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.
This policy addresses the role of the treating physician in assisting their patients return to work after an illness or injury. The treating physician's role is to diagnose and treat the illness or injury, to advise and support the patient, to provide and communicate appropriate information to the patient and the employer, and to work closely with other involved health care professionals to facilitate the patient's safe and timely return to the most productive employment possible. Fulfilling this role requires the treating physician to understand the patient's roles in the family and the workplace. Furthermore, it requires the treating physician to recognize and support the employee-employer relationship and the primary importance of this relationship in the return to work. Finally, it requires the treating physician to have a good understanding of the potential roles of a return-to-work coordinator and of other health care professionals and employment personnel in assisting and promoting the return to work.
The CMA recognizes the importance of a patient returning to all possible functional activities relevant to his or her life as soon as possible after an injury or illness. Prolonged absence from one's normal roles, including absence from the workplace, is detrimental to a person's mental, physical and social well-being. The treating physician should therefore encourage a patient's return to function and work as soon as possible after an illness or injury, provided that a return to work does not endanger the patient, his or her co-workers or society. A safe and timely return to work benefits the patient/employee and his or her family by enhancing recovery and reducing disability. A safe and timely return to work by the employee also preserves a skilled and stable workforce for employers and society and reduces demands on health and social services as well as on disability plans.
In recent years, an increasing level of responsibility in the return-to-work process has been placed on treating physicians. There has been an increased demand for medical information and advice from physicians and other health care providers concerning patient functionality, restricted work and modifications to the workplace to help accommodate the disabled patient. i There has also been a blurring of the lines between the provision of forms/reports for benefits and dealing with requests for information related to helping patients return to work (e.g., completing Functional Abilities Forms). Treating physicians are often asked to provide information related to complex issues affecting patients in the workplace and to assist in the eligibility of insurance claims while lacking information related to job description or the insurance company's definition of disability.
There is also the issue of consent, where employers/insurers are asking employees to sign "blanket consents," which include information well outside what is medically necessary to determine eligibility to return to work. In addition, the complex nature of the return-to-work process can lead to conflict between employees, physicians, and employers. Finally, the majority of physicians outside occupational medicine have not received training on the return-to-work process and thus may feel uncomfortable providing these types of services.
Cooperation from the employee, employer, insurer and health care provider is necessary to ensure a safe and timely return to work for the patient. The purpose of this statement is to address the role of the treating physician in the patient's return to work. A treating physician refers to a physician from any medical specialty - including a family physician - who preferably knows the patient the best. The CMA supports a shift away from reliance on physician certification for work absences and a move toward greater cooperation between the employee and his or her employer with the use of medical input, advice and support from the employee's treating physician and other involved health care professionals.ii
Although this policy addresses the treating physician's role in helping patients return to work after an illness or injury, many of the concepts are applicable to accommodating employees who are in need of a modified work arrangement with their employer.
The Role of the Employer
The employee and the employer generally have an established relationship and this is central to the return-to-work process. In all cases of impairment or disability, an unbiased workplace supervisor, manager or employer representative must be a closely involved partner in this process.
Employers increasingly recognize the value of making changes to the workplace than can facilitate a return to work. The employer's role is to ensure that the workplace culture supports a safe and timely return to work; for example, by being flexible in modifying tasks, schedules and environmental conditions to meet the temporary or permanent needs of the employee. Employees are often unaware of their employer's capacity to accommodate special needs. Direct communication by an employee with his or her employer after an illness or injury often enhances the employee's perception of his or her ability to work. With careful planning and appropriate physician input and advice to both the employee and the employer, an employee may often successfully return to work before full recovery.
The employer and employee have a responsibility to provide the treating physician with any employment-related information that can be useful in giving medical advice and support. It is the employer's responsibility to provide the treating physician with a written job description, identifying the job risks and available work modifications, upon request.
The Role of the Treating Physician
The treating physician's role in helping a patient return to work has four main elements:
1. Providing to the patient medically necessary services related to the injury or illness to achieve optimum health and functionality;
2. Providing objective, accurate and timely medical information for the consideration of eligibility of insurance benefits;
3. Providing objective, accurate and timely medical information as part of the timely return-to-work program; andiii
4. Considering whether to serve as a Timely Return-to-Work Coordinator when requested by the employer/employee or other third party (outlined below).
In relation to the first three elements, the treating physician should remain cognizant of the potential for legal proceedings and should, therefore, ensure, as always, that any statements made regarding a patient's capacity to return to work are defensible in a court of law. The physician should ensure that any statements made are, to the best of the physician's knowledge, accurate and based upon current clinical information about the patientiv. If the physician relies on information that cannot be substantiated independently, then the physician should note in the report the source of the information and the fact that it has not been independently confirmed. Comments unrelated to the treating physician's professional opinion or that are extraneous to the stated objectives should not be included in the report. Reports should be written in language that is appropriate for the intended audience. This may require the physician to avoid medical short forms, or jargon. Where this is not possible, the physician should include, in addition to technical medical terminology, more colloquial terms or explanations to ensure the reader understands the report's contents. Where the physician is not able to answer some of the questions, even with the assistance of the patient, the physician should indicate his or her inability to respond.
