autonomy, meaning that they are able to make decisions for their individual patients based on the specific facts of the clinical encounter. In order to ensure that this autonomy is maintained, physicians need to continue to embrace the concept of clinical standards and minimization of inter-practice variations, where appropriate, while also recognizing the absolute need to allow for individual differences in care based on the requirements of specific patients. Professional autonomy plays a vital role in clinical decision-making, and it is at the heart of the physician-patient relationship. Patients need to feel that physicians are making decisions that are in the best interest of the patient, and that physicians are not unduly limited by external or system constraints. As part of this decision-making, physicians may also need to consider carefully the appropriate balance between individual patient needs and the broader societal good.
In recent years, governments have sometimes made use of the "legislative hammer" to force physicians to conform to the needs of the health system, thus undermining physicians' individual or personal autonomy. Historically, physicians have organized themselves to provide 24-hour coverage of the emergency room and other critical hospital services. This has proven increasingly challenging in recent years, particularly in the case of small hospitals that serve sparsely populated areas where there are few physicians.
Physicians need to continue to make sure that they do not confuse personal with professional autonomy and that they continue to ensure that health care is truly patient-centred. Physicians have rights but also obligations in this regard and they need to make sure that they continue to use a collaborative approach to leadership and decision-making. This includes an ongoing commitment to the concept of professionally-led regulation and meaningful physician engagement and participation in this system.
While physicians will continue to value and protect their clinical and professional autonomy, and rightly so as it is also in the best interests of their patients, they may need to consider which aspects of personal and individual autonomy they may be willing to concede for the greater good.
For example, physicians may need to work together and collaboratively with administrators and with the system to ensure that call coverage is arranged and maintained so that it need not be legislatively mandated, or imposed by regions or institutions. They may need to consider changing the way they practice in order to serve a larger patient population so that patients in need of a primary care physician do not go wanting, and so that the overall patient care load is more evenly balanced amongst colleagues. New primary care models established in Ontario and Alberta over the past decade that provide greater out-of-hours coverage are one example of such an initiative.
By working collaboratively, both individually and collectively, physicians are finding creative ways to balance their very important personal autonomy with the needs of the system and of their patients. These efforts provide a solid foundation upon which to build as the profession demonstrates its willingness to substantively engage with others to transform the system.
To paraphrase from the discussion at the CMA's General Council meeting in August 2011: Physicians need to carefully examine their individual and collective consciences and show governments and other partners that we are willing to play our part in system reform and that we are credible partners in the process.
All parties in the discussion, not only physicians, must be able to agree upon an appropriate understanding of professional autonomy if the health care system is to meet the current and future needs of Canadians.
Physician advocacy has been defined as follows:
Action by a physician to promote those social, economic, educational and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.8
This can consist of advocacy for a single patient to assist them in accessing needed funding for medications, or lobbying the government for changes at a system level. How and when individual physicians choose to undertake advocacy initiatives depends entirely on that individual practitioner, but physicians as a collective have long recognized their obligation to advocate on behalf of their individual patients, on behalf of groups of patients, and at a societal level for changes such as fairer distribution of resources and adequate pandemic planning.
Traditionally, physicians have served as advocates for their patients in a number of arenas; however, various factors such as provincial/territorial legislation, regulatory authorities, and hospital contracts have combined to make them more reluctant to take on this important role and as a result overall patient care may suffer and the patient-physician relationship may be threatened. Increasingly, hospital bylaws urge or require physicians to consult with their institution or health region before going public with any advocacy statements, and in at least one health region physicians are required to sign a confidentiality agreement. Because of this, many physicians fear reprisal when they decide to act as an advocate.
The ability to undertake advocacy initiatives is a fundamental concept and principle for Canadian physicians. Indeed, the CMA Code of Ethics encourages physicians to advocate on behalf of the profession and the public. Patients need to feel that their concerns are heard, and physicians need to feel safe from retribution in bringing those concerns forward.
A well-functioning and respectful advocacy environment is essential to health care planning. Health care is about making choices every day. Governments struggling to balance budgets should be aware that the public can accept that hard choices must and will get made - but they are less likely to be supportive if physicians and their patients do not feel that their opinions are sought and considered as part of the process.
Frontline health care providers, many of whom work in relative isolation in an office or community setting, also need to feel that they have a voice. The CMA supports the need for a forum where primary care physicians can speak with one voice (and make sure that this voice is heard and respected) in a community setting.
In addition to advocating for issues related directly to patient care, physicians, as community leaders, may also be called upon to advocate for other issues of societal importance, such as protection of the environment or social determinants of health. These advocacy undertakings can also be of great importance.
There can be a fine line between advocacy that is appropriate and is likely to affect important and meaningful change, and advocacy that others will perceive as being obstructive or counterproductive in nature. To further complicate matters, what might be seen as appropriate advocacy in one circumstance might not be in a different setting. Physicians should be clear on whose behalf they are speaking and whether they have been authorized to do so. If they have any questions about the possible medicolegal implications of their advocacy activities, they may also wish to contact their professional liability protection provider (e.g., CMPA) for advice in these instances.
Depending on the facts of the individual circumstances, physicians may need to consider other factors as well when deciding if, when and how to undertake advocacy activities. They should also be aware that their representative medical organizations, such as national specialty societies, provincial and territorial medical associations and the CMA, may be able to assist them with their initiatives in certain situations.
Physicians should not feel alone when advocating for their patients, particularly when this is done in a reasonable manner and in a way that is likely to effect meaningful and important change.
Physician accountability can be seen to occur at three levels: accountability to the patients they serve, to society and the health care system and to colleagues and peers.
Accountability to patients
The physician-patient relationship is a unique one. Based on, optimally, absolute trust and openness, this relationship allows for a free exchange of information from patient to physician and back again. Physicians often see patients at their most vulnerable, when they are struggling with illness and disease. While other health care providers make essential contributions to patient care, none maintain the unique fiduciary relationships that are at the heart of the physician's role and which are recognized by law.
Physicians are accountable to their individual patients in a number of important ways. They provide clinical services to their patients and optimize their availability so that patients can be seen and their needs addressed in a timely fashion. They follow up on test results. They facilitate consultations with other physicians and care providers and follow up on the results of these consultations when needed. They ensure that patients have access to after hours and emergency care when they are not personally available.
Physicians can also fulfill their obligation to be accountable to patients in other ways. They can participate in accreditation undertakings to ensure that their practices meet accepted standards. They can ensure, through lifelong learning and maintenance of competency activities, that they are making clinical decisions based on the best available evidence. They can undertake reviews of their prescribing profiles to ensure that they are consistent with best current standards. All of these activities can also be used to maximize consistencies within and between practices and minimize inter-practice variability where appropriate.
Accountability to society and the health care system
Physician accountability at this level is understandably more complex. In general, society and the health care system in Canada provide physicians with financial compensation, with a significant degree of clinical autonomy as reflected by professionally-led regulation, and with a high level of trust. In some cases, physicians are also provided with a facility in which to practice and with access to necessary resources such as MRIs and operating rooms.
In return, physicians agree to make their own individual interests secondary in order to focus on those of their patients, and they agree to provide necessary medical services. Accountability then can be examined based on the extent that these necessary services are provided (i.e. patients have reasonable access to these services) and also the level of quality of those services. Clearly, neither access nor quality can be considered in isolation of the system as a whole, but for the purposes of this paper the focus will be on the role of the physician.
The issue of level and comprehensiveness of service provision has been considered to some extent above under the concept of physician autonomy. Physicians as individuals and as a collective need to ensure that patients have access to timely medical care and follow up. They also need to make sure that the transition from one type of care to another (for example, from the hospital to the community setting) is as seamless as possible, within the current limitations of the system.
Collectively and individually, physicians also have an obligation to make sure that the quality of the care they provide is of the highest standard possible. They should strive for a "just culture of safety", which encourages learning from adverse events and close calls to strengthen the system, and where appropriate, supports and educates health care providers and patients to help prevent similar events in the future.9
Thousands of articles and hundreds of books have been published on the subjects of quality assurance and quality improvement. From a physician perspective, we want to be able to have access to processes and resources that will provide us with timely feedback on the level of quality of our clinical care in a way that will help us optimize patient outcomes and will be seen as educational in nature rather than punitive. As a self-regulated profession, medicine already has strong accountability mechanisms in place to ensure the appropriate standards of care are maintained.
To ensure that physicians are able to meet their obligation to be accountable to the health care system for high quality care, the CMA has developed a series of recommendations for Continuous Quality Improvement (CQI) activities (see box below).
Physicians need to take ownership of the quality agenda. New medical graduates are entering practice having come from training systems where they have access to constant feedback on their performance, only to find themselves in a situation where feedback is non-existent or of insufficient quality to assist them in caring for their patients. While regulators and health care facilities have a legitimate interest in measuring and improving physician performance, ultimately physicians themselves must take responsibility for ensuring that they are providing their patients with the highest possible standard of care, and that mechanisms are in place to ensure that this is in fact the case.
Accountability to colleagues
Physicians are also accountable to their physician peers and to other health care providers. While much of this accountability is captured by the concept of "collegiality," or the cooperative relationship of colleagues, there are other aspects as well.
Anecdotal evidence suggests strongly that many physician leaders find themselves marginalized by their peers. They describe being seen as having "gone over to the other side" when they decide to curtail or forego their clinical practices in order to participate in administrative and leadership activities. Physicians should instead value, encourage and support their peers who are dedicating their time to important undertakings such as these. As well, physicians should actively engage with their administrative colleagues when they have concerns or suggestions for improvement. Collaboration is absolutely vital to the delivery of safe and quality care.
Physicians also need to make sure that they do everything they can to contribute to a "safe" environment where advocacy and CQI activities can be undertaken. This can mean encouraging physician colleagues to participate in these initiatives, as well as serving as a role model to peers by participating voluntarily in CQI undertakings.
Physicians are also accountable to ensure that transition of care from one physician to another occurs in as seamless a manner as possible. This includes participating in initiatives to improve the quality and timeliness of both consultation requests and results, as well as ensuring professional and collegial communications with other physicians and with all team members.
Finally, physicians need to support each other in matters of individual health and well-being. This can include support and care for colleagues suffering from physical or psychological illness, as well as assisting with accommodation and coverage for duty hours and professional responsibilities for physicians who are no longer able to meet the demands of full-time practice for whatever reason.
"You will not find a high performing health system anywhere in the world that does not have strong physician leadership."
Dan Florizone, Deputy Minister of Saskatchewan Health
As we can see from the discussion above, having strong physician leaders is absolutely critical to ensuring that the relationship between physicians and the health care system is one of mutual benefit. Physicians as a collective have an obligation to make sure that they support both the training required to produce strong physician leaders, as well as providing support for their colleagues who elect to undertake this increasingly important role.
Physicians are well-positioned to assume leadership positions within the health care system. They have a unique expertise and experience with both the individual care of patients, as well as with the system as a whole. As a profession, they have committed to placing the needs of their patients above those of their own, and this enhances the credibility of physicians at the leadership level as long as they stay committed to this important value. Leadership is not just about enhancing the working life of physicians, but is about helping to ensure the highest possible standard of patient care within an efficient and well-functioning system.
As part of their leadership activities, physicians need to ensure that they are consistently engaged with high quality and reliable partners, who will deliver on their promises and commitments, and that their input is carefully considered and used in the decision-making process. These partners can include those at the highest level of government, and must also include others such as medical regulators and senior managers. Without ensuring that they are speaking with the right people, physicians cannot optimize their leadership initiatives.
Physician leadership activities must be properly supported and encouraged. Many physicians feel increasingly marginalized when important meetings or training opportunities are scheduled when they are engaged in direct patient care activities. Non-clinician administrators have time set aside for these activities and are paid to participate, but physicians must either miss these discussions in order to attend to the needs of their patients, or cancel clinics or operating room times. This means that patient care is negatively impacted, and it presents a (sometimes significant) financial disincentive for physicians to participate. Some jurisdictions have recognized this as a concern and are ensuring that physicians are compensated for their participation.
Patients want their physicians to be more involved in policy-making decisions and this must be enabled through the use of proper funding mechanisms, reflective learning activities, continuing professional development credits for administrative training and participation, assisting in the appropriate selection of spokespersons including guidelines on how to select them, and guidelines for spokespersons on how to provide meaningful representation of the profession's views.
Physician leadership training must take place throughout the continuum of medical education, from the early days of medical school through to continuing professional development activities for those in clinical practice. Physicians with an interest in and aptitude for leadership positions should ideally be identified early on in their careers and encouraged to pursue leadership activities and training through means such as mentorship programs and support from their institutions to attend training courses and meetings where they will be able to enhance and refine their leadership skills.
There has been action on several fronts to support the organized professional development of physicians in leadership roles. Since the 1990s the Royal College of Physicians and Surgeons of Canada (RCPSC) has been implementing its CanMEDs framework of roles and competencies in the postgraduate medical training programs across Canada, and this has also been adopted by the College of Family Physicians of Canada (CFPC). The CanMEDs framework sets out seven core roles for physicians. Two that are most pertinent to the relationship between physicians and the health care system are those of manager and health advocate.10 These roles highlight the importance of physician involvement in leadership and system engagement activities, and are relevant for physicians in training as well as those in practice.
As managers, physicians are integral participants in health care organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system.
As health advocates, physicians responsibly use their expertise and influence to advance the health of individual patients, communities and populations.
A number of key enabling competencies have been identified for each role, and the RCPSC has developed a variety of resource materials to support the framework.
For almost 30 years, the CMA has been offering the Physician Manager Institute (PMI) program in order to provide training for physicians pursuing leadership and management positions. PMI is offered in "open enrolment" format in major cities across Canada, and also "in house" through longstanding associations with hospitals and health regions (e.g., Calgary zone of Alberta Health Services [AHS]). In 2010 the CMA and the Canadian Society of Physician Executives introduced the Canadian Certified Physician Executive (CCPE) Program. The CCPE is a peer-assessed credential that can be attained either through an academic route that is based on completion of PMI courses or through a practice-eligibility route based on formal leadership experience.11
The CMA also partners with several provincial and territorial medical associations to provide leadership training. Currently CMA has agreements with the Saskatchewan, Ontario and Quebec medical associations and this will extend to the four Atlantic medical associations and the Alberta Medical Association/AHS in 2012.
In addition, a number of university business schools have developed executive program offerings for health leaders. During the past decade, a number of physicians have taken up CEO positions in Canada's major academic health organizations.
Internationally, it has been recognized that physician leadership is critical to the success of efforts to improve health services.12, 13
Having well trained and qualified physicians in leadership roles is critical in making sure that physicians continue to play a central role in the transformation of the Canadian health care system. The CMA and its membership unreservedly support our physician colleagues who dedicate their time and energies to these leadership activities and the CMA will continue to play an integral part in supporting and training the physician leaders of the future.
CONCLUSION: THE CMA'S VISION OF THE NEW PROFESSIONAL RELATIONSHIP BETWEEN CANADIAN PHYSICIANS AND OUR HEALTH CARE SYSTEM
We have explored the factors that have brought us to this point, as well as the issues that must be examined and addressed to enable us to move forward. It is now time for the physicians of Canada to commit to meaningful participation in the process of transforming our health care system. This can only be achieved through the concerted efforts of all parties, including governments, health authorities, health care facilities, physicians and other health care providers. It will not be easy, and it is not likely that this transformation will take place without commitment and sacrifice on our part.
However, now is the time for physicians to demonstrate to their patients, to their colleagues and to society that they are willing to do their share and play their role in this critically important process, at this critically important time. Doing so will help them to achieve the CMA's vision of the new professional relationship between Canadian physicians and the health care system.
In this vision:
Physicians are provided with the leadership tools they need, and the support required, to enable them to participate individually and collectively in discussions on the transformation of Canada's health care system.
Physicians are provided with meaningful opportunities for input at all levels of decision-making, with committed and reliable partners, and are included as valued collaborators in the decision-making process.
Physicians recognize and acknowledge their individual and collective obligations (as one member of the health care team and as members of a profession) and accountabilities to their patients, to their colleagues and to the health care system and society.
Physicians are able to freely advocate when necessary on behalf of their patients in a way that respects the views of others and is likely to bring about meaningful change that will benefit their patients and the health care system.
Physicians participate on a regular and ongoing basis in well-designed and validated quality improvement initiatives that are educational in nature and will provide them with the feedback and skills they need to optimize patient care and outcomes.
Patient care is team based and interdisciplinary with seamless transition from one care setting to the next and funding and other models are in place to allow physicians and other health care providers to practise within the full scope of their professional activities.
1. Canadian Medical Association. CMA Code of Ethics. http://policybase.cma.ca/PolicyPDF/PD04-06.pdf. Accessed 05/20/11.
2. ABIM Foundation. Medical professionalism in the new millennium: a physician charter. Annals of Internal Medicine 2002; 136(3): 243-6.
3. Lesser C, Lucey C, Egener B, Braddock C, Linas S, Levinson W. A behavioral and systems view of professionalism. JAMA 2010; 304(24): 2732-7.
4. Canadian Medical Association. Medical professionalism 2005 update. http://policybase.cma.ca/dbtw-wpd/Policypdf/PD06-02.pdf. Accessed 06/03/11.
5. Canadian Medical Protective Association. Changing physician : hospital relationships. Managing the medico-legal implications of change. 2011. https://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/com_2011_changing_physician-e.cfm. Accessed 02/07/12.
6. Thrall JH. Changing relationship between radiologists and hospitals Part 1: Background and major issues. Radiology 2007; 245: 633-637.
7. Reichenbach L, Brown H. Gender and academic medicine: impact on the health workforce. BMJ. 2004; 329: 792-795.
8. Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: what is it and how do we do it? Acad Med 2010 Jan; 85(1): 63-7.
9. Canadian Medical Protective Association. Learning from adverse events: Fostering a just culture of safety in Canadian hospitals and health care institutions. 2009. http://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/com_learning_from_adverse_events-e.cfm. Accessed 02/07/12.
10. Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 Framework. http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf. Accessed 05/20/11.
11. Canadian Society of Physician Executives and Canadian Medical Association. Canadian Certifies Physician Executive. Candidate Handbook. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Leadership/CCPE/2012CCPE-Handbook_en.pdf. Accessed 05/20/11.
12. Ham C. Improving the performance of health services: the role of clinical leadership. Lancet 2003; 361: 1978-80.
13. Imison C, Giordano R. Doctors as leaders. BMJ 2009; 338: 979-80.
Vision for e-Prescribing: a joint statement by the Canadian Medical Association and the Canadian Pharmacists Association
By 2015, e-prescribing will be the means by which prescriptions are generated for Canadians.
e-Prescribing is the secure electronic creation and transmission of a prescription between an authorized prescriber and a patient's pharmacy of choice, using clinical Electronic Medical Record (EMR) and pharmacy management software.
Health Information Technology (HIT) is an enabler to support clinicians in the delivery of health care services to patients. The Canadian Medical Association (CMA) and the Canadian Pharmacists Association (CPhA) each have identified e-prescribing as a key tool to deliver better value to patients. The integration of HIT into clinics and health care facilities where physicians and pharmacists provide care is a priority for both associations1.
As part of its Health Care Transformation initiative, the CMA highlighted the need to accelerate the introduction of e-prescribing in Canada to make it the main method of prescribing. In its policy on optimal prescribing the CMA noted that one of the key elements was the introduction of electronic prescribing. The CPhA, as part of its Blueprint for Pharmacy Implementation Plan, highlights information and communication technology, which includes e-prescribing, as one of five priority areas.
We applaud the ongoing efforts of Canada Health Infoway, provinces and territories to establish Drug Information Systems (DIS) and the supporting infrastructure to enable e-prescribing. We urge governments to maintain e-prescribing as a priority and take additional measures to accelerate their investments in this area.
It is our joint position that e-prescribing will improve patient care and safety. e-Prescribing, when integrated with DIS, supports enhanced clinical decision-making, prescribing and medication management, and integrates additional information available at the point of care into the clinical workflow.
The following principles should guide our collective efforts to build e-prescribing capability in all jurisdictions:
* Patient confidentiality and security must be maintained
* Patient choice must be protected
* Clinicians must have access to best practice information and drug cost and formulary data
* Work processes must be streamlined and e-prescribing systems must be able to integrate with clinical and practice management software and DIS
* Guidelines must be in place for data sharing among health professionals and for any other use or disclosure of data
* The authenticity and accuracy of the prescription must be verifiable
* The process must prevent prescription forgeries and diversion
* Pan-Canadian standards must be set for electronic signatures
Benefits of e-Prescribing
A number of these benefits will be realized when e-prescribing is integrated with jurisdictional Drug Information Systems (DIS).
o Improves patient safety and overall quality of care
o Increases convenience for dispensing of new and refill prescriptions
o Supports collaborative, team-based care
o Supports a safer and more efficient method of prescribing and authorizing refills by replacing outdated phone, fax and paper-based prescriptions
o Eliminates re-transcription and decreases risk of errors and liability, as a prescription is written only once at the point-of-care
o Supports electronic communications between providers and reduces phone calls and call-backs to/from pharmacies for clarification
o Provides Warning and Alert systems at the point of prescribing, supporting clinician response to potential contraindications, drug interactions and allergies
o Facilitates informed decision-making by making medication history, drug, therapeutic, formulary and cost information available at the point of prescribing
* Health Care System:
o Improves efficiency and safety of prescribing, dispensing and monitoring of medication therapy
o Supports access to a common, comprehensive medication profile, enhancing clinical decision-making and patient adherence
o Increases cost-effective medication use, through improved evidence-based prescribing, formulary adherence, awareness of drug costs and medication management
o Improves reporting and drug use evaluation
While evidence of the value of e-prescribing is established in the literature, its existence has not fostered broad implementation and adoption. In Canada, there are a number of common and inter-related challenges to e-prescribing's implementation and adoption. These include:
* Improving access to relevant and complete information to support decision-making
* Increasing the level of the adoption of technology at the point of care
* Focusing on systems-based planning to ensure continuum-wide value
* Integrating e-prescribing into work processes to gain support from physicians, pharmacists and other prescribers
* Increasing leadership commitment to communicate the need for change, remove barriers and ensure progress
* Updating legislation and regulation to support e-prescribing
Enabling e-Prescribing in Canada
CMA and CPhA believe that we can achieve the vision that is set out in this document and address the aforementioned challenges by working collectively on five fronts:
* Health care leadership in all jurisdictions and clinical organizations must commit to make e-prescribing a reality by 2015
* Provinces and territories, with Canada Health Infoway, must complete the building blocks to support e-prescribing by increasing Electronic Medical Record (EMR) adoption at the point of care, finishing the work on the Drug Information Systems (DIS) in all jurisdictions and building the connectivity among the points of care and the DIS systems
* Pharmacist and medical organizations in conjunction with provinces, territories and Canada Health Infoway must identify clear benefits for clinicians (enhancing the effectiveness of care delivery and in efficiencies in changing workflows) to adopt e-prescribing and focus their efforts on achieving these benefits in the next three years
* Provinces, territories and regulatory organizations must create a policy/regulatory environment that supports e-prescribing which facilitates the role of clinicians in providing health care to their patients
* Provinces and territories must harmonize the business rules and e-health standards to simplify implementation and conformance by software vendors and allow more investment in innovation.
1 Health Care Transformation in Canada, Canadian Medical Association, June 2010; Blueprint for Pharmacy Implementation Plan, Canadian Pharmacists Association, September 2009
In 2007, The College of Family Physicians of Canada (CFPC) and The Canadian Medical Association (CMA) established a partnership to explore wait times in primary medical care - the CFPC-CMA Primary Care Wait Time Partnership (PCWTP). The goal of the Partnership is to advocate for timely access to health care for all Canadians.
The first part of the wait time continuum that can be measured is when the patient schedules his or her first visit ith a family physician. A family physician may then refer the patient to specialty care. Both of these stages in the continuum have not been addressed in wait time discussions thus far. The available evidence suggests that one-half of the total waiting time for family physician referral to treatment is from family physician referral to when the patient is seen by the consulting specialist.
Thus, there are three main issues around our focus on primary care wait times:
Access to primary care for those without a family physician;
Access to primary care for those with a family physician; and
Referral from primary to more highly specialized care.
The CFPC has proposed a target that 95% of Canadians in each community have a family physician by 2012. There are two ways to achieve this goal: 1. increase the number of family physicians practicing in Canada and 2. increase the capacity of existing family physicians. To help address the supply issue, medical schools must find innovative ways to encourage more medical students to choose family medicine. A second approach to increasing the supply of family physicians is to provide more training opportunities so that qualified International Medical Graduates can be integrated into the family physician workforce. In terms of capacity, there are a number of approaches that have been taken to help improve family physicians' ability to take on additional patients. For example, financial incentives geared towards this objective have been included in some physician contracts. However, much more can be done in this regard, such as improving patient flow with more efficient practice management procedures
There are several models for primary care delivery operating in Canada, including various collaborative practice arrangements with different care providers working together. However, thus far there is no conclusive evidence that any one particular model is better than all of the others in terms of providing timely access to care. Many studies have compared various models in a variety of ways; each with different conclusions. While there is no definitive research on best models for primary care delivery, there is a range of innovative approaches to enhancing timely access to quality primary medical care. More research is necessary to help determine which model or models of primary care, if broadly implemented, will make considerable improvements to patient access.
Aside from collaborative care practice models, we must look for solutions that increase patient access to care through enhanced practice efficiency and not by expecting family physicians to work harder and longer. Physicians should be educated on how to run a practice from a patient flow point of view as well as a financial one. To address this, enhanced practice management training should be provided during medical school education and residency levels and Continuing Medical Education programs should be created.
One method of improving practice efficiency is through a process known as Clinical Practice Redesign (CPR). The main objective CPR is to improve patient flow through a medical practice. This involves the use of effective scheduling management techniques that allow appropriate prioritizing of patient visits. This undertaking requires commitment from physicians as well as effective information management and measurement tools, additional practice support and assistance from change management experts. These efforts can go a long way to help improve patient access and increase capacity to accommodate patient appointments.
One of the key challenges of primary care wait times is to establish guidelines for timely access to specialty care. This is potentially an enormous undertaking given that there are some 60 recognized specialties and sub-specialties in Canada and each of them is responsible for treating a number of conditions presenting to the family physician. Due to the varying degree of complexity of a patient's medical problem, an appropriate wait time would be difficult to define by a particular disease or illness.
Given the wide spectrum of illnesses that are assessed in a primary care setting, any approach to developing wait time targets must be done in consultation with family physicians and with clinical guidelines in mind.
When a patient is referred to more highly specialized care, a concerted effort must be made to keep the lines of communication as open as is feasible between family physicians and consulting specialists, in both directions. Improved communication between providers is essential to improving the wait time at this point in the continuum.
While timely access to family physicians and the referral time to other specialists is a nationwide concern, access to health care can be a greater challenge in rural locations. Any guidelines regarding wait times to specialty care must also account for the geographic factors that affect access.
When considering the concept of target-setting, a significant investment in information infrastructure is required to facilitate the measurement and monitoring of access to primary care physicians and referrals to other specialists. Furthermore, it must be acknowledged that regardless of how targets are determined, even if they are met, not everyone will receive care within the most appropriate period of time for their particular situation.
In 2007, The College of Family Physicians of Canada (CFPC) and The Canadian Medical Association (CMA) established a partnership to explore wait times in primary medical care - the CFPC-CMAPrimary Care Wait Time Partnership (PCWTP). The goal of the Partnership is to advocate for timely access to primary care for Canadians.
The Partnership released its interim report, ... And Still Waiting: Exploring Primary Care Wait Times in Canada, in April 2008 to stimulate discussion and
agreement about ways to improve timely access to primary care and from primary to more highly specialized care. It reviewed a broad range of issues faced by family doctors in a health system that has largely ignored the wait time challenges their patients face and was very well received by members of the CMA, CFPC and other stakeholders. This final report is a focused approach to some of the recommendations and solutions, especially of relevance in primary medical care.
The difficulty in measuring primary care wait times for myriad illnesses and conditions was identified in the first report as one that may impede progress in finding solutions to the wait time challenges that family doctors experience. The PCWTP believes that the initial requirement is the ability to measure and track wait times along the continuum of the patient's care but that this capacity in primary as well as more highly specialized levels of care is still very limited. There is also the need to prioritize which benchmarks or targets should be attained along the patient's wait time continuum: 1) to find a family physician; 2) to be seen by a family physician; and 3) to have a diagnostic intervention or to be seen by a consulting specialist.
The difficulty in measuring primary care wait times for myriad illnesses and conditions...may impede progress in finding solutions to the wait time challenges that family doctors experience.
Methodology and Scope of Report
This paper is an opportunity to draw attention to issues of relevance to family physicians and their patients waiting for care - either to find a family doctor, or to be seen by their family doctor or to be seen by another specialist. The paper is a reflection of several data sources, including:
Expert opinion from family physician leaders in practice and research
The National Physician Survey (NPS) results from 2004 and 2007
Given the available expertise within the PCWTP representing two national medical organizations that advocate for patients in primary care and for the resources that support high quality care, the authors of this paper are in a unique position to use their knowledge and understanding to contribute to the proposed solutions and recommendations.
It is easier to define what is in than what is out of scope for this paper. There is a variety of important influences coming to bear on primary care wait times. Some are beyond the scope of this discussion. For example, the health system is promoting more collaborative care and while this is an increasingly important part of practice, its influence on primary care wait times has yet to be determined.
There are also enablers and impediments to improved access to care, some of these still poorly defined. For example, where a physician practices and the influence of location, e.g. suburban in contrast to rural communities, makes a difference to access. The location of resources based on criteria such as cost-effectiveness and skill maintenance requires more attention. Likewise, new models of primary care are encouraging incentives to practice differently. But it is still uncertain how these new models of care are affecting access to timely care.
Finally, there are many personal factors that affect patient choice and physician decision in determining when access is acceptable or when it is intolerable. Risk plays an important part in these decisions but not all risk is measurable. Some experts have also suggested not every waiting list is a bad list. These issues require much more analysis than this paper allows.
In short, recommendations for further research will be reinforced as much by what we know as by what we still do not know.
What Does It Mean?