For more information with respect to completing forms and reports, please refer to Canadian Medical Protective Association articles entitled "Forms and Reports: The Case for Care (2002)" v and "Reasonable Delays for Filling out Insurance Forms (2007)." vi
Considerations for Treating Physicians who wish to Participate in the Timely Return-to-Work Process
Treating physicians need to ensure that a timely return-to-work plan is incorporated into the care plan for their patient. A timely return-to-work program is one that is initiated early and ensures a safe return to work at the earliest and most appropriate time. The treatment or care plan should be evidence-based, when possible, and should identify the best sequence and timing of interventions for the patient.
The treating physician should facilitate the patient's return to work by encouraging him or her early in treatment or rehabilitation to take an active role in and take responsibility for the return to work, and to communicate directly and regularly with his or her employers. Furthermore, the physician should discuss expected healing and recovery times with the patient, as well as the positive role in physical and psychological healing of a graduated increase in activity.
Unnecessary waiting periods and other obstacles in the care plan should be identified and discussed, when relevant, by those involved in the patient/employee's return to work. In some cases, it may be appropriate for the treating physician to advise the patient that a timely return to work can facilitate his or her recovery by helping to restore or improve functional capabilities. The physician should be familiar with the family and community support systems available to the patient. Moreover, the physician should be knowledgeable about and use, when appropriate, the services of a multidisciplinary team of health care professionals, who can be helpful in facilitating the patient's safe and timely return to work. In cases of employers with occupational medical departments, the treating physician, with the patient's prior expressed consent, may contact the occupational physician or nurse to understand specific workplace policies, supportive in-house resources, essential job demands and possible health and safety hazards in the patient's workplace. Where occupational medical resources are available, the treating physician generally assumes a supportive or advisory medical role. For assistance with specific cases, provincial and territorial medical associations and the Occupational Medicine Specialists of Canada, as well as the Occupational and Environmental Medicine Association of Canada, have information identifying physicians who specialize in assisting with the return to work. vii In complex cases, the treating physician should consider referring the patient/employee to medical specialists or other appropriate health care professionals for a comprehensive, objective assessment of his or her functional capabilities and limitations and their relation to the demands of the employee's job.
The Return-to-Work Coordinator
The CMA supports the concept of the return-to-work coordinator as described in the Ontario Medical Association Position Paper, "The Role of the Primary Care Physician in Timely Return to Work."viii A return-to-work coordinator may be a health care professional who "works with the employer and the patient/employee to assist in developing and overseeing a timely return to work program that is individualized to the employee and meets the requirements of the employer. A return to work plan or program is "a compilation of services required to safely and effectively return an individual to work as soon as possible." ix Return to work requires that the employee's capabilities match or exceed the physical, psychological and cognitive requirements of the work offered. It may involve designing a modified work setting and timetable to facilitate reintegration in the workplace based on the patient's physical and psychological condition.
Specific services of the return-to-work coordinator may include:
* Compiling all medical information, along with the employee's workplace and job functions information.
* Providing advice on the limitations, restrictions and modifications that may be necessary to accommodate the employee in a timely return-to-work program.
* Periodically reviewing the prescribed program and suggesting modifications until the patient eventually assumes full-duty status or has resumed work in a modified manner acceptable to all parties.
The treating physician has the choice to assume this role or it may be assumed by an alternate health care provider. It is the employer/insurer's responsibility to ensure that a health care provider is assigned to this role. The treating physician also has the choice to suggest the patient/employee undergo a functional capacity assessment or an independent medical examination (IME). Treating physicians should only provide such services if they have the necessary training and expertise. The CMA believes educational sessions should be provided to support treating physicians who feel they need them and who wish to assume the role of the timely return-to-work coordinator.
If the treating physician agrees to participate in developing a modified work plan, the physician should consider and make recommendations related to the employee's task limitations, schedule modifications, environmental restrictions and medical aids or personal protective equipment. Whenever possible, the physician should state whether restrictions are permanent or temporary and give an estimate of recovery time. The physician should also specify the date when the patient's progress and his or her work restrictions need to be reassessed.
The treating physician must be aware of the risks to the patient, his or her coworkers or the public that could arise from the patient's condition or drug therapy. If the patient's medical condition and the nature of the work performed are likely to endanger the safety of others significantly, the physician must put the public interest before that of the patient/employee.
When the treating physician, acting as a return-to-work coordinator, believes that the patient has recovered sufficiently to return to work safely, the patient should be clearly informed of this judgment. If the employer and the employee cannot agree on a return-to-work plan, the employer should contact the treating physician and employee to identify the minimum level of capability that can be accommodated in the workplace.
When there is a conflict between the employer and the employee, it is recommended that the treating physician use, where available, the skills of an occupational physician. The CMA recommends that, when conflicts occur, conflict-resolution processes be put in place to address all participants' concerns. The treating physician's role should be limited to providing relevant clinical information about the functional limitations of the employee and recommending any corresponding work restrictions.