In the first report by the PCWTP, primary care was defined as first-contact medical care and services provided by family physicians and general practitioners. In contrast, primary health care was defined as the broader determinants of health, including health services delivered by other professional providers. Likewise, in that report it was acknowledged that "primary care is the foundation and family physicians are the backbone of the health system as the first points of contact for most patients." Patients have access to a continuum of medical services by first presenting to their family physician at the primary care level.
Individuals may require specialty care at various points in their lives. Patients may see several specialists for a variety of problems; however, patients' family physicians play an important role during interaction with specialty care throughout the continuum of lifelong care.
(Figure 1) [SEE PDF FOR CORRECT DISPLAY]
What does it mean to have a family physician? As set out in the CFPC's Four Principles of Family Medicine, a person may be said to have a family physician when they have established a patient-physician relationship that provides for continuing care through repeated contacts across the life cycle and in which the physician becomes an advocate for the patient by referring to other specialists and other health care resources as appropriate. While in the past this relationship has often been established through an unwritten contract, in some of the new practice models patients are formally "rostered", that is to say they sign a commitment to seek all of their non-emergent care from the particular physician or clinic.
Patients may see several specialists for a variety of problems; however, patients' family physicians play an important role during interaction with specialty care throughout the continuum of lifelong care.
What does it mean to not have a family physician? Persons without a family physician are those without an established relationship with a primary care physician who maintains a continuous medical record for them.
The largest population-based surveys that collect data on health care use among the general population have been conducted by Statistics Canada. They have not asked specifically about "family physicians" but rather about "regular doctors" or "regular medical doctor". In its 2007 Canadian Community Health Survey (CCHS), Statistics Canada asked the simple question, Do you have a regular medical doctor?1 Nationally, 85% of the population aged 12 or older reported that they did. In 2008, the CFPC commissioned a Harris/Decima survey and found that 86% of respondents had a family physician. 2 The CFPC proposed a target that 95% of Canadians in each community have a family physician by 2012. Some regions of the country may be close to attaining this target while others have far to go.
Persons with a regular doctor are more likely to report greater continuity of care. According to Statistics Canada's 2007 Survey of Experiences with Primary Health Care, among the 86% of the population reported to have a regular medical doctor, 95% said that they would either definitely or probably be taken care of by the same physician or nurse each time they visited their physician's office. In contrast, among the 10% of the population with no regular doctor but some regular place of care, just 31% said they would definitely or probably see the same physician or nurse with each visit. 3
What does it mean to not have a family physician? Persons without a family physician are those without an established relationship with a primary care physician who maintains a continuous medical record for them. These are referred to as unattached (or orphaned) patients. They obtain episodic care from places like walk-in clinics and hospital emergency rooms (ERs). A recent report by the Institute for Clinical Evaluative Sciences (ICES) found that there are significant excess visits to ERs among people with chronic conditions who do not have a regular family physician. 4 Reducing the number of unattached patients could therefore have a substantial impact on the problem of overcrowded ERs.
Of the estimated 4.1 million Canadians aged 12 and over who indicated that they did not have a regular doctor in the 2007 CCHS, 78% reported that they had some other usual source of care. Among these individuals, the most frequently cited source of care was walk-in clinics (64%), followed by hospital emergency rooms (12%), community health centres (10%) and "other" (14%). 5
The Concept of the Medical Home
For those with a family physician there has been an increase in the literature in the United States on the concept of a "medical home". In 2007 the American Academy of Family Physicians and three other medical associations adopted "joint principles of the patient-centered medical home" that include:
-each patient having a personal physician
-physician directed medical practice
-whole person orientation
-coordinated care across all elements of the health system
-quality and safety (e.g. support for optimal patient-centered outcomes)
-enhanced access to care (e.g. open appointment scheduling); and
-appropriate payment incentives. 6
The Commonwealth Fund attempted to assess the proportion of patients with a medical home in their 2007 International Health Policy Survey. Their definition included patients that have "a regular doctor or place that is very/somewhat easy to contact by phone, always/often knows medical history, and always/often helps coordinate care (yes)." While 84% of Canadian respondents on the survey reported that they had a doctor that they usually see (consistent with all other survey estimates), just under one out of two (48%) were considered to have a medical home according to the Commonwealth Fund definition. Of the seven countries surveyed, respondents in New Zealand and Australia were the most likely to be considered as having a medical home (61% and 59% respectively). 7
Primary Care Models
There are several models for primary care delivery and thus far there is no conclusive evidence that any one particular model is better than all of the others. Many studies have compared various models in a variety of ways; each with different conclusions. For example, a comprehensive comparative study on the productive efficiencies of four models of primary care delivery in Ontario concluded that no one type of model dominates and that further research is required. 8
Furthermore, another study comparing various primary health care models with regard to a number of variables including access and quality came to the same conclusion. It found that the fee-for-service physician practice model ranked highest in terms of patient access and responsiveness, while community health centres ranked highest in effectiveness, productivity, continuity and quality. 9
Finally, another study that compared patient satisfaction in walk-in clinics, ERs and family practices came to the conclusion that in terms of waiting time, patients were most satisfied with family practices. 10
While there is no definitive research on best models for primary care delivery, this report shows there is a range of innovative approaches to enhancing timely access to quality primary medical care.
The issue of wait times has dominated the health policy agenda in Canada, particularly since the First Ministers Accord in 2004. Prior to that however, in their February 2003 Accord, which they considered to be a "covenant", governments agreed to develop and report on common indicators. Among the 40 indicators listed in the 2003 Accord, in addition to access to primary care (measured as a percentage of the population with a regular family doctor and a percentage of doctors accepting new patients), the list included seven wait-time/volume indicators, of which the following were pertinent to primary care:
-referral to specialists for cancers (lung, prostate, breast, colo-rectal), heart and stroke;
-diagnostic tests (MRI, CT); and
-proportion of services/facilities linked to a centralized (provincial/regional) wait list management system for selected cancers and surgeries, referral to specialists, emergency rooms and diagnostic tests. (11)
These commitments were overtaken, however, by the 2004 Accord which called for evidence-based benchmarks for five procedures including cancer, heart, diagnostic imaging, joint replacements and sight restoration. (12) National benchmarks were achieved in December 2005, but they begin from the point where the decision has been reached on treatment between the consulting specialist and patient. (13)
A. To Family Medicine
In discussions regarding the total time patients wait for care, what is often overlooked is the fact that the wait time continuum starts when a patient has a medical problem. However, the first part of the continuum that can be measured is when the patient schedules his or her first visit with a family physician. Figure 2 below illustrates the full wait time continuum.
[figure 2. SEE PDF]
Access to a family physician is a major concern in this country. In a series of focus groups conducted by Ipsos-Reid across Canada in 2007 on behalf of the CMA, the following concerns/issues were raised by some patients:
-people had been searching for a family physician for several years without success;
-people with a family physician were frightened about the prospect of their doctor retiring; and
-people with a family physician reporting waits of three or four weeks to get an appointment.(14)
According to the Commonwealth Fund survey in 2007, Canada had the lowest rate of same-day physician appointments by a wide margin. 22% of respondents said they could see their physician on the same day, versus 30% in the US and 41% and higher for the remaining five countries. Canada also had the highest rate of respondents noting it took six or more days to see their physician, at 30%, as opposed to 20% for Germany and the US and lower for the other four
countries surveyed (7). However, in the 2007 National Physician Survey (NPS), 65% of family physicians stated that their patients with urgent needs are able to see them within one day. For non-urgent cases, 41% are able to see their patients within one week and 66% are able to see their non-urgent patients within four weeks.(15)
In the 2007 Health Council of Canada survey, of the 26% of respondents who stated they require routine or ongoing care, 45% noted that they had to wait too long for an appointment and 29% said it was difficult to get an appointment. 16 Furthermore, according to the 2007 NPS, when other specialists were asked to rate their patients' access to family physicians, only 13% gave it a very good or excellent rating, while over half (55%) gave it a fair or poor rating.
This survey also found that 86% of family physicians stated they had made arrangements for care for their patients outside of their normal office hours. When asked to list the arrangements they have in place, one third (33%) said they extend their office hours, over one third (37%) operate an after-hours clinic that is staffed by members of their practice and 41% included calling a 24/7 telehealth phone line as an option. However, over half (52%) included going to an ER as one of these arrangements.(15)
The aforementioned surveys have shown there is evidence of a disparity between patients' and physicians' perspectives regarding access to primary care. Moreover, Canada lags behind other countries in access to primary care.
B. To Specialty Care
The next stage of the wait time continuum is also often overlooked. This is when a family physician refers the patient to specialty care. The Fraser Institute's research on patient wait times does take this into account, however. According to their most recent survey, the average wait time between referral by a family physician and a consulting specialist fell from 9.2 weeks in 2007 to 8.5 weeks in 2008.(17) It is encouraging to see some movement in the right direction, but there is much more room for improvement. According to the 2007 NPS, only one quarter (24%) of family physicians rated patient access to other specialists as very good or excellent, while over one third (36%) of family physicians rated patient access to other specialists as fair or poor. 15 Some specialists will not take phone calls from family physicians - the only method of communication is by fax, which makes it difficult for the family physician to confirm whether the consulting specialist has received the referral and acted on it.
Efforts must be made to keep the lines of both communication and access as open as is feasible between family physicians and consulting specialists, in both directions. Other specialists have noted having some difficulty scheduling appointments for their patients with their family physicians after consultation and/or treatment.
The Canadian Medical Protective Association (CMPA) has identified a specific process for referring physicians to follow and includes the following guidance: When a patient is referred to a consulting specialist, the family physician should provide sufficient clinical information so that the consultant can appropriately prioritize his or her referrals. The consultant should notify the family physician of the patient's scheduled appointment. If the timing of this appointment does not seem reasonable to the family physician, he or she should then attempt to schedule an earlier appointment. If this is not possible, the family physician should consider alternative options to seek specialty care and discuss these with the patient. The patient should also be informed of what to expect if his or her condition changes while waiting for specialty care, and what to do and who to consult if this occurs. 18 The Collaborative Action Committee on Intra-professionalism (CACI) was established in 2006 by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada to discuss enhancing intra-professionalism and exploring ways to encourage desired behaviours that will improve physicians' intra-professional relationships. This work is vital to ensure a seamless continuum of care for patients between family physicians and other specialists. Working groups have been established to focus on improving relations through medical education, training and accreditation and in practice by developing enhancements to the referral-consultation process. (19)
Should a timely referral not be available, the CMPA's latest guidance on wait times in a September 2007 information sheet addresses the issue of liability when health-care resources such as specialty care are limited. The sheet notes that physicians may be requested to provide care outside their area of expertise when resources are scarce. While noting that the courts have yet to address this issue, it suggests the "courts will not evaluate your decisions against a standard of perfection. Rather, your decisions will be evaluated in light of what a reasonable and prudent physician like you would have decided in similar circumstances". 20 Nonetheless, given that the decision to refer implies that a physician has determined that a problem is beyond his or her scope of practice, the issue of support for the physician managing what might be long waits for specialty care will need to be addressed.
An additional barrier to timely patient access to specialty care is the inconsistency in family physicians' abilities to order advanced diagnostic tests. The Canadian Association of Radiologists (CAR) has guidelines for all physicians to follow when ordering diagnostic tests.
C. Rural Versus Urban Access
While timely access to family physicians and the referral time to other specialists is a nationwide concern, access to health care is often considered a greater challenge in rural locations. The 2007 NPS survey found that this is not the case. In fact, the opposite is true. There is very little difference in same-day family physician access rates between urban and rural locations and with regard to other specialties, the difference between urban and rural physicians is notable, with 51% of rural physicians stating that urgent appointments can be made on the same day as opposed to only 37% of urban physicians.
However, there is a difference between rural and urban settings with regard to factors that increase demand on a physician's time. For example, the 2007 NPS found a lack of availability of other specialists locally was a more significant factor for rural physicians (65%) than for urban (55%), as was the lack of other health care professionals, which was a concern for 66% of rural physicians in contrast to 54% for urban physicians. This survey shows that health human resources is a concern for all physicians, especially in rural settings. (15)
It should be pointed out that rural and urban physicians' differing perceptions about access for their patients may have an effect on survey findings; the weather and distance to travel to obtain specialty care, for example, affect a rural family physician's view of the quality of access.
The 2007 NPS found that access to Routine andAdvanced Diagnostics was rated very similarly by rural and urban physicians of all specialties, with access to routine services rated higher than access to advanced services in all respects. When the physician's specialty is taken into account, both rural and urban family physicians rated access to routine diagnostics higher than other specialists (very good or excellent - 48% versus 37%). The reverse is true for access to advanced diagnostics, with 15% of family physicians rating it very good or excellent, whereas 21% of other specialists gave it these rankings. (15)
Any guidelines regarding wait times to specialty care must also account for the geographic factors that affect access. The most commonly regarded solution to the problem of access to specialty care in rural regions is to increase the number of specialty services in that area; for many specialties, however, this may not be feasible due to insufficient numbers of patients residing in the area to support an effective workload.
Next Steps - Finding Solutions
For the purposes of this paper, "target" is defined as a time-based standard for accessing care.
A. Measuring Primary Care Wait Times
What primary care wait times should be measured? How can they be measured? While the selection of the five priority areas noted earlier has stimulated progress in the measurement of waiting for treatment once the consulting specialist has been seen, as the Fraser Institute has reported for the past two years, nationally one-half of the total waiting time for family physician referral to treatment is from family physician referral to when the patient is seen by the consulting specialist. In 2008 the Institute estimated the average total wait from referral to treatment at 17.3 weeks; of this the wait from referral to specialty consultation was estimated at 8.5 weeks - 49% of the total (17).
Among the recent provincial/territorial initiatives there has been no systematic effort to capture the time from family physician referral to specialty consultation. For its part, the Wait Time Alliance is launching a project in spring 2009 that will record the actual total waiting time from initial referral to treatment among a sample of consulting specialists and their patients.
B. Setting Targets
For the purposes of this paper, "target" is defined as a time-based standard for accessing care. This may be further graduated by the urgency for which the care is needed, and it may also be qualified by a percentage threshold of attainment. For example, "90% of patients with the least urgent requirement for care will be seen within one month of referral".
When considering the concept of target-setting, two important points must be stressed:
- before any reasonable wait time targets can be established, a significant investment in information infrastructure is required to facilitate the measurement and monitoring of access to primary care physicians, appointments and referral to other specialists; and
- regardless of how the targets are determined, even if the targets are met, not everyone will receive care within the most appropriate period of time for their particular situation.
Targets to Accessing Primary Care
There are two key considerations in this paper with regard to targeting wait times in access to primary care. While other jurisdictions and researchers have considered other approaches, e.g. wait times to access a primary care setting, this paper is focused on ways to improve timely access to primary medical care for those Canadians who have their own family physician and for those who do not - as well as timely access to specialty care services from their family physician.
Finding a Family Physician
What would it take to reach the target of 95% of Canadians in each community having a family physician by 2012? An estimated 4.1 million Canadians aged 12 or older do not have a family physician. Statistics Canada further subdivides the 4.1 million into those who have not looked for a family physician (2.4 million) and those who have looked but cannot find one (1.7 million) (1). A telephone survey conducted by Harris/Decima in October and November 2008 found that of the 14% of respondents who do not have a family physician, 61% were not looking for a family physician for themselves or a family member. 45% of these stated they are not looking for one because they go to a walk-in clinic or an ER instead, whereas the other half were not looking because they presumed no family physicians were available.(2)
It would seem reasonable that the population who has looked for but cannot find a family physician should be a priority target to advancing toward the 2012 goal. As advocated and explored by the CFPC, this may entail establishing registries for unattached patients in communities across Canada. Several provinces and territories have included incentives in their physician contracts for taking on unattached patients and it would be useful to assess their effectiveness.
One way to increase the number of family physicians practicing in Canada is to encourage more medical students to choose family medicine by exposing them to family practices early on and to obtain placements in practices that are keenly interested in demonstrating the benefits of family practice to medical students. Support for family practice preceptors and teachers is also important. Incentives to attract more preceptors are required and facilities should be created to improve medical students' awareness of these opportunities across the country.
Ontario has set a target of finding a family physician for 500,000 unattached patients over the next three years. 21 Ontario already has in place an incentive schedule for patients in its primary care models to take on new patients. The most common of these models (i.e. with the largest number of physicians participating) is the Family Health Group, which provides a payment of $100 each for up to 50 newly enrolled patients without a family physician per year with a premium of 10% for patients aged 65-74 and 20% for those aged 75 and over. There is also a payment of $150 for rostering unattached patients discharged from an inpatient hospital stay. Effective April 1, 2009 a complex/vulnerable new patient fee of $350 will also be introduced, with criteria still under development.
New Brunswick has a pilot project in place that is based on a $150 premium, payable in addition to fee-for-service (FFS) billings in installments of $50 per visit up to the maximum. In the Yukon, family physicians who accept unattached patients are paid $200 over and above the initial visit fee.
95% of Canadians in each community should have their own family physician by 2012
Another option currently being discussed in a number of jurisdictions is to allow faster integration of qualified International Medical Graduates (IMGs) by evaluating the equivalency of family medicine training and qualification programs done in other countries. In order to increase the number of family physicians who are trained to provide high-quality care, the CFPC recently approved the following initiatives:
-Expansion of the Alternative Route to Certification for practicing FPs interested in Certification in Family Medicine (practice eligible) to those who have been practicing for at least five years in Canada.
-Granting Certification to family physicians who hold Certification with the American Board of Family Medicine (ABFM), are in good standing with the American Academy of Family Physicians and are moving to Canada.
-Evaluate other postgraduate family medicine training and certification programs in jurisdictions outside Canada in order to consider granting reciprocity for family physicians with training and certification equivalent to family medicine programs in Canada.
Access to Family Physicians
In terms of targeting approaches to the time to get an appointment to see the family physician, it would appear that the "evidence-based" approaches of urgency scoring will be impractical because they require an assessment of the patient. It may be worth investigating the methodology used by the provincial health phone lines to triage patients based on the use of structured algorithms and exploring whether this can be used in a primary care physician office to better gauge the level of each patient's need to see their physician and to organize the physician's patient schedule in a more effective manner. This would require additional resources (both staff and technology) be made available to the family physician's practice.
Want to learn more?
Capital Health in Halifax is exploring "a program of supports for family physicians and family practice nurses working in fee-for-service practices in Nova Scotia: www.cfpc.ca/nursinginfamilypracticeTQVI
When considering approaches to address the issue of increasing access for patients with a family physician, we must look for solutions that do so through enhanced practice efficiency and not by expecting family physicians to work longer.
Improving practice efficiencies can be accomplished through enhanced practice management training during medical school education and residency levels. Continuing Medical Education programs on this topic will also be beneficial. Physicians should be educated on how to run a practice from a patient flow point of view as well as a financial one. To encourage interest in this aspect of running a medical practice it is important that they are made aware of all of the benefits of a well-managed office (e.g. more time spent doing direct patient care, the ability to increase patient load and attain a better work-life balance).
New Approaches to Practice Management
Some progress is being made to enhance Canadians' access to primary care. A variety of projects are underway that have already shown improvements in this area, including a number of successful efforts occurring in British Columbia, Alberta and Saskatchewan that include the implementation of a innovative practice management system known as Advanced Access. The term Clinical Practice Redesign (CPR) is becoming a more popular description of the process involved.
"Advanced Access is about reengineering clinic practices so that patients can see a physician or other primary care practitioner at a time and date that is convenient for them. The advanced access model is often considered to be another scheduling system; however, it is in fact a comprehensive approach to effective patient care delivery."(22)
The main objective of CPR is to improve patient flow through a medical practice. This involves the use of effective scheduling management techniques that allow appropriate prioritizing of patient visits. The main premise is that if patient demand for appointments is overall in balance with the physician capacity to schedule appointments, it should be possible to offer patients an appointment on the same day that they telephone for one. The challenge is to work down the backlog and achieve that balance. Once this is accomplished, the wait time to see the physician can be dramatically reduced.
The originators of this concept have identified six steps in implementing CPR:
1. Measure and balance supply and demand
2. Eliminate the accumulated backlog
3. Reduce the number of appointment types
4. Develop contingency plans (e.g., flu season)
5. Reduce and shape demand (e.g., phone and e-mail for answering questions)
6. Increase effective supply by delegating tasks 23
Want to learn more?
Family Physician Dr. Ernst Schuster presents advanced access in family practices through the Alberta Access Improvement Measures (AIM): www.cfpc.ca/advancedaccessTQVI
The sentinel indicator that is used to monitor CPR is what is termed "third next available appointment" and is defined as the average length of time in days between the day a patient makes a request for an appointment with a physician and the third available appointment.
Another common patient scheduling technique, often misinterpreted as Advanced Access, is more accurately referred to as the "carve out" model. It involves keeping a block of time open each day for patients who call that day for an urgent appointment. While it allows patients with an urgent problem to see their family physician the same day, it could potentially make the wait time for non-urgent problems longer as there are fewer appointment times that can be used for those cases. It is nonetheless a step in the right direction and shows that family physicians are making efforts to alleviate the primary care access problem.
CPR is gaining momentum as a popular method of improving practice efficiency. The first group practice to adopt this system in Saskatchewan was able to reduce its average wait time from 17 days to just two. (24) In addition to reducing wait times, many practices in British Columbia, Alberta and Saskatchewan have been able to increase their patient load due to efficiency improvements. This is therefore also addressing the concern about the large number of Canadians who do not have a family physician.
The United Kingdom Experience
The UK has adopted fixed targets for primary care, irrespective of the patient's presenting condition. The 2004 National Health Service (NHS) Improvement Plan set out a 24/48 hour access target, by which UK patients would be guaranteed the opportunity of seeing a primary care provider within 24 hours and a GP within 48 hours. (25) The UK has since adopted an incentive approach to achieving this target through an Improved Access Scheme. First implemented on a voluntary basis in 2007, some 5 million surveys were sent to GPs' patients across England about their recent experience with access to their GP. The survey results are linked to a reward payment that has four elements:
- 48 hour target reward element;
- advance booking target reward element;
- ease of telephone access target reward element; and
- preferred health care professional target reward element.
The level of payment for each element is linked to the satisfaction level reported by the patients. (26)
The survey has now been successfully administered twice. In 2008, almost two million responses were received - a 41% response rate. Key findings from the 2008 survey include the following:
- 87% of patients reported that they were satisfied with their ability to get through to their doctor's surgery on the phone.
- 87% of patients who tried to get a quick appointment with a GP said they were able to do so within 48 hours.
- 77% of patients who wanted to book ahead for an appointment with a doctor reported that they were able to do so.
- 88% of patients who wanted an appointment with a particular doctor at their GP surgery reported that they could do this. (27)
Any kind of patient-based reporting on access requires an up-to-date electronic roster of patients. The survey tool used in the UK is very simple and can be completed online. It should be noted however that the cost of the 2007 survey was estimated at £11 million although this also includes the patient choice survey. (28)
No doubt less complex approaches could be developed for applying an incentive approach to reach targets in Canada. However, this would involve the types of supports and resources available to general practitioners in the UK. In addition, the views of the public and patients should be sought before adopting any targeting approaches in primary care. This was emphasized by Berta et al in a Canadian public opinion study of the importance of ten measures of primary care performance. They found that the most important factors for patients were related to the family physicians' knowledge and skills, while the access indicators were least important. (29)
Targets to Accessing Specialty Care
One of the key challenges of primary care wait times is to establish guidelines for timely access to specialty care. This is potentially an enormous challenge given that there are some 60 recognized specialties and sub-specialties in Canada and each of them is responsible for treating a number of conditions presenting to the family physician. Due to the varying degree of complexity of a patient's medical problem, an appropriate wait time would be difficult to define by a particular disease or illness. National and international experience would suggest that there have been two broad approaches:
- the development of "condition-specific" approaches to target-setting linked to a clinical assessment of urgency; and
- the adoption of targets that apply to all conditions that are progressively shortened as they are achieved.
Since the early 1990s, the NHS has made remarkable progress in tackling wait times through the adoption of targets that have been gradually shortened. This began with the first UK patient charter that was adopted in 1991. Reflecting the long waiting lists at that time, it included the right, "to be guaranteed admission for treatment by a specific date within two years". (30) In 1995 a second version of the Patient Charter lowered this period to 18 months, and to one year for coronary artery bypass grafts. (31) In the late 1990s the NHS moved from the Charter to a series of national service frameworks for conditions such as heart disease and cancer. These frameworks evolved into shortened targets. For example in 2001 the target was a maximum one month wait from diagnosis to first treatment for breast cancer by the end of 2001, in 2005 this was extended to all cancers by December 2005. 32 The most recent development has been the 2004 commitment that by the end of 2008 no patient will have to wait longer than 18 weeks from GP referral to hospital treatment.(33) The UK is on track to meet this target, but it must be emphasized that this has been achieved through a combination of a large infusion of resources, plus policy changes such as the shift from block funding to Payment by Results that reimburses hospitals on the basis of the number of patients treated. It should also be emphasized that the NHS is a much more integrated system than Canada's health care system, and it would be more challenging to define accountability for reaching wait time targets.
Past Work on Improving Specialty Care Access
In Canada, the "gold standard" of target-setting is considered to be the work done by Naylor and colleagues in developing the urgency rankings for coronary revascularization procedures that underpin the Cardiac Care Network (CCN) of Ontario. This was done using a modified version of the techniques developed by the RAND Corporation in the 1980s to establish appropriateness guidelines for various procedures. In this work a panel of cardiologists and cardiac surgeons rated 438 fictitious case-histories on a seven-point scale of maximum acceptable waiting time for surgery. A regression model was then used to derive a scoring system based on the regression coefficients attached to the major determinants of urgency. (34) This system was implemented to prioritize waitlists by CCN which now works with 18 cardiac care centres in Ontario.
A group urology practice in Saskatchewan has initiated a process whereby referring family physicians are provided with a standard form listing the necessary tests.
The Diagnostic Imaging Program Standards Committee of the Winnipeg Regional Health Authority in Manitoba found that when physicians requesting a diagnostic test provided a time frame for the test to be completed as well as information about the patient's condition, the process of prioritizing requests became more manageable for radiologists.
In Alberta and British Columbia, some family physicians have signed service agreements with other specialists. Such an agreement defines the scope of the work of family physicians and other specialists. It formally encourages all specialties to work collaboratively and to this end regular meetings are held to discuss all relevant matters.
Manitoba has recently launched a pilot project called Bridging Generalist and Specialist Care - The Right Door, The First Time that will focus on reducing the wait time between family physician referral and specialty consultation.
In the late 1990s a similar approach was used by the Western Canada Waiting List (WCWL) Project to develop priority scoring tools for cataract surgery, general surgery, hip and knee replacement, MRIs and children's mental health. (35) The tool for hip and knee replacement has been adapted for use by family physicians to determine priority of referral to orthopaedic surgeons,although to date it has only been tested on simulated paper cases.(36) The Saskatchewan Surgical network has applied the WCWL approach to develop scoring tools in 12 procedural areas. (37) Clearly it would be a large undertaking to adopt all these tools for use in primary care and to develop tools for the numerous areas that have yet to be tackled. Thus far, governments have concentrated, for the most part, on their initial five priorities. In the Fall of 2007 the Wait Time Alliance added five new benchmark areas, including emergency care, psychiatric care, plastic surgery, gastroenterology and anesthesiology (pain management) and it has challenged governments to adopt them. (38)
Recent Efforts to Improve Specialty Care Access
How can we work to achieve these targets? There are a variety of initiatives underway to expedite the referral and consultation process. In 2006, the CFPC and the Royal College of Physicians and Surgeons of Canada said that three steps could improve the referral and consultation process:
- a defined single access point within local referral/consultation systems;
- templates for referrals and consultations advice;
- an agreement amoung key players (relevant GP/FP and other specialty organizations) on referral/consultation criteria."(39)
As an example, a group urology practice in Saskatchewan has initiated a process whereby referring family physicians are provided with a standard form listing the necessary tests. This process has been very successful in reducing the need for repeat appointments. This practice also implemented a policy that the patient is referred to the first available urologist rather than to a specific physician. This new pooled referral system has reduced patient wait times remarkably and has been very well received by all parties. (40) In addition, other specialties in that province have shown interest in introducing a similar system in their practices.
As an additional example of simple ways to gain efficiencies, the Diagnostic Imaging Program Standards Committee of the Winnipeg Regional Health Authority in Manitoba found that when physicians requesting a diagnostic test provided a time frame for the test to be completed as well as information about the patient's condition, the process of prioritizing requests became more manageable for radiologists. (41)
In Alberta and British Columbia, some family physicians have signed service agreements with other specialists. Such an agreement defines the scope of the work of family physicians and other specialists. It formally encourages all specialties to work collaboratively and to this end regular meetings are held to discuss all relevant matters.
Manitoba has recently launched a pilot project called Bridging Generalist and Specialist Care (BGSC) - The Right Door, The First Time that will focus on reducing the wait time between family physician referral and specialty consultation.
This pilot project is intended to address priority areas, including:
- mental health: anxiety and depression
- lower back pain management
- lower gi endoscopy
- orthopaedics: arthroplasty
- plastic surgery: carpal tunnel, breast reconstruction, breast reduction and skin lesions
- lung cancer (42)
One of the objectives of this pilot project is to establish guaranteed time frames from referral to consulting specialist in the specific practice areas and to offer alternative options to patients who may exceed these time lines. The BGSC software includes primary care pathways and an electronic referral process, allowing family physicians to send all necessary referral information, such as primary care workups, treatments and testing results, to the other specialist offices electronically. These specialists can then respond to the referrals electronically, advising family physician offices of referral acceptance, appointment dates and times and any additional information within days of receiving the referral request.
Want to learn more? Ms. Brie DeMone offers an overview of the government of Manitoba's project to improve communication and coordination between family physicians and other specialists. "Bridging General and Specialist Care" and "the Catalogue of Specialized Services". www.cfpc.ca/BGSCTQVI
In January 2009, the web-based Catalogue of Specialized Services (CSS) was launched, which, is, according to provincial director of patient access Dr. Luis Oppenheimer, "like a catalogue order entry system. If you're a GP/FP looking for a service, you will get a catalogue of who provides that service, [...] some idea of the waiting time or capacity for that service [...] and have immediate confirmation of whether [your request] is accepted." By clearly providing family physicians and their offices with information on "who does what", referrals can be accurately directed to the right specialist at the right time, saving time and effort for the family physician, other specialist and patient (42),(43).