Ultimately, the employer determines the type of work available and whether a physician's recommendations concerning an employee's return to work can be accommodated. Under provincial and territorial human rights laws, an employer may not discriminate on the basis of disability or other illness and has legal obligations with respect to the accommodation of employees. For details, refer to the Human Rights Code in the relevant jurisdiction.
The CMA holds that legislation should be enacted in all jurisdictions to protect physicians from liability associated with such decisions.
Respecting Patient Confidentiality and Managing Medical Information
Medical records are confidential. Physicians must respect the patient's right to confidentiality except where required or permitted by law to disclose requested information. In general, physicians should not, without the patient's consent, give information to anyone concerning the condition of a patient or any service rendered to a patient, unless required by law to do so. For example, in some cases, provincial or territorial legislation may require physicians to provide information to workers' compensation boards without prior patient approval. Physicians should be aware of the legal requirements with regard to prior patient approval and of the legal requirements in their province or territory. Where a physician has the discretion to make a disclosure (i.e., where it is permitted by law but not required), the decision should be made bearing in mind the duty of confidentiality and the facts of the case. Physicians will want to consider if it is appropriate under the circumstances to advise the patient when a disclosure has been made pursuant to applicable legislation.x
In circumstances where a physician provides a third party with information or an opinion for an individual he/she is not otherwise treating (for example during an IME mandated by the employer), the duty to provide the individual with access to the information, opinion and or notes prepared for the opinion will vary according to the applicable law, the nature of the agreement with the third party and the consent of the individual. Physicians should be aware that their working notes may be, in some circumstances, accessible to an individual being examined for the purpose of a third-party process. Physicians conducting an IME and preparing a report on behalf of a third party should ensure the individual being examined understands the nature and extent of the physician's responsibility to the third party, including that the report will be forwarded to this third party. Moreover, an IME is distinct from a regular physician-patient encounter and, as such, it does not obligate the independent examiner to treat or provide health care to the examinee. However, should the medical examiner discover an unexpected significant clinical finding which requires essential intervention, then he or she should advise the examinee of this fact to enable the examinee to obtain timely medical attention.
The treating physician should not provide information about the patient to the patient's employer without the patient's authorization. The following are best practices when obtaining patient consent:
* Consent should be specific rather than general;
* Written authorization for such disclosure is desirable and may be required in some jurisdictions;
* A separate patient consent should be obtained for each request for medical information; and
* Patient consent should be considered time-limited.
To respect the privacy of the patient, the treating physician should be careful not to provide medical information that is not needed to facilitate the patient's return to work. The patient has the right to examine and copy medical records that pertain to him or her. Patient access to records may be denied only in accordance with the exceptions specified under the relevant privacy legislation, such as reasonable risk of serious harm, solicitor-client privilege or identification of another person. The treating physician should ensure that he/she is familiar with the applicable legislation and rules with respect to a patient's right of access. If access is denied and the patient challenges the treating physician's decision, the onus is on the physician to justify denial of access.
Treating physicians should consult appropriate statements from the relevant provincial or territorial licensing body and from the Canadian Medical Protective Association for additional information and guidance. Physicians should also be aware of any relevant legislation or other legal requirements in their jurisdictions.
Billing for Return-to-Work Services
Many services related to a timely return-to-work program are not covered by public medical insurance. Although often the case, patients should not be required to cover the costs of services related to a timely return-to-work program. The CMA recommends that the requesting party bear these costs.xi Payment should be commensurate with the degree of expertise and the time expended by the physician and office staff. The physician should consult the billing policy of his/her provincial medical association for further guidance.
i Ontario Medical Association, The role of the primary care physician in timely return to work. OMA position paper. Ontario Medical Review, March 2009. https://www.oma.org/Resources/Documents/2009PCPandTimelyReturn.pdf (accessed 2013 Jan 07).
ii Canadian Medical Association, Short-Term Illness Certificate, 2010. http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-06.pdf (accessed 2013 Jan 07).
iii The College of Physicians and Surgeons of Ontario, Third Party Forms, Update 2012. https://www.cpso.on.ca/uploadedFiles/policies/policies/policyitems/ThirdParty.pdf (accessed 2013 Jan 07).
iv The College of Physicians and Surgeons of British Columbia, Medical Certificates policy, Update 2009. https://www.cpsbc.ca/files/u6/Medical-Certificates.pdf (accessed 2013 Jan 07).
v Canadian Medical Protective Association, Forms and Reports: The Case for Care, Update 2008. http://www.cmpa-acpm.ca/cmpapd04/docs/resource_files/infosheets/2002/com_is0227-e.cfm (accessed 2013 Jan 07).
vi Canadian Medical Protective Association, Reasonable Delays for Filling out Insurance Forms, 2007. http://www.cmpa-acpm.ca/cmpapd04/docs/resource_files/infoletters/2007/com_il0720_2-e.cfm (accessed 2013 Jan 07).