A third new initiative currently underway in Manitoba, the Patient Access Registry Tool (PART), will provide other specialists with the clinical information they need to manage patient demand. Patient demographics and provider information as well as a diagnosis and planned interventions will be available through this tool and it will also document several key wait time dates, including when a referral was first received, the date of the first specialist consultation and when a patient is ready for treatment. Once it is fully operational, PART will capture information on all patients needing a medical consultation or surgery in Manitoba. (44)
British Columbia offers a Full Service Family Practice Program with a broad range of incentives
The Nova Scotia agreement includes new Chronic Disease Management Incentives that will be linked to guideline-based care for chronic diseases such as diabetes, chronic heart failure and hypertension
Given the wide spectrum of illnesses that are assessed in a primary care setting, any approach to developing wait time targets must be done in consultation with family physicians and with clinical guidelines in mind. Currently there is simply not enough information available to establish reasonable wait time targets. The ability to accurately measure and monitor access at all points along the care continuum will require a significant investment in information infrastructure and this system must be in place and used effectively before targets are developed. More importantly, this cannot be effectively implemented without coordinated support from all governments. The Manitoba Government is a pioneer with this particular effort and their pilot projects will be closely monitored for effectiveness.
C. Remuneration Models
Since the early 1990s there has been a steadily declining trend in fee-forservice (FFS) as the sole mode of payment for family physicians. In 1990, the CMA's Physician Resource Questionnaire (PRQ) survey results showed that 71% of family physicians received 90% or more of their professional income from FFS.45 Subsequent PRQ surveys showed successive decreases and on the 2007 NPS, fewer than one out of two (48%) family physicians reported receiving 90% or more of their income from FFS. 15 While the majority of physicians continue to receive some income from FFS, increasingly it is being blended with other remuneration methods.
A blended payment model known as the Family Health Network is now available in Ontario. In this model, capitation accounts for about 65% of a family physician's remuneration. The remainder consists of fee-for-service and other incentive payments and premiums.
Over the past decade there has been an international trend towards the adoption of "pay-for-performance" (P4P), in which a variety of payment incentives are used to promote certain physician behaviours. To date, these incentives have been used mainly to encourage process improvements in the delivery of care. The earliest forms of P4P focused on prevention screening, but more recently they have expanded to address chronic disease management. P4P generally works by linking a bonus payment to the achievement of a specific performance target in the patient population. In its new primary care models, Ontario provides bonus payments for cancer prevention screening and diabetes management, as well as other incentives for activities including palliative care and care for patients with serious mental illness. (46)
Similarly, British Columbia offers a Full Service Family Practice Program with a broad range of incentives. (47) The recently concluded Nova Scotia agreement includes new Chronic Disease Management Incentives that will be linked to guideline-based care for chronic diseases such as diabetes, chronic heart failure and hypertension.(48)
As previously noted, several jurisdictions also provide incentives to acquire new patients. Internationally the UK has gone further by providing a bonus to the attainment of timely access targets as reported by patients. However, the UK also has a long-established rostering system and it has a much less geographically dispersed population than does Canada. Nonetheless it might be interesting to assess the potential for incentives to enhance access to primary and specialty care in Canada.
D. Electronic Medical Records
Regardless of how a wait time management strategy might be implemented (e.g., at the level of the province, health region, hospital) it will be critical to be able to capture and monitor referral data electronically, starting with the family physician. It may be seen in Table 1 below that according to the 2007 National Physician Survey, there remains a large gap in this regard. Nationally almost two out of three family physicians (63%) continue to use paper charts as their method of record keeping. One out of five (19%) uses a combination of electronic and paper charts while just over one out of 10 (12%) report using electronic charts instead of paper charts.Across the country there is more than two-fold variation of those using paper charts ranging from a low of 36% inAlberta to a high of 81% in PEI and Quebec.
[TABLE 1. SEE PDF]
Internationally, the Commonwealth Fund has shown that Canada lags far behind comparator countries in the uptake of electronic medical records (EMRs). On its 2006 survey of primary care physicians in seven countries, fewer than one out of four (23%) Canadian respondents reported that they used EMRs in their offices compared to nine out of ten in the UK, New Zealand and the Netherlands.(49)
Aside from the issues of wait times for those patients with a family physician there is also the challenge of capturing information about access to primary medical care for those without their own family physician.
E. Practice Support
Improvements in access to family physicians can also be accomplished through the addition of staff support, of which there are two types:
1 clinical practice support(ie nurse or MOA for patient care),and
2 change management practice support (those with knowledge of clinical practice redesign to support physicians in making, monitoring and sustaining change).
The Practice Support Program in British Columbia offers training and financial incentives for family physicians working with medical office assistants and in one district health authority in Nova Scotia, a project is underway where family physicians can obtain financial support to employ family practice nurses through enhanced fee-for-service billings. At present, however, widespread deployment of practice support personnel is constrained by rules of fee-for-service payment that require the physician to have direct contact with each patient for whom a service is billed to the provincial or territorial medicare plan.
In terms of change management practice support, thus far CPR has had limited uptake in the rest of the country, primarily due to a lack of awareness. However, stories of the successes with this program are now being heard in the rest of the country and it is increasing in popularity. For example, a new Advanced Access initiative has been recently introduced in Manitoba through their Ministry of Health. In Nova Scotia, one practice that has had great success with Advanced Access is managed by the 2008 recipients of the Health Care Provider of the Year Award in Cape Breton, Elaine Rankin and Steven MacDougall. They worked together on an Advanced Access research project beginning in 2006. Once Dr. MacDougall cleared his patient wait list, he began to operate a same day access practice where his patients can call in the morning for an appointment that day. Now, the number of non-urgent patients from his practice who go to the emergency department has dropped by 28%. 50 By all accounts, those who have implemented CPR indicate they would never return to the traditional model where the appointment schedule is full before the work day starts.
CPR is not a tool to be used exclusively in family practices. The group urology practice in Saskatchewan that introduced the notion of pooled referrals with much success has also been engaged in the process of CPR since early 2007. Their practice is now beginning to enjoy the fruits of their labour through reduced wait times for patients who are referred to their practice. The "champion" of this undertaking, Dr. Visvanathan, noted that Clinical Practice Redesign involves improving practice work flow, the introduction of Electronic Medical Records and getting the right staff to do the right jobs. (40)
The implementation of a more efficient practice management system such as CPR requires commitment from physicians as well as effective information management and measurement tools, additional practice support and assistance from change management experts. Experience to date suggests that these efforts pay off in terms of improved patient access and increased capacity to accommodate patient appointments.
There are three main issues that should concern our focus on primary care wait times:
- Access to primary care for those without a family physician;
- Access to primary care for those with a family physician; and
- Referral from primary to more highly specialized care.
There are general recommendations that would help address these issues and other recommendations that are more specific to each. This paper has provided valuable information that supports the following recommendations.
As noted in the introduction to this paper, it is difficult to measure primary care wait times for myriad illnesses and conditions, and this difficulty may impede progress in finding solutions to the wait time challenges that family doctors experience. The Primary Care Wait Time Partnership (PCWTP) believes that the ability to measure and track wait times along the full continuum of the patient's care is of utmost importance, but that this capacity in primary as well as more highly specialized levels of care is still very limited.
1) Primary care wait time tracking, analysis and improvements should be patient-centred, taking into account the whole wait time continuum that patients experience, starting from the time they first seek medical care.
2) More research and evaluation is needed to analyze primary care wait times so that the inequities and inconsistencies in access to care can be addressed for patients from region to region across Canada.
3) More study on collaborative care is necessary. The PCWTP recognizes that collaboration has the potential to enhance access to primary care. But before we can state with certainty that access to primary care is improved through particular models of care delivery, we need to continue to collect data and analyze results. It makes little sense to invest tremendous resources into any model if patient access to primary care is not improved.
4) Primary care wait time measurement should be a priority for Canadian governments, health authorities and other stakeholders, (e.g. Canadian Institute for Healthcare Information). Reliable data that represents the patient's total wait time experience will need to be collected to support the development of primary care wait time targets in the future. This data must be validated and tracked for the purpose of continuous evaluation.
5) Before reasonable wait time targets can be established and effectively used in primary care, information infrastructures, (e.g. electronic medical records and communication tools) , must be adequately supported and in place. Enhancements in information technology and learning in family practice will be necessary to facilitate the adoption and widespread use of electronic medical records. No measuring or tracking of primary care wait times can be effectively accomplished without financial support from government for electronic communication systems in and between medical practices.
6) There are a number of jurisdictions pursuing important and different ways to improve timely access to care for patients, (e.g. Manitoba's catalogue system and registry tool, Alberta's formal service agreements between referring and consulting physicians). These worthwhile endeavours should be monitored at a national level for opportunities to implement more universal improvements to wait times in our Canadian health care system.
Recommendations for Patients without a Family Physician
The CFPC and CMA have recommended and supported several strategies to increase the supply of family physicians through education and training (e.g. promotion of family medicine to medical students and residents, better support for preceptors and teachers), to address changing patterns of family practice (e.g. supports for inter-professional collaboration), and to develop models of care that would attract and retain family physicians (e.g. blended remuneration methods). While these recommendations will not be repeated here, they should be given full consideration in seeking to achieve an adequate family physician workforce that can support timely access to care for all Canadians.
1) The PCWTP believes that every Canadian should have a family doctor and supports the CFPC position that all stakeholders, (e.g. governments, medical schools and professional organizations), should work together to achieve a target of 95% of the population in every Canadian community with a family doctor by 2012.
2) Patient registries should be developed and maintained to track patients who do not have a family doctor and are actively looking for one.
3) Other strategies should be more fully developed and supported to find family doctors for patients without a family doctor , (e.g. physician incentives to accept new patients and the use of tools for workload management and patient flow in family practice).
4) Efforts currently underway to integrate appropriately trained and certified international medical graduates as family physicians into our health care system are welcome, should be supported and enhanced.
Recommendations for Patients who have a Family Physician
1) Family physicians who see a need to improve timely access to care for their patients could consider Clinical Practice Redesign tools such as Advanced Access . System support should be in place for family physicians who want to adopt these tools. The training and ongoing learning of new and practicing family physicians should include education in practice flow and design. To further assist physicians in the use of these tools, websites should be established with lists of those who have been successful at improving patient flow through their practices and who are willing to assist others attempting to do the same.
2) Practice management education and training should be enhanced in residency in order to teach new family physicians about effective office processes and practice flow efficiencies that improve timely access to care for patients, (e.g. electronic tracking tools).
3) Financial incentives should be available to support the valuable roles of office assistants as well as other health professionals in family practice, (e.g. family practice nurses), for better patient flow and more efficient use of the physician's time. In addition, family physician remuneration should compensate for patient encounters beyond just face-to-face in order to support increasingly important opportunities for electronic encounters with patients and members of the care team.
Recommendations for Referral from Primary to Specialty Care
1) All recommendations to address timely access to more highly specialized care must include the wait time from the first visit with the family physician to referral and specialty consultation.
2) Based on four years' experience with benchmarks for the five procedural areas established in 2004, we do not believe it is possible to develop a broad array of condition-specific, evidence-based benchmarks for access to consultations in the near future. However, where they are or do become available and are supported by sufficient infrastructure, wait time targets should be used as guides to drive improvements in timely access to care. Nonetheless, family physicians must continue to be free to use their clinical judgment in the patient's best interests.
3) Good intra-professional relationships between family physicians and other specialists should be promoted and supported in the health care system to improve communications and the continuity of care for patients. Strategies to support good relationships should consider recommendations that have been developed by the Canadian Medical Protective Association as well as the Collaborative Action Committee on Intra-professionalism that is supported by the CFPC and Royal College of Physicians and Surgeons of Canada with CMA participation.
4) Tools that will improve the timeliness of the referral-consultation process between physicians should also be enhanced; however, any development of referral-consultation process tools must be undertaken collaboratively with family physicians, (e.g. referral-consultation frameworks that identify and support the availability of appropriate and timely information to and from referring and consulting physicians, electronic communication of patient information between physicians, and better system supports for electronic communication between physicians and patients).
5) Family physicians should have access to routine and advanced diagnostic tests for their patients in all clinical settings, equal to that of other specialists. There should be no difference in the criteria for access to advanced diagnostic testing from region to region. All physicians should be expected to follow appropriate clinical guidelines in the use of diagnostic tests. These guidelines should be readily available and easily understood by physicians and other health care professionals with whom they work.
6) Guidelines or targets for timely access from primary to specialty care must account for differences in geographic settings and proximity to care that are characteristic of rural and remote locations in contrast to urban and suburban locations.
While the Canadian Medical Association (CMA) and The College of Family Physicians of Canada (CFPC) are proud to represent doctors across Canada, at the centre of everything we do stands the patient. We know that many Canadians are concerned about timely access to see their own family doctor while others continue a sometimes fruitless search for a family doctor of their own.
In this paper we have presented many problems but also a number of solutions to addressing wait times in primary care. We've acknowledged that there are obstacles, but we do not think these obstacles are insurmountable. Canadians exercised considerable political courage, often in the face of adversity, to pioneer a health care system based on the principles of fairness, equality and social justice. Through political will, we are certain we can make the changes necessary to ensure timely access to primary care.
The PCWTP hopes that governments, health care providers and the public will read this report and consider the recommendations. We know that these recommendations do not represent an exhaustive list and indeed we may have inadvertently omitted something you think is critical. We encourage you to let us know what you think and how we can work together to improve access to primary care.
This is not a task merely for the CFPC or the CMA; all of us must work together to offer better access to health care to our patients.
1Statistics Canada. Canadian community health survey: 2007 questionnaire. [Online][Accessed 2008 Nov 20]. Available from:
2The College of Family Physicians of Canada. CFPC Decima survey results. Toronto: Decima Research; November 2008. 3Statistics Canada. Frequency of whether taken care of by same medical doctor or nurse each visit by source of regular care. Canadian survey of experiences with primary care, 2007. Custom Tabulation.
4Glazier RH, Moineddin R, Agha MM, Zagorski B, Hall R, Manuel DG, et al. The impact of not having a primary care physician among people with chronic conditions. ICES investigative report. Toronto: Institute for Clinical Evaluative Sciences; 2008 Jul. 5Canadian Community Health Survey, 2007. Statistics Canada The Daily. [Online] [Accessed 2008 Nov 18]. Available from:
6American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home: March 2007. [Online] [Accessed 2008 Nov 19]. Available from: http://www.medicalhomeinfo.org/Joint%20Statement.pdf
7Schoen C, Osborn R, Doty MM, Bishop M, Peugh J, Murukutla N. Toward higher-performance health systems: Adults' health care experiences in seven countries, 2007. Health Aff 2007 Oct 31; 26(6):w717-34.
8Milliken O, Devlin RA, Barham V, Hogg W, Dahrouge S, Russell G. Comparative efficiency assessment of primary care models using data envelopment analysis. Ottawa: University of Ottawa; 2008 Mar.
9Lamarche PA, Beaulieu M-D, Pineault R, Contandriopoulos A-P, Denis J-L, Haggerty J. Choices for change: The path for restructuring primary healthcare services in Canada. Ottawa: Canadian Health Services Research Foundation; 2003 Nov. 10Hutchison B, Østbye T, Barnsley J, Stewart M, Mathews M, Campbell MK, et al. Patient satisfaction and quality of care in walk-in clinics, family practices and emergency departments: the Ontario walk-in clinic study. Can Med Assoc J 2003 Apr 15:168(8): 977-83.
11Canadian Intergovernmental Conference Secretariat. 2003 First Ministers' accord on health renewal. [Online] [Accessed Nov 24]. Available from: http://www.scics.gc.ca/pdf/800039004_e.pdf
12Canadian Intergovernmental Conference Secretariat. A 10-year plan to strengthen health care. [Online] [Accesssed Nov 24]. Available from: http://www.scics.gc.ca/cinfo04/800042005_e.pdf
13Ontario Ministry of Health. First ever common benchmarks will allow Canadians to measure progress in reducing wait times. [Online][Accessed 2008 Nov 25]. Available from:
14Ipsos-Reid. Physicians today: Respect, reputation and role. Ottawa: Canadian Medical Association; 2007 Nov. 15The College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons. National Physician Survey. [Online] [Accessed 2008 Nov 14]. Available from:
Health Council of Canada. Canadian survey of experiences with primary health care in 2007. [Online] [Accessed 2008 Nov 25]. Available from:
Esmail N, Hazel M, Walker M. Waiting your turn: Hospital waiting lists in Canada, 2008 report, 18 edition. Fraser Institute. [Online][Accessed 2008 Nov 18]. Available from:
18Canadian Medical Protective Association. Wait times: a medical liability perspective. [Online] [Accessed 2008 Nov 24] Available from: http://www.cmpa-acpm.ca/cmpapd04a/pub_index.cfm?LANG=E&URL=cmpa%5Fdocs%2Fenglish%2Fcontent%2Fissues%2Fcommon%2Fcom %5Fwait%5Ftimes%5F2007%2De%2Ehtml
19Borsellino, M. 10 questions with...RCPSC president Dr. William Fitzgerald. The Medical Post. 2009 Jan 13. [Online][Accessed 2009 Feb 11]. Available from:
20Ross M. Limited health-care resources: the difficult balancing act. Information sheet IS0770E. Ottawa: Canadian Medical Protective Association; 2007.
21Ontario Medical Association, Ministry of Health and Long Term Care. Memorandum of agreement between: The OMA and the MOHLTC. 2008 Sep.
22Manitoba Health. Advanced access initiative. [Online][Accessed 2009 Jan 16]. Available from:
23Murray N, Berwick D. Advanced access: reducing waiting and delays in primary care. JAMA 2003;289(8):1035-40.
24Bartok B. Experts offer 'CPR' for your practice: Saskatchewan's Advanced Access school revives struggling practices. Nat R Med 2008 Apr. [Online] [Accessed 2008 Nov 25];5(4):[3 screens]. Available from:
25Department of Health. Patients get booking 'guarantee' on NHS GP appointments. [Online][Accessed 2008 Nov 26]. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4118856
26Department of Health. GMS statement of financial entitlements. [Online][Accessed 2008 Nov 26]. Available from:
27The Information Centre. GP patient survey. [Online][Accessed 2008 Nov 26]. Available from: http://
28Department of Health. FOI releases: GP patient survey. [Online][Accessed 2008 Nov 26]. Available from:
29Berta W, Barnsley J, Brown A, Murray M. In the eyes of the beholder: Population perspectives on performance priorities for primary care in Canada. Healthc Policy 2008;4(2):86-100.
30British Medical Journal. Patients first. 1991 Nov 9;303:1153.
31Department of Health. The patient's charter & you. London: DOH; 1996 Nov.
32Department of Health. The NHS cancer plan and the new NHS. [Online][Accessed 2008 Nov 26]. Available from:
33Department of Health. About the programme - 18 weeks patient pathway. [Online][Accessed 2008 Nov 25]. Available from:
34Naylor CD, Baigrie RS, Goldman BS, Basinski A. Assessment of priority for coronary bypass revascularization procedures. Lancet 1990 May 5; 335:1070-73.
35Noseworthy TW, McGurran JJ, Hadorn DC, WCWL Steering Committee. Waiting for scheduled services in Canada: development of priority-setting scoring systems. J Eval Clin Pract 2002 Mar 22;9(1): 23-31.
36De Coster C, McMillan S, Brant R, McGurran J, Noseworthy T, WCWL Primary Care Panel. The western Canada wait list project: development of a priority referral score for hip and knee arthroplasty. J Eval Clin Pract 2005 Sep 26;13(2007):192-7. 37Saskatchewan Surgical Care Network. Patient assessment questionnaires, guides & urgency profiles for surgical procedures. [Online][Accessed 2008 Nov 25]. Available from: http://www.sasksurgery.ca/ayn-tools-scoringguides.htm
38Wait Time Alliance. Time for progress: new benchmarks for achieving meaningful reductions in wait times. Ottawa: Canadian Medical Association; 2007.
39The College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons. MD Lounge. 2008 Sep: 3.
40Canadian Medical Association. Health Policy & Negotiations Conference. Proceedings of the HP&N Conference. 2008 Oct 18-19; Ottawa.
41College of Physicians and Surgeons of Manitoba Newsletter. September 2005. [Online][Accessed 2008 Nov 24]. Available from: http://www.cpsm-secure.com/newsletter/05-09.php
42DeMone, B. Improving Family Physician and Specialist Communication & Coordination: Bridging General and Specialist Care (BGSC) & the Catalogue of Specialized Services (CSS). Presented at Taming of the Queue VI; 2009 Mar 26; Ottawa. [Online][Accessed 2009 Oct 28]. Available from: http://www.cfpc.ca/BGSCTQVI
43The College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons. MD lounge. 2008 Sep: 6-7.
44Borsellino, M. Manitoba developing wait time measurement registry. The Medical Post. 2008 Dec 22. [Online][Accessed 2009 Jan 19]. Available from: http://www.medicalpost.com/news/article.jsp?content=20081222_111206_13308&s=1
45Canadian Medical Association. Physician resource questionnaire. 1990.
46Primary care funding models in Ontario: new comprehensive care model available October 1, 2005. Ontario Medical Review 2005 Jul/Aug: 17-19.
47Ministry of Health Services. Full service practice incentive program. [Online][Accessed 2008 Nov 27]. Available from:
48Minister of Health, Medical Society of Nova Scotia. Physician services master agreement. 2008 Oct 29.
49Schoen C, Osborn R, Huynh PT, Doty M, Peugh J, Zapert K. On the front lines of care: Primary care doctors' office systems, experiences, and views in seven countries. Health Aff 2006 Nov 2; 25(2006): w555-71.
50King N. Doctor, administrator, advocate recognized for work in health care. The Cape Breton Post. 2008 May 13. [Online][Accessed 2008 Nov 25]. Available from: http://www.capebretonpost.com/index.cfm?sid=134095&sc=145
FUNDING THE CONTINUUM OF CARE
The continuum of care may be defined as the array of health services that spans the range over the life course from primary care (including prevention and health promotion) through institutionally based secondary and tertiary care to community and home-based services that promote health maintenance, rehabilitation and palliation at the end of life. Given the ever-increasing diversity of service offerings and providers, and aging populations, governments worldwide face the ongoing challenge of what to fund for whom.
After a lengthy period of examination that began in the 1930s, Canada arrived at a social consensus on universal, first-dollar coverage provision of hospital (1957)1 and physician (1966)2 services. All provinces bought into "Medicare" by the early 1970s and the 1984 Canada Health Act (CHA)3 was the capstone of the national hospital and medical insurance program, adding the principle of accessibility, which effectively prohibited user charges for insured hospital and physician services.
Notwithstanding the more recent legislation, the foundation of Medicare was set in the health and health care reality of 1957. Hospital and medical services accounted for two-thirds of health spending (65%).4 Prescription drugs accounted for just 6% of spending, less than half of their 14.6% share in 2008. Life expectancy was almost a decade shorter than it is today, hence there was less concern about long-term care. The first knee replacement was not done until a decade later. The 1957 Hospital and Diagnostic Services Act specifically excluded tuberculosis hospitals, sanitaria and psychiatric hospitals as well as nursing homes/homes for the aged. These exclusions carried forward to the CHA.
By all accounts the CHA has taken on an iconic status, but at the same time it is agreed that it is an impediment to modernizing Medicare through its definitions and program criteria and how they are interpreted by the provinces and territories. The CHA narrowly defines insured health services as "hospital services, physician services and surgical dental services provided to insured persons." While the CHA recognizes "extended" health services such as home care and ambulatory health care services, these are not subject to the program criteria.
Over the years, the CHA has been extremely effective in preserving the publicly funded character of physician and hospital services. As of 2008, the Canadian Institute for Health Information (CIHI) has estimated that 98.4% of physician and 90.7% of hospital expenditures are publicly funded.5 The dividing line of the CHA may be seen in virtually all other categories of service. Fewer than one-half of prescription drugs (44.5%) and less than one-tenth (6.9%) of the services of other health professionals (e.g., dentistry and vision care) are publicly covered. Canada is unique among industrialized countries in its approach to Medicare. Countries with social insurance (Bismarck) funded systems tend to provide a similar total level of public expenditure over a wider range of services.
Over time, as health care has moved from institutions to the community, the CHA is diminishing with respect to the share of total health spending it covers. At the time the CHA was passed, physician and hospital services represented 57% of total health spending; this has declined to 41% as of 2008. It must be emphasized that there is significant public spending beyond CHA-covered services (in excess of 25% of total spending) for programs such as seniors' drug coverage and home care; however, those programs are not subject to the CHA's program criteria. In addition, they can be subject to arbitrary cutback. While a majority of the working age population and their families are covered by private health insurance, those with lower incomes are less likely to have such benefits. Since the late 1990s, notwithstanding the widely shared concern about the sustainability of Canada's Medicare program, several high profile studies have advocated for its expansion, starting with the 1997 Report of the National Forum on Health6 and latterly with the Kirby7 and Romanow8 reports in 2002, both of which strongly recommended home care and catastrophic drug coverage. There is also growing concern about the availability of so-called "orphan drugs" that treat rare diseases such as Fabry disease, and can cost hundreds of thousands of dollars per patient for a single year of treatment.
First Ministers have concluded three health accords in 20009, 200310 and 200411, each of which addresses expanding the boundaries of Medicare. To date there are a series of unfulfilled commitments from these accords, including a national basket of home care services and first-dollar coverage for home care and catastrophic drug coverage. In its 2007 report, the Health Council of Canada summarized progress on catastrophic drug costs as "disappointing."12
There is no appetite among governments in Canada to implement new universal programs with first-dollar coverage. In fact, recently governments have removed services that had previously been publicly insured, as evidenced by recent examples such as physiotherapy and chiropractic services in some jurisdictions.
The CMA puts forward the following principles for funding the continuum of care in a national context, recognizing that there will continue to be a mix of public-private funding.
* Canadians should take personal responsibility to plan ahead for the contingency that they may eventually require support with their activities of daily living;
* home care and long-term care should be delivered in appropriate and cost-effective settings that respect patient and family preferences;
* there should be quality and accreditation standards for both public and private service delivery;
* there should be uniform approaches to needs assessment for home care and long-term care;
* there should be a uniform means of distinguishing the medically necessary component of home care and long-term care from the accommodation component;
* there should be a means of mitigating against open-ended public coverage of pharmaceutical, home care and long-term care coverage;
* there should be recognition and financial support for informal care givers;
* there should be consideration of risk-pooling, risk adjustment and risk sharing1 between public and private funders/providers of pharmaceutical, home care and long-term care coverage;
* there should be a uniform approach to individual/household cost-sharing (e.g., copayments and deductibles); and
* provision should be made for pre-funding long-term care from public and private sources.
Prevention and Health Promotion
The continuum of care begins with prevention and this requires a strong public health foundation that includes the core elements of population health assessment, health surveillance, health promotion, disease and injury prevention and health protection.13 An investment in public health, including health promotion and disease prevention, is critical to the future health of Canadians.
One important component of effective prevention is immunization. The National Immunization Strategy was implemented in 2001 with the goal of reducing vaccine preventable diseases and improving vaccine coverage rates. The 2004 federal budget allocated $400 million to support this strategy and in 2007, $300 million was set aside in the federal budget for a Human Papillomavirus Immunization program. However, permanent funding should be allocated towards immunization programs for all illnesses that are preventable through vaccinations.
The federal government also has a role to play in establishing and promoting partnerships that will enhance prevention and promotion programming down to the local level.
The CMA recommends that:
the federal government continue funding of the national immunization strategy consistent with the original three-year funding program;
governments fund appropriate additions to the vaccination schedule, as new vaccines are developed, within the context of a national immunization strategy; and
the federal government establish a Public Health Infrastructure Renewal Fund ($350 million annually) to build partnerships between all levels of government to build capacity at the local level.
Prescription drugs are the fastest growing item in the health envelope. Over the past two decades, prescription drugs as a proportion of total health spending have doubled from 7% in 1986 to an estimated 14.6% in 2008, and they are now the second largest category of health expenditure. It is estimated that less than one-half (44.5%) of prescription drug costs were paid for publicly in 2008; just over one-third (37.1%) were paid by private insurers and almost one-fifth (18.4%) out-of-pocket.
The studies reported in 2002 by the Senate Standing Committee on Social Affairs, Science and Technology (Kirby) and by the Commission on the Future of Health Care in Canada (Romanow) have forged a consensus on the need for "catastrophic" pharmaceutical coverage, which may be defined as out-of-pocket prescription drug expenditures that exceed a certain threshold of household income.
In the Kirby proposal, in the case of public plans, personal prescription drug expenses for any family would be capped at 3% of total family income. The federal government would then pay 90% of prescription drug expenses in excess of $5,000. In the case of private plans, sponsors would have to agree to limit out-of-pocket costs to $1,500 per year, or 3% of family income (whichever is less). The federal government would then agree to pay 90% of drug costs in excess of $5,000 per year. Both public and private plans would be responsible for the difference between out-of-pocket and $5,000, and private plans would be encouraged to pool their risk. Kirby estimated that this plan would cost approximately $500 million per year. For his part, Romanow recommended a Catastrophic Drug Transfer through which the federal government would reimburse 50% of the costs of provincial and territorial drug insurance plans above a threshold of $1,500 per year. Romanow estimated that this would cost approximately $1 billion.
The National Pharmaceuticals Strategy (NPS) has continued to explore cost projections of catastrophic pharmaceutical coverage, leaning toward a variable percentage threshold linked to income but there has been no public reporting on progress since 2006.14 At their September 2008 meeting, provincial/territorial health ministers called for the federal government to be an equal partner (50/50) to support a national standard of pharmacare coverage so that prescription drug costs will not exceed 5% (on average) of the net income base of provincial/territorial populations. The total estimated cost of such a program for 2006 was estimated at $5.03 billion.15
Data from Statistics Canada indicate that there is wide variation in levels of household spending on prescription drugs in Canada. In 2006 almost one in twenty (3.8%) households in Canada spent more than 5% of net income on prescription drugs; there was almost a five-fold variation across the provinces, ranging from 2.2% in Ontario to 10.1% in Prince Edward Island.16
Canada does not have a nationally coordinated policy in the area of very costly drugs that are used to treat rare diseases. Moreover, there is also an issue of expensive drugs that may be used for common diseases (wide variation has been documented across provinces/territories).