vii See also Presley Reed, The Medical Disability Advisor: Workplace Guidelines for Disability Duration, Reed Group, As amended. and the American College of Occupational and Environmental Medicine, Guidelines in Preventing Needless Work Disability, 2006. http://www.acoem.org/PreventingNeedlessWorkDisability.aspx. (accessed 2013 Jan 07).
viii Ontario Medical Association, The role of the primary care physician in timely return to work. OMA position paper. Ontario Medical Review, March 2009. https://www.oma.org/Resources/Documents/2009PCPandTimelyReturn.pdf (accessed 2013 Jan 07).
ix Ontario Medical Association, The role of the primary care physician in timely return to work. OMA position paper. Ontario Medical Review, March 2009. https://www.oma.org/Resources/Documents/2009PCPandTimelyReturn.pdf (accessed 2013 Jan 07).
xCanadian Medical Association, Principles for the Protection of Patients' Personal Health Information. 2004, http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-03.pdf (accessed 2013 Jan 07).
xi Canadian Medical Association, Third Party Forms: The Physician's Role (Update 2010). http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-04.pdf (accessed 2013 Jan 07).
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://184.108.40.206/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.
CMA's position on physician compensation is based on several overarching principles. Physicians must receive fair and reasonable remuneration for the full spectrum of their professional activities. Payment models must not compromise the ability of physicians to provide high quality medical services to their patients, and should also be consistent with overall health system objectives including timely access to quality care. There should be an appropriate relationship between the provincial /territorial medical association and its respective government-one built on mutual respect, trust, consultation and co-operation as well as an expectation of bargaining in good faith.
Key tenets of CMA's policy are as follows:
* Physicians should have the liberty to choose among payment methods. Physicians should not be compelled to adopt any particular method of payment where options are available.
* Physician compensation arrangements must allow for a balance between professional demands and physician wellness.
* Physicians must receive reasonable consideration and compensation when facilities and programs are discontinued, reduced or transferred.
* Provincial/territorial governments should enact legislation that expressly recognizes the representational role of the provincial and territorial medical associations or federations in negotiations and dispute resolutions. Provincial and territorial medical associations must be expressly recognized as the sole bargaining agent for physicians.
* In the event a negotiated settlement is not achieved, such disagreement must be resolved by binding arbitration or other mutually agreed upon, timely process of dispute resolution.
Trends in physician compensation
Many different physician compensation models have been introduced over the past two decades in Canada and elsewhere. Some include alternatives to fee-for-service models while others involve a blended approach that incorporate a variety of compensation models (e.g., capitation, salary, sessional fees and fee-for-service). In recent years, pay-for-performance models have been introduced in some provinces and other countries that involve the use of an incentive payment to reward a provider for achieving a target for the quality of patient care. This may be linked to processes or outcomes of care and could be related to the attainment of a specified threshold and/or percentage improvement.i
Fee for service remains the predominant option for the provision of insured medical services for Canadian physicians although an increasing number of physicians are compensated through blended funding modelsii.
Overarching values for physician compensation
Regardless of which funding models are considered, they should all be consistent with several important overarching values. Recognizing that the range of professional responsibilities placed on physicians extends well beyond the strict provision of medically required services, the CMA maintains that all medical practitioners are entitled to receive fair and reasonable remuneration for the full spectrum of their professional activities including administration, teaching, research and committee work, as well as throughout the full spectrum of payment modalities. In addition, service complexity, length of training and the demands of work should be considered. Payment systems must not compromise the ability of physicians to provide high quality cost effective medical services to their patients, and should also be consistent with overall health system objectives including timely access to quality care and ensuring a productive and effective use of resources. Finally, an appropriate relationship between the provincial/territorial medical association and its respective government is necessary-one built on mutual respect, trust, consultation and co-operation as well as an expectation of bargaining in good faith.
Choice of payment model
Physicians may have the option of remuneration through an increasing array of payment methods. In keeping with the democratic rights accorded to all associations the CMA maintains that all individual medical practitioners should have freedom to choose their method of remuneration. Physicians should not be compelled to adopt any particular method of payment where options are available. Moreover, the implementation of these models should not result in intersectional fee/income inequities.
Funding for physicians negotiated with provincial and territorial governments should be flowed exclusively to physicians regardless of whether the funds are channeled through other agencies.
Balance between professional demands and physician wellness
Physician compensation arrangements must allow for a balance between professional demands and physician wellness. This is important when considering issues such as on-call services and availability of locum tenens. In this regard, the scheduling of physicians' services and training need to be limited to reasonable hours, both to safeguard their ability to provide quality care and in consideration of their need to balance professional and personal life.
Reasonable compensation when programs are discontinued, reduced or transferred
Health care professionals in hospitals and institutional settings are normally given reasonable compensation packages when facilities are closed, downsized, transferred, etc. In these settings, physicians' employment status may not necessarily be the same as other staff members. They may therefore lack certain benefits and risk having their interests inadequately captured by existing mechanisms. Physicians therefore need to receive reasonable consideration and compensation when facilities and programs are discontinued, reduced or transferred. Affected physicians should be involved in any discussions and decision making relating to the discontinuing, reduction or transfer of programs/facilities.
Right to representation
All physicians, including those indirectly affected, exercise their freedom of association through their respective provincial or territorial medical association, and have the right to be represented by their respective association in negotiations on issues of payment, funding and the terms and conditions of their work. The CMA strongly supports the provincial and territorial medical associations in their right to representation as the sole bargaining agents for physicians, regardless of payment method, and in their efforts to fulfill the profession's commitments to negotiated agreements. The CMA exhorts all provincial/territorial governments to immediately enact legislation that expressly recognizes the representation status of provincial and territorial medical associations in negotiations and dispute resolutions.
Consistent with the process of negotiation and the guiding principles of contract law, the CMA fully expects paying agencies to fulfill the terms of agreements with the medical profession and be obliged to honour a mutually agreed upon and established process of negotiation.
Appropriate dispute resolution process
The CMA's Code of Ethics places a high priority on patient care. Withdrawal of services by physicians has been infrequent. The medical profession must be afforded the protection of good-faith negotiations and binding arbitration.iii
The CMA calls on the federal minister of health to strengthen the provisions of the Canada Health Act (section 12.2) to mandate provincial and territorial governments to enter into an agreement with provincial and territorial medical associations with regard to negotiations on compensation and requiring binding arbitration or other mutually agreed upon timely process of dispute resolution for the settlement of disputes related to physician compensation to satisfy the "reasonable compensation" criteria of section 12.1 (c) of the Act for full federal funding.
In instances where the compensation agreement has expired before a new agreement between the jurisdiction and its medical association can be reached, all pre-existing funding arrangements and programs should be continued until such time that a new agreement comes into effect.
i Canadian Medical Association, Health Care Transformation in Canada: Change that works. Care that lasts. Ottawa. 2010.
ii 2010 National Physician Survey. The College of Family Physicians of Canada, Canadian Medical Association, The Royal College of Physicians and Surgeons of Canada. http://www.nationalphysiciansurvey.ca/nps/2010_Survey/2010nps-e.asp. See also, Canadian Collaborative Centre for Physician Resources, How Physician in Canada are paid? Results of the 2010 National Physician Survey. http://www.nationalphysiciansurvey.ca/nps/news/PDF-e/PhysicianRemuneration-Nov-2011.pdf
iii This was acknowledged by Justice Emmett Hall in his 1980 report to the minister of national health and welfare, Canada's National-Provincial Health Program for the 1980's. Hall concluded that "when negotiations fail and an impasse occurs, the issues in dispute must be sent to binding arbitration."
In 2010, 14% of Canada's population was 65 or older. With the aging of the baby boom generation, this proportion is estimated to rise to about 25% in 2036 (1). The aging of Canada's population is expected to have a major impact on the country's economy, society and health care system over the next 25 to 30 years.
Though age does not automatically mean ill health or disability, the risk of both does increase as people age. In 2006, 33% of Canadians aged 65 or older had a disability; the proportion climbed to 44% among people aged 75 or older (2). Nearly three-quarters of Canadians over 65 have at least one chronic health condition (3). Because of increasing rates of disability and chronic disease, the demand for health services is expected to increase as Canada's population ages. Currently Canadians over 65 consume roughly 44% of provincial and territorial health care budgets (4), and governments are concerned about the health care system's capacity to provide quality services in future.
The CMA believes that to provide optimal care and support for Canada's aging population, while taking care to minimize pressure on the health-care system as much as possible, governments at all levels should invest in:
* programs and supports to promote healthy aging;
* a comprehensive continuum of health services to provide optimal care and support to older Canadians; and
* an environment and society that is "age friendly."
This policy describes specific actions that could be taken to further these three goals. Its recommendations complement those made in other CMA policies, including those on "Funding the Continuum of Care" (2009), Optimal Prescribing (2010) and Medication Use and Seniors (Update 2011).
2) Providing Optimal Health and Health Care for Older Persons:
This section discusses in detail the three general areas in which the CMA believes governments should invest:
a) Promotion of "Healthy Aging"
The Public Health Agency of Canada (PHAC) defines healthy aging as "the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life." It is believed that initiatives to promote healthy aging, and enable older Canadians to maintain their health, will help lower health-care costs by reducing the overall burden of disability and chronic disease. Such initiatives could focus on:
Physical activity. Being physically active is considered the most important step that older Canadians can take toward improving health, even if they do not start being active until later in life. However in 2008, 57% of seniors reported being physically inactive (5).
Injury prevention. Falls are the primary cause of injury among older Canadians; they account for 40% of admissions to nursing homes, 62% of injury-related hospitalizations, and almost 90% of hip fractures (6). The causes of falls are complex, and both physiology (e.g. effect of illness) and environment (e.g. poorly maintained walkways) can contribute. Most falls can be prevented through a mix of interventions: for the person (such as strength and balance training); and for the person's environment, (such as grab bars and railings, slip-proof floor surfaces, walkways that are cleared of snow and ice in winter.)
Nutrition. In 2008, 28% of men and 31% of women over 65 were obese (BMI = 30); this is higher than the population average. Underweight is also a problem among seniors, 17% of whom report a BMI of 20 or less (7). The reasons for nutrition problems among older Canadians are complex; they may be related to insufficient income to purchase healthy foods, or to disabilities that make shopping or preparing meals difficult.
Mental health. An estimated 10-15% of seniors report depression, and the rate is higher among those with concomitant physical illness, or those living in long-term care facilities (8). Depression among older people may be under-recognized and under-treated, since it might be dismissed as a normal consequence of aging. Poor mental health is often associated with social isolation, a common problem among seniors.
Governments and National Associations
The CMA recommends that:
1. Governments at all levels support programs to promote physical activity, nutrition, injury prevention and mental health among older Canadians.
Health Service Delivery
The CMA recommends that:
2. Older Canadians have access to high-quality, well-funded programs and supports to help them achieve and maintain physical fitness and optimal nutrition.
3. Older Canadians have access to high-quality, well-funded programs aimed at determining the causes and reducing the risk of falls.
4. Older Canadians have access to high-quality, well-funded programs to promote mental health and well-being and reduce social isolation.
Physicians and Patients
The CMA recommends that:
5. Older Canadians be encouraged to follow current guidelines for healthy living, such as the 2012 Canadian Physical Activity Guidelines for adults 65 and over.
6. Physicians and other health care providers be encouraged to counsel older patients about the importance of maintaining a healthy and balanced life style.
7. All stakeholders assist in developing health literacy tools and resources to support older Canadians and their families in maintaining health.
b) A Comprehensive Continuum of Health Services
Though, as previously mentioned, age does not automatically mean ill health, utilization of health services does increase with increasing age. Patients over 65 have more family physician visits, more hospital admissions and longer hospital stays than younger Canadians (the overall length of stay in acute inpatient care is about 1.5 times that of non-senior adults) (9).
In addition, seniors take more prescription drugs per person than younger adults; 62% of seniors on public drug programs use five or more drug classes, and nearly 30% of those 85 and older have claims for 10 or more prescription drugs (10). Heavy medication use by people over 65 has a number of consequences:
* The risk of adverse drug reactions is several-fold higher for seniors than for younger patients.
* Medication regimes, particularly for those taking several drugs a day on different dosage schedules, can be confusing and lead to errors or non-adherence.
* Patients may receive prescriptions from multiple providers who, if they have not been communicating with each other, may not know what other medications have been prescribed. This increases the risk of harmful drug interactions and medication errors.
For seniors who have multiple chronic diseases or disabilities, care needs can be complex and vary greatly from one person to another. This could mean that a number of different physicians, and other health and social-services professionals, may be providing care to the same person. A patient might, for example, be consulting a family physician for primary health care, several medical specialists for different conditions, a pharmacist to monitor a complex medication regime, a physiotherapist to help with mobility difficulties, health care aides to clean house and make sure the patient is eating properly, and a social worker to make sure his or her income is sufficient to cover health care and other needs.
Complex care needs demand a flexible and responsive health care system. The CMA believes that quality health care for older Canadians should be delivered on a continuum from community based health care, (e.g. primary health care, chronic disease management programs), to home care (e.g. visiting health care workers to give baths and footcare), to long-term care and palliative care. Ideally, this continuum should be managed so that the patient can remain at home, out of emergency departments, hospitals and long term care unless appropriate, can easily access the level of care he or she needs, and can make a smooth transition from one level of care to another when needed.
Care managers are an essential part of this continuum, working with caregivers and the patient to identify the most appropriate form of care from a menu of alternatives. Care managers can co-ordinate the services of the various health professionals who deliver care to a given patient, and facilitate communication among them so that all work to a common care plan. A family physician who has established a long-standing professional relationship with the patient and is familiar with his or her condition, needs and preference is ideally placed to serve as manager of a patient's overall care, supported by geriatric and other specialists as appropriate.
Not all of the patient's caregivers may be health professionals; more than 75% of the care of older Canadians is delivered by unpaid informal caregivers, usually relatives. The role of the family caregiver can be demanding financially, physically and emotionally. Though governments have instituted tax credits and other forms of support for caregivers, more may be required. The Special Senate Committee on Aging has called for a National Caregiving Strategy to help put in place the supports that caregivers need. (11)
Finally, many of the services required by seniors, in particular home care and long-term care, are not covered by the Canada Health Act. Funding of these services varies widely from province to province. Long-term care beds are in short supply; as a result more than 5,000 hospital beds are occupied by patients waiting for long-term care placement (12), making them unavailable for those with acute-care needs. CMA's Health Care Transformation Framework (2010) makes a number of recommendations aimed at improving access to continuing care in Canada.
Governments and National Associations
The CMA recommends that:
8. Governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians.
9. Governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate.
10. Governments and other stakeholders work together to develop and implement a National Caregiver Strategy, and expand the support programs currently offered to informal caregivers.
11. All stakeholders work together to develop and implement a national dementia strategy.
12. Governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy.
13. Governments work with the health and social services sector, and with private insurers, to develop a framework for the funding and delivery of accessible and sustainable home care and long-term care services.
The CMA recommends that:
14. Medical schools enhance the provision, in undergraduate education and in residency training for all physicians, of programs addressing the clinical needs of older patients.
15. Medical students and residents be exposed to specialty programs in geriatric medicine and other disciplines that address the clinical needs of older patients.
16. Continuing education programs on care for older patients be developed and provided to physicians of all specialties, and to other health care providers, on a continuous basis.
Health System Planners
The CMA recommends that:
17. Health systems promote collaboration and communication among health care providers, through means such as:
a. Interdisciplinary primary health care practice settings, that bring a variety of physicians and other health professionals and their expertise into a seamless network;
b. Widespread use of the electronic health record; and
c. A smooth process for referral between providers.
18. All stakeholders work toward integration of health care along the continuum by addressing the barriers that separate:
a. acute care from the community;
b. health services from social services; and
c. provincially-funded health care services such as physicians and hospitals, from services funded through other sources, such as pharmacare, home care and long term care.
19. Programs be developed and implemented that promote optimal prescribing and medication management for seniors.
20. Research be conducted on a continuous basis to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and health care costs.
Physicians in Practice
The CMA recommends that:
21. Continuing education, clinical practice guidelines and decision support tools be developed and disseminated on a continuous basis, to help physicians keep abreast of best practices in elder care.
c) An Age-Friendly Environment:
One of the primary goals of seniors' policy in Canada is to promote the independence of older Canadians in their own homes and communities, avoiding costly institutionalization for as long as feasible. To help older Canadians successfully maintain their independence, it is important that governments and society ensure that the social determinants of health care addressed when developing policy that affects them. This includes assuring that the following supports are available to older Canadians:
* Adequate Income: Poverty among seniors dropped sharply in the 1970s and 1980s. In 2008, 6% of Canada's seniors were living in low income, as opposed to nearly 30% in 1978. However, there has been a slight increase in poverty levels since 2007, and it may be necessary to guard against an upward trend in future (13). Raising the minimum age for collecting Old Age Security, as has been proposed, may weigh heavily on seniors with lower incomes, and make prescription drugs, dental care and other needed health services unaffordable.
* Employment Opportunities: it has been recommended that seniors be encouraged to work beyond age 65 as a means of minimizing a future drain on pension plans (14). Many older Canadians who have not contributed to employee pension plans may be dependent on employment income for survival. However, employment may be difficult to find if workplaces are unwilling to hire older workers.
* Housing. Nearly all of Canada's seniors live in their own homes; fewer than 10% live in long-term care facilities. Options are available that permit older Canadians to live independently even with disabilities and health care needs, such as:
o Home support for services such as shopping and home maintenance; and
o Assisted-living facilities that provide both independent living quarters and support services such as nursing assistance, and cafeterias if desired.
* An Age-friendly built environment. To enable seniors to live independently, the World Health Organization's "Age-Friendly Communities" initiative recommends that their needs be taken into consideration by those who design and build communities. For example, buildings could be designed with entrance ramps and elevators; sidewalks could have sloping curbs for walkers and wheelchairs; and frequent, accessible public transportation could be provided in neighbourhoods where a large concentration of seniors live.
* Protection from Abuse. Elder abuse can take many forms: physical, psychological, financial, or neglect. Often the abuser is a family member, friend, or other person in a position of trust. Researchers estimate that 4 to 10% of Canadian seniors experience abuse or neglect, but that only a small portion of this is reported (15). CMA supports awareness programs to bring the attention of elder abuse to the public, as well as programs to intervene with seniors who are abused, and with their abusers.
* A Discrimination-Free society. Efforts to boost income and employment security, health care standards and community support for older Canadians are hampered if the pervasive public attitude is that seniors are second-class citizens. An age-friendly society respects the experience, knowledge and capabilities of its older members, and accords them the same worth and dignity as it does other citizens.
Governments and National Associations
The CMA recommends that:
22. Governments provide older Canadians with access to adequate income support.
23. Governments devote a portion of national infrastructure funding to providing an adequate supply of accessible and affordable housing for seniors.
24. Older Canadians have access to opportunities for meaningful employment if they desire.
25. Communities take the needs and potential limitations of older Canadians into account when designing buildings, walkways, transportation systems and other aspects of the built environment.
Health System Planners
The CMA recommends that:
26. The health system offer a range of high-quality, well-funded home care and social support services to enable older Canadians to remain independent in the community for as long as possible.
27. Physicians receive advice and education on optimal community supports and resources to keep seniors independent and/or at home.
Physicians in Practice
The CMA recommends that:
28. Training and programs be provided to physicians and other care providers to enable them to identify elder abuse, and to intervene with abused people and their abusers.
Aging is not a disease, but an integral part of the human condition. To maximize the health and well-being of older Canadians, and ensure their continued functionality and independence for as long as possible, CMA believes that the health care system, governments and society should work with older Canadians to promote healthy aging, provide quality patient-centered health care and support services, and build communities that value Canadians of all ages.
1 Public health Agency of Canada. "Growing Older: Adding Life to Years. Annual report on the state of public health in Canada, 2010." Accessed at http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2010/fr-rc/index-eng.php
2 Statistics Canada: A Portrait of Seniors in Canada (2008). Accessed at http://www.statcan.gc.ca/pub/89-519-x/89-519-x2006001-eng.htm
3 Canadian Institute for Health Information. "Seniors and the health care system: What is the impact of multiple chronic conditions?" (January 2011.) Accessed at https://secure.cihi.ca/free_products/air-chronic_disease_aib_en.pdf
4 Canadian Institute for Health Information. National Health Expenditure Trends, 1975 to 2010. Accessed at http://www.cihi.ca/cihi-ext-portal/internet/en/document/spending+and+health+workforce/spending/release_28oct10
5 PHAC 2010
6 PHAC 2010
7 PHAC 2010
8 Mood Disorders Society of Canada. "Depression in Elderly" (Fact sheet). Accessed at http://www.mooddisorderscanada.ca/documents/Consumer%20and%20Family%20Support/Depression%20in%20Elderly%20edited%20Dec16%202010.pdf
9 Canadian institute for Health Information. Health Care in Canada, 2011: A Focus on Seniors and Aging. Accessed at https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf
10 CIHI 2011
11 Special Senate Committee on Aging. "Canada's Aging Population: Seizing the Opportunity." (April 2009). Accessed at http://www.parl.gc.ca/Content/SEN/Committee/402/agei/rep/AgingFinalReport-e.pdf
12 CIHI 2009
13 PHAC 2010
14 Department of Finance Canada. Economic and fiscal implications of Canada's Aging Population (October 2012). Accessed at http://www.fin.gc.ca/pub/eficap-rebvpc/report-rapport-eng.asp#Toc01.
15 PHAC 2010
Ensuring equitable access to effective and appropriate health care services is one strategy which can help to mitigate health inequities resulting from differences in the social and economic conditions of Canadians.
Equitable access can be defined as the opportunity of patients to obtain appropriate health care services based on their perceived need for care. This necessitates consideration of not only availability of services but quality of care as well.1
There is far ranging evidence indicating that access to care is not equitable in Canada. Those with higher socio-economic status have increased access for almost every health service available, despite having a generally higher health status and therefore a decreased need for health care. This includes insured services (such as surgery), as well as un-insured services such as pharmaceuticals and long-term care.
Those from disadvantaged groups are less likely to receive appropriate health care even if access to the system is available. They are more likely to report trouble getting appointments, less testing and monitoring of chronic health conditions, and more hospitalizations for conditions that could be avoided with appropriate primary care.
There is a financial cost to this disparity in equitable care. Reducing the differences in avoidable hospitalizations alone could save the system millions of dollars.
Barriers to equitable access occur on both the patient and health care system or supply side. Common barriers include:
(see pdf for correct display of table)
Demand Side or Patient Barriers
Supply Side or System Barriers
Services not located in areas of need
Cultural beliefs and norms
Patients lack family physicians
Lack of management of chronic disease
Cost of transportation
Long waits for service
Time off work for appointments
Payment models which don't account for complexity of patients
Access to child care
Coordination between primary care and speciality care and between health care and community services
Payment for medications or other medical devices/treatments
Standardization of referral and access to specialists and social services
Immobility- due to physical disabilities, and/or mental health barriers
Lack of needs based planning to ensure that population has necessary services
Cognitive issues, ie. Dementia, that adversely affect ability to access and comply with care
Attitudes of health care workers
To tackle barriers on the patient side there is a need to reduce barriers such as transportation and the prohibitive cost of some medically necessary services. Further, there is a need to increase the health literacy of patients and their families/caregivers as well as providing support to health care providers to ensure that all patients are able to be active participants in the management of their care.
On the system side the strategies for action fall into four main categories: patient-centred primary care which focuses on chronic disease management; better care coordination and access to necessary medical services along the continuum of care; quality improvement initiatives which incorporate considerations of equity as part of their mandate; and health system planning and assessment which prioritizes equitable access to care.
Recommendations are provided for CMA and national level initiatives; health care planners; and physicians in practice.
Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. By removing barriers on both the patient and system side it is hoped that greater access to appropriate care will follow.
In Canada as in many countries around the world there are major inequities in health status across the population. Those lower on the socio-economic scale face higher burdens of disease, greater disability and even shorter life expectancies.2 Many of these disparities are caused by differences in social and economic factors such as income and education known as the social determinants of health.3,1 While many of these factors are outside of the direct control of the health care system, ensuring equitable access to effective and appropriate health care services can help to mitigate some of these disparities. The alternative can also be true. In health systems where access to care and appropriateness are unequal and skewed in favour of those of higher socio-economic status, the health system itself can create further inequities and add greater burden to those already at an increased risk of poor