Thus far the term "catastrophic" has been used by First Ministers and the NPS to describe their vision of national pharmaceutical coverage. As defined by the World Health Organization catastrophic expenditure reflects a level of out-of-pocket health expenditures so high that households have to cut down on necessities such as food and clothing and items related to children's education.17 From the CMA's perspective, this does not go far enough and what must be strived for is "comprehensive" coverage that covers the whole population and effectively pools risk across individuals and public and private plans in various jurisdictions.
The CMA recommends that:
governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies;
such a program should include the following elements:
* a mandate for all Canadians to have either private or public coverage for prescription drugs;
* a uniform income-based ceiling (between public and private plans and across provinces/territories) on out-of-pocket expenditures on drug plan premiums and/or prescription drugs (e.g., 5% of after-tax income);
* FPT cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal share of reimbursement or by scaling the household income ceiling or both;
* group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size; and,
* a continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs);
the federal government establish a program for access to expensive drugs for rare diseases where those drugs have been demonstrated to be effective;
the federal government assess the options for risk pooling to cover the inclusion of expensive drugs in public and private drug plan formularies;
the federal government provide adequate financial compensation to the provincial and territorial governments that have developed, implemented and funded their own public prescription drug insurance plans;
governments provide comprehensive coverage of prescription drugs and immunization for all children in Canada; and
the Canadian Institute for Health Information and Statistics Canada conduct a detailed study of the socio-economic profile of Canadians who have out-of-pocket prescription drug expenses to assess barriers to access and to design strategies that could be built into a comprehensive prescription drug coverage program.
Home care began in Canada in the late 19th century as a charitable enterprise delivered by non-profit groups such as the Victorian Order of Nurses. In the expansionary period of the 1960s and 1970s, governments moved increasingly into this area. The New Brunswick Extra-Mural Program, arguably Canada's most successful/ambitious home care program, accepted its first clients in 1981. The Established Programs Financing Act of 1977 recognized home care as one of several extended health services and included a fund initially set at $20 per capita to cover such services. These extended services are also recognized in the CHA but are not subject to the five program criteria (principles). The 1997 Report of the National Forum on Health recommended that home care be added to Medicare (along with pharmacare). The $150 million Health Transition Fund supported several demonstration projects in the home care area. Both the Kirby and Romanow reports recommended expanded home care funding. In February 2003, First Ministers concluded an accord in which they committed to determine a basket of home care services by 30 Sept. 2003, covering short-term acute home care, community mental health and end-of-life care. To date this has not happened. The federal government implemented a Compassionate Care Benefit in 2003 to support family caregivers; however, this only applies to those who are in the paid labour force.18
According to the Canadian Institute for Health Information, there is almost a five-fold variation in the use of home care across provinces/territories.19 The extent of private expenditure on home care services is not presently known. However, Statistics Canada has reported that the proportion of Canadians living in the community who require assistance with their personal activities of eating, bathing and dressing who are receiving government-subsidized home care declined from 46% in 1994-1995 to 35% in 2003; the suggestion is that some of the burden may have shifted to home care agencies or family and friends.20 Statistics Canada has reported that in 2002, over 1.7 million adults aged 45 to 64 provided informal care to almost 2.3 million seniors with long-term disabilities or physical limitations.21
In light of the foregoing, the CMA believes that:
optimal management of the continuum of care requires that patients take an active part in developing their care and treatment plan, and in monitoring their health status;
the issue of the continuum of care must go beyond the question of financing and address questions related to the organization of the delivery of care and to the shared and joint responsibilities of individuals, communities and governments in matters of health care and promotion, prevention and rehabilitation;
support systems should be established to allow elderly and disabled Canadians to optimize their ability to live in the community;
strategies should be implemented to reduce wait times for accessing publicly funded home and community care services;
integrated service delivery systems should be created for home and community care services; and
any request for expanding the public plan coverage of health services, in particular for home care services and the cost of prescription drugs, must include a comprehensive analysis of the projected cost and potential sources of financing for this expansion.
The CMA recommends that:
governments adopt a policy framework and design principles for access to publicly funded medically necessary services in the home and community setting that can become the basis of a "Canada Extended Health Services Act;"
governments initiate a national dialogue on the Canada Health Act in relation to the continuum of care;
governments and provincial/territorial medical associations review physician remuneration for home and community-based services; and
governments undertake pilot studies to support informal caregivers and long-term care patients, including those that:
a) explore tax credits and/or direct compensation to compensate informal caregivers for their work,
b) expand relief programs for informal caregivers that provide guaranteed access to respite services in emergency situations,
c) expand income and asset testing for residents requiring assisted living and long-term care, and
d) promote information on advance directives and representation agreements for patients.
Mental Health Care
In 2000 mental illness was the fourth-ranking contributor to the total economic burden of illness in Canada.22 The exclusion of psychiatric hospitals from the CHA means that they are not subject to the five principles and were not included in the original basis of the federal transfer payments. While a major Senate Committee report has pointed out that the closure of psychiatric facilities means that this exclusion is no longer pertinent, the Committee also noted that many essential services for persons with mental illness such as psychological services or out-of-hospital drug therapies are not covered under provincial health insurance plans.23 Moreover, there remain 53 psychiatric hospitals in Canada.24
The CMA recommends that:
the federal government make the legislative and/or regulatory amendments necessary to ensure that psychiatric hospital services are subject to the five program criteria of the Canada Health Act;
in conjunction with legislative and/or regulatory changes, funding to the provinces/territories through the Canada Health Transfer be adjusted to provide for federal cost sharing in both one-time investment and ongoing cost of these additional insured services; and
Canadian physicians and their organizations advocate for parity of allocation of resources (relative to other diseases) toward the continuum of mental health care and research.
According to Statistics Canada's most recent population projections, the proportion of seniors in the population (65+) is expected to almost double from its present level of 13% to between 23% and 25% by 2031.25 The Organization for Economic Cooperation and Development has projected that the share of Gross Domestic Product devoted to long-term care will at least double from its 2005 level of 1.2% to 2.4% by 2050, and could almost triple to (3.2%) depending on the success of efforts to contain cost.26
The potential need for long-term care is not confined to the senior population. Based on the results of its 2006 Participation and Activity Limitation Survey, Statistics Canada estimated that there were 2 million adults aged 15-64 with disabilities, of whom 40% were severely disabled; in addition there were 202,000 children with disabilities, of whom 42% were severely disabled.27
A lack of appropriate long term care is imposing a bottleneck in the acute care system. The term Alternate Level of Care (ALC) is used to describe a situation when a patient is occupying a bed in a hospital and does not require the acute care provided in this setting. According to a 2009 CIHI report, in 2007-08, there were more than 74,000 ALC patients and more than 1.7 million ALC hospital days in Canada (excluding Manitoba and Quebec), accounting for 5% of hospitalizations and 14% of hospital days. In other words, every day almost 5,200 beds in acute care hospitals were occupied by ALC patients28.
This has significant consequences; emergency departments are being used as holding stations while admitted patients wait for a bed to become available, surgeries are being postponed, and the care for ALC patients may not be as good as it might be in an alternate site that is better equipped to suit their specific needs. Insufficient access to long term care at all ages is an obstacle to improving the health care system. Major investment is required in community and institutionally based care.
Most of the discussion in Canada since the mid-1990s has focused on the sustainability of the current Medicare program and the prospect for enhancements such as pharmacare. There has been little attention since the early 1980s on the future funding of long-term care. Internationally, in contrast, the United Kingdom has had a Royal Commission on long-term care, and Germany has moved to put in place a contributory social insurance fund.
A cursory assessment of the literature would suggest that there is a consensus that long-term care cannot/should not be financed on the same pay-as-you-go basis (i.e., current expenditures funded out of current contributions) as medical/hospital insurance programs.
The federal government has several options available to promote the pre-funding of long-term care:
Long-term care insurance: Policies are offered in Canada and are of fairly recent origin. There has been little take-up of such policies to date. At the end of 2005, about 52,700 Canadians were covered under long-term care insurance. One option could be to make long-term care insurance premiums deductible through a tax credit, similar to what Australia has done for private health insurance.
Tax-deferred savings: The Registered Retirement Savings Plan (RRSP) has been a very popular method for Canadians to save for retirement. As of 2007, an estimated 7 out of 10 (68%) of Canadians reported having an RRSP. However, in 2002, just 27% of all tax returns filed in Canada reported deductions for RRSP contributions. In 1998, Segal proposed a Registered Long-term Care Plan that would allow Canadians to save against the possibility of their need for a lengthy period of care. Another option to consider would be to add a provision to RRSPs similar to the Lifelong Learning Plan and the Home Buyer's Plan. This would be referred to as the Long-term Care Plan and would allow tax-free withdrawals from RRSPs to fund long-term care expenses for either the RRSP investor's own care or their family members' care.
Tax-prepaid saving: In Canada, the Registered Education Savings Plan (RESP) is an example of a plan whereby after-tax earnings are invested and allowed to grow tax-free until they are distributed and included in the recipient's income. In the 2007 federal budget, the government announced the introduction of a Registered Disability Savings Plan. Parents and guardians will be able to contribute to a lifetime maximum of $200,000 and similar to the RESP program there will be a related program of disability grants and bonds, scaled to income. This approach could have more general applicability to long-term care. The 2008 federal budget has introduced a tax-free savings account (TFSA) that, starting in 2009, enables those 18 and over to contribute up to $5,000 per year in after-tax income to a TFSA, whose investment growth will not be taxed; however, funds can be withdrawn at any time for any purpose29.
Payroll deduction (Social Insurance): A compulsory payroll tax that would accumulate in a separate fund along the lines of the Canada Pension Plan has been recommended in provincial reports in Quebec and Alberta.
In summary, whatever vehicle might be chosen, governments need to impress upon younger Canadians the need to exercise personal responsibility in planning for their elder years, given continuing gains in longevity.
The CMA recommends that:
governments study the options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance; and
the federal government review the variability in models of delivery of community and institutionally based long-term care across the provinces and territories as well as the standards against which they are regulated and accredited.
The Senate of Canada, and the Honourable Sharon Carstairs in particular, have provided leadership over the last decade in highlighting both the progress and the persistent variability across Canada in access to quality end-of-life care. In the latest (2005) of three reports issued since 1995, the Senate again calls for the development of and support for a national strategy for palliative and end-of-life care.30 In that report Still Not There it is noted that it is commonly estimated that no more than 15% of Canadians have access to hospice palliative care, and that for children, the figure drops further to just over 3%. To date, palliative care in Canada has primarily centred on services for those dying with cancer. However, cancer accounts for less than one-third (30%) of deaths in Canada. Diseases at the end of life such as dementia and multiple chronic conditions are expected to become much more prevalent in the years ahead. The demand for quality end-of-life care is certain to increase as the baby boom generation ages. By 2020 it is estimated that there will be 40% more deaths per year. While there has been a decreasing proportion of Canadians dying in hospital over the past decade, many more Canadians would prefer to have the option of hospice palliative care at the end of life than current capacity will permit. In its April 2009 report, the Special Senate Committee on Aging recommended a federally funded national partnership with provinces, territories and community organizations to promote integrated quality end-of-life care for all Canadians, the application of gold standards in palliative home care to veterans, First Nations and Inuit and federal inmates, and renewed research funding for palliative care.31
The CMA recommends that:
governments work toward a common end-of-life care strategy that will ensure all Canadians have equitable access to and adequate standards of quality end-of-life care.
1 Risk pooling is defined by the World Health Organization as the practice of bringing several risks together for insurance purposes in order to balance the consequences of the realization of such individual risk. Risk adjustment and risk sharing are means of adjusting or compensating for risk differentials between risk pools.
1 Canada. Hospital Insurance and Diagnostic Services Act. Statutes of Canada 1956-57 Chap 28. Ottawa: Queen's Printer, 1957.
2 Canada. Medical Care Act 1966-67, C. 64, 5.1. Revised Statutes of Canada 1970 Volume V. Ottawa: Queen's Printer, 1970.
3 Canada. Canada Health Act. Chapter C - 6. Ottawa, 1984.
4 Hall, E. Royal Commission on Health Services, Volume 1. Ottawa: Queen's Printer, 1964.
5 Canadian Institute for Health Information. National Health Expenditure Trends 1975-2008. Ottawa, 2008.
6 National Forum on Health. Canada Health Action: Building on the legacy - Volume 1 - the final report. Ottawa: Minister of Public Works and Government Services, 1997.
7 Standing Senate Committee on Social Affairs, Science and Technology. The health of Canadians - the federal role Volume six: recommendations for reform. Ottawa, 2002.
8 Commission on the Future of Health Care in Canada. Building values: the future of health care in Canada. Ottawa, 2002.
9 Canadian Intergovernmental Conference Secretariat. First Ministers' meeting communiqué on health. September 11, 2000. http://www.scics.gc.ca/cinfo00/800038004_e.html. Accessed 09/24/09.
10 Canadian Intergovernmental Conference Secretariat. 2003 First Ministers' Accord on Health Care Renewal. February 5, 2003. http://www.scics.gc.ca/pdf/800039004_e.pdf. Accessed 08/05/08.
11 Canadian Intergovernmental Conference Secretariat. A 10-Year plan to strengthen health care. September 16, 2004. http://www.scics.gc.ca/cinfo04/800042005_e.pdf. Accessed 08/05/08.
12 Health Council of Canada. Health care renewal in Canada: Measuring up? Toronto, 2007.
13 Canadian Institutes of Health Research. The future of public health in Canada: Developing a public health system for the 21st century. Ottawa, 2003.
14 Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceuticals Strategy. National Pharmaceuticals Strategy Progress Report. June 2006. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 08/05/08.
15 Canadian Intergovernmental Conference Secretariat. Backgrounder: National Pharmaceutical Strategy Decision Points. September 24, 2009. http://www.scics.gc.ca/cinfo08/860556005_e.html. Accessed 09/24/09.
16 Statistics Canada. Survey of Household Spending 2006. Detailed table 2, 62FPY0032XDB.
17 Xu K, Evans D, Carrin G, Aguilar-Riviera A. Designing health financing systems to reduce catastrophic health expenditure. Geneva: World Health Organization, 2005.
18 Service Canada. Employment insurance (EI) compassionate care benefits. http://18.104.22.168/eng/ei/types/compassionate_care.shtml. Accessed 09/24/09.
19 Canadian Institute for Health Information. Public sector expenditures and utilization of home care services in Canada: exploring the data. Ottawa, 2007.
20 Wilkins K. Government-subsidized home care. Health Reports 2006;17(4):39-42.
21 Pyper W. Balancing career and care. Perspectives on labour and income 2006;18(4): 5-15.
22 Public Health Agency of Canada. Table 2 Summary - Economic burden of illness in Canada by diagnostic category, 2000. Ottawa, 2000.
23 Standing Committee on Social Affairs, Science and Technology. Out of the shadows at last: transforming mental health, mental illness and addiction services in Canada. Ottawa, 2006.
24 Canadian Healthcare Association. September 2009.
25 Statistics Canada. Population projections. The Daily, Thursday, December 15, 2005.
26 Organization for Economic Co-operation and Development. Projecting OECD health and long-term care expenditures. What are the main drivers? Paris, 2006.
27 Statistics Canada. Participation and Activity Limitation Survey 2006: Tables. Catalogue no. 89-628-XlE-No. 003. Ottawa: Minister of Industry, 2007.
28 Canadian Institute for Health Information. Alternate level of care in Canada. Ottawa, 2009.
29 Canada Revenue Agency. Tax-free savings account (TFSA). http://www.cra-arc.gc.ca/E/pub/tg/rc4466/rc4466-e.html#P44_1114. Accessed 09/24/09.
30 Carstairs S. Still not there. Quality end-of-life care: a status report. http://sen.parl.gc.ca/scarstairs/PalliativeCare/Still%20Not%20There%20June%202005.pdf. Accessed 09/24/09.
31 Special Senate Committee on Aging. Final report: Canada's aging population: Seizing the opportunity. Apr 2009.
FETAL ALCOHOL SPECTRUM DISORDER (UPDATE 2009)
Fetal Alcohol Spectrum Disorder (FASD) is a leading cause of environment-related birth defects and developmental disabilities in North America. The Canadian Medical Association (CMA) believes that the prudent choice for women who are or may become pregnant is to abstain from alcohol, and encourages their partners to support them in this endeavour. The CMA urges Canadian governments to enact legislation that requires alcoholic beverages sold in Canada to be labelled with warnings of the hazards of consuming alcohol during pregnancy. The CMA also calls upon the federal government to examine the role that advertising plays in promoting the consumption of alcoholic beverages and to review existing policies and regulations in this area.
Fetal alcohol spectrum disorder (FASD) is an umbrella term used to describe the range of disabilities and diagnoses that result from drinking alcohol during pregnancy. It is estimated that more than 3,000 babies in Canada are born with FASD every year.
Those who live with FASD may have mild to very severe problems with their health. They may have delays in their development, intellectual problems and problems in their social lives. Examples of these include:
* skeletal abnormalities such as facial deformities
* physical disabilities such as kidney and internal organ problems
* depression or obsessive-compulsive disorder
* difficulty understanding the consequences of their actions
These disabilities are lifelong and those affected may need lifelong support.
The drinking patterns of teenagers and the potential for women of reproductive age to consume alcohol mean that the health care system must actively address the prevention of FASD. Also, alcohol use may play a considerable role in unplanned pregnancy and inadequate prenatal and postnatal care.
The CMA strongly supports all activities that encourage Canadians to moderate their alcohol consumption. The association encourages the public to be aware of the issues related to alcohol consumption, particularly the adverse effects on the fetus.
In a continued effort to support the reduction of alcohol consumption, the CMA urges Canadian governments to enact legislation that requires alcoholic beverages sold in Canada to be labelled with warnings of the hazards of alcohol consumption during pregnancy.1 Appropriate agencies should also adopt regulations and/or policies to ensure that warnings about the adverse interaction between alcohol and both prescription and non-prescription products are prominently displayed or distributed wherever alcohol and drugs are sold or dispensed.2 The CMA also calls upon the federal government to examine the role that advertising plays in promoting the consumption of alcoholic beverages and to review existing policies and regulations in this area.
The adverse effects of alcohol consumption by pregnant women are preventable. The CMA believes that the prudent choice for women who are or may become pregnant is to abstain from alcohol and encourages their partners to support them in this endeavour. Physicians should use appropriate screening methods to identify alcohol use in their patients. Physicians can play a leading role in educating and counselling women, spouses and family members about the dangers of alcohol to the fetus. The CMA also recommends that alcohol and drug addiction treatment services give high priority to the needs of pregnant women seeking help.
1 General Council resolution 89-67: That the Canadian Medical Association urge Governments in Canada to enact legislation requiring that all alcoholic beverages sold in Canada be labelled with warnings on the hazard from the consumption of alcohol during pregnancy. Note: this motion was rescinded because it was superseded by the Policy on Fetal Alcohol Syndrome (2000).
2 General Council resolution 87-31
What do we mean by "personal information"?
Throughout this policy, we discuss "personal information," and it is important from the outset to set out what we mean by this term. "Personal information" is information that reveals a distinctive trait about yourself and helps others identify you. Some personal information such as your business address may be found in the public domain by accessing publications like telephone or professional directories. The focus of this policy is personal information collected, used and disclosed by the CMA that is NOT in the public domain.
What types of personal information does the CMA collect and use?
Primarily, the CMA collects and uses personal information about its members. CMA also has personal information about individuals who purchase CMA products and services, attend CMA sponsored events and seminars and submit manuscripts to CMA publications. The CMA assigns a personal identifier called a "CMA ID" to each member or purchaser of a CMA product or service so that you can use this number when contacting the CMA, ordering CMA products and publications or registering for the cma.ca Web site.
The CMA collects personal information directly from individuals or receives it from one of its provincial or territorial medical associations ("PTMAs") or subsidiaries, the CMA group of subsidiary companies, including our primary financial services company, MD Physician Services Inc.
-If you are a CMA member, you might have provided on an application form or will provide to the CMA or a PTMA or a CMA subsidiary, personal information like your home address, date of birth and gender. If you are both a client of one or more of CMA's financial subsidiaries and a CMA member, the fact of your client status, but not detailed financial information, will be known to CMA. A circumscribed and limited number of CMA employees, all of whom receive enhanced privacy training and sign specific undertakings, will have access to more detailed MD PS information such as frequency of meetings about your MD client status (but still not specific financial transactional details) in order to perform statistical analysis.
- If you have attended an event organized through CMA's Meetings and Travel Department, you might have provided us with credit card data as well as information about certain travel preferences and food sensitivities.
- If you have purchased a CMA product (e.g., classified advertising) or attended a CMA seminar (e.g., Physician Manager Institute), you provided us with personal contact information such as your name and address. We might also have collected credit card information if you chose to pay for the product or service by this method.
- If you have submitted a manuscript for publication in a CMA journal, you provided us with contact information, financial disclosure and competing interests data and the manuscript itself.
Why does the CMA collect and use personal information?
The CMA will collect and use only the personal information necessary to achieve the following purposes or one consistent with them:
1. to determine an individual's eligibility for membership in the CMA or to serve as a potential contributor to a CMA publication
2. to determine an individual's eligibility to benefit from the services of one of CMA's subsidiaries or its preferred third-party suppliers
3. to provide and to communicate information about CMA member benefits and services (e.g., the delivery of publications and travel reservations, financial services, advocacy, etc.)
4. to develop and to market products and services tailored to the interests of CMA members and the purchasers of CMA products and services
5. to update contact information in the CMA database
6. to assist the CMA PTMAs and CMA's subsidiaries with the maintenance of their membership and client contact information
7. to provide individuals with the opportunity to benefit from supporting the Canadian Medical Foundation which provides CMA members and others with valuable educational programs and services
8. to conduct surveys and research studies of the physician population in order to analyze for statistical and research purposes such issues as the demographics of physician human resources
9.to engage members and physicians in CMA's policy development process
10.to broadcast urgent health alerts of national significance
When and to whom does the CMA disclose personal information?
The CMA does not sell personal information. The CMA will only disclose your personal information to an organization for a purpose outlined in this policy, unless we obtain your consent for a new purpose. For example, one purpose identified above is maintaining up-to-date membership and client contact information. The CMA and its subsidiariesshare a core data field for the purposes of updating addresses and confirming membership status.
In addition to a core data field for the purposes of updating addresses and confirming membership status, CMA shares with its wholly owned subsidiary, MDPS, information about a member's participation in CMA activities and products such as Physician Manager Institute events. MDPS, as the most highly rated provider of CMA products and services, is seeking to have a better understanding and appreciation of physicians' relationship and interaction with CMA. Knowledge of an individual's participation in CMA events and activities provides this complete or "integrated" picture. If a CMA member objects, a note will be entered in the database.
If you are both a CMA member and a client of a CMA subsidiary company, when you inform us of an address change, with your permission, this information will be changed for both organizations.
The CMA might also disclose personal information to third parties or to organizations or companies that are not CMA-affiliated companies or Divisions if these organizations have contracted or partnered with the CMA to help us provide products and services or do research. For example, the CMA might out-source the mailing list function for one of its publications or work with the Canadian Post-MD Education Registry to study physician resource planning.
We may, in certain instances, contract with a third party service provider located in other countries such as the United States. Your information may be processed and stored in the United States and the United States governments, courts or law enforcement or regulatory agencies may be able to obtain disclosure of your information under a lawful order made in that country. If you would like more information about the jurisdictions in which we our service providers may operate please contact us as noted in the What if you have a question... section of this policy.
Within the CMA itself, your personal information in the form of interactions with the CMA will be shared amongst CMA departments. This will enable CMA to have a better understanding of your interests and activities such that CMA might tailor its product and service offerings to your interests. For example, if a member has completed a number of Physician Manager Institute courses, we might send him or her information about our Physician Leadership Credential Program. If a member objects to a particular disclosure of an activity, for instance a particular CME course, a note will be entered into the database
What if you object to CMA's collection, use or disclosure of personal information?
The CMA seeks to respect and honour your privacy and communication preferences. For instance, if you indicate to the CMA that you do not wish to receive certain publications, participate in surveys or receive information about new or specific benefits and services such as communications from CMA's subsidiaries, your preference will be noted and you will no longer receive correspondence from us on these issues. Please contact the CMA Member Service Centre at 888-855-2555 to make such a request.
You may also at any time, subject to restrictions required by law, object to the CMA's collection, use or disclosure of personal information. You need only provide the CMA with reasonable notice in writing of your intention and the details of your objection. For instance, if you do not wish to have contact and demographic information shared with the Canadian Medical Foundation, we will respect your choice.
Please note, however, that your objection to the disclosure of other information might mean that the CMA is unable to continue to provide you with some products or services. For example, if you object to the sharing of your CMA membership status with CMA's financial subsidiaries, then you will not be eligible to benefit from their products or services. MD Physician Services has to confirm your CMA membership status in order to offer you financial services.
It is your responsibility to contact the CMA in order to determine how an objection to the collection, use and disclosure of personal information might affect the services supplied.
How accurate is the personal information held by the CMA?
The CMA makes every reasonable effort to ensure the accuracy and currency of your personal information so that we might fulfill the purposes for which it was first collected. Your personal information is subject to change so please advise us accordingly of such changes so that we might better meet your needs.
How do you access the personal information held by the CMA?
You may send a written request to the attention of the Chief Privacy Officer at 1867 Alta Vista Drive, Ottawa, Ontario, K1G 5W8or to email@example.com to obtain the personal information held about you by the CMA. Within a reasonable time frame, the CMA will then advise you in writing whether it has such personal information and the nature of this information unless there is the rare occurrence that the release of such information is legally prohibited. If the CMA cannot release the personal information, we will provide you with the reasons for denying access.
You may challenge the accuracy and completeness of the personal information that is maintained by the CMA. The CMA will amend personal information when an individual successfully demonstrates inaccuracy or incompleteness.
How secure is your personal information?
The CMA makes every reasonable effort to protect your personal information by implementing security safeguards against loss or theft, as well as unauthorized access, disclosure, copying, use or modification. The CMA uses physical, organizational and technological measures as methods of protection. For instance, only a limited number of staff have access to such sensitive information as credit card numbers. Moreover, the CMA will ensure that employees are aware of the importance of maintaining the confidentiality of personal information.
How long does the CMA retain personal information?
The CMA keeps personal information as long as it is needed to fulfill the purposes identified above. When personal information is no longer required to fulfill the identified purposes, it will be safely and securely destroyed. Moreover, the CMA will retain personal information that is the subject of an access request for as long as is necessary to allow an individual to exhaust any legal remedy that is provided for in applicable federal or provincial/territorial privacy legislation.
Health, health care and the environment are linked inextricably. Environmental contaminants have been associated with compromised health status, including cancer, birth defects, respiratory and cardiovascular illness, gastrointestinal ailments and death - and an increased demand for a range of health care services.
The health sector is a significant part of Canada's economy, contributing approximately 10% of gross domestic product (GDP). Thus, the sector uses considerable energy, consumes large quantities of plastics, paper and other resources, and produces significant solid, liquid and gaseous waste. With the improvement of health care technologies and a growing awareness of environmentally responsible practices, there is an increased opportunity for reducing the health sector's environmental footprint. Although there are important health, financial and ethical reasons for adopting such practices in the health sector, a number of challenges exist, including financial, technical and administrative challenges.
We envision the health sector as a leader in integrating environmentally responsible practices into the delivery of health care. We also see it as an advocate in sharing information on best practices and encouraging Canadians and Canadian organizations to limit their environmental footprint. In a green health sector, minimizing negative impact on the environment would be a priority for all organizations and individuals in their day-to-day practices and at all levels of decision-making.
A collaborative approach
Achieving our vision requires a collaborative approach to delivering environmentally responsible health care. For example:1
Greener health infrastructure
* support investment in renewing physical plant infrastructure that allows for the retrofit of facilities that function more efficiently, use cleaner technologies and meet new environmental standards for energy efficiency, water management and waste management
* educate staff and the public on the link between health and the environment and on the health impact of environmental degradation, and help in the development, dissemination and implementation of knowledge and best practices
* support and encourage research on health and the environment, and on environmentally responsible practices in a variety of health care settings
* implement energy-conserving techniques and products
* request rationalized packaging and other environmentally responsible actions from vendors of health care products
* promote safer substitutes to reduce exposure to toxic substances
* reduce waste by reusing and recycling when possible
* practise safe disposal practices for biomedical and infectious waste, outdated medications, and polyvinyl plastics, mercury and other toxic substances
* establish green teams to support the practice of ecologic stewardship
We recognize that our efforts to achieve a greener health sector must fit into broader societal and global actions to improve the environment. The health sector plays a role in supporting the efforts of all Canadians to find environmentally responsible ways to perform their daily activities by contributing to the management of global environmental issues, such as greenhouse gas emissions and toxic waste disposal.
Calls to Action
We call on governments and policymakers at all levels to understand and address links between health and the environment and to incorporate these links into policy decisions through legislative and budgetary actions.
We call on all health care organizations to pledge to minimize the negative impact of their activity on the environment and to seek solutions to existing barriers.
We call on individuals working in the health sector to both model and advocate for environmentally responsible approaches to delivering health care without compromising patient safety and care.
Association of Canadian Academic Healthcare Organizations
Canadian Coalition for Green Health Care
Canadian College of Health Service Executives
Canadian Dental Association
Canadian Healthcare Association
Canadian Medical Association
Canadian Nurses Association
Canadian Pharmacists Association
Canadian Public Health Association
David Suzuki Foundation
Developed by a working group of the above organizations
1 Canadian Nurses Association/Canadian Medical Association. Joint position statement: Environmentally responsible activity in the health care sector. Ottawa. 2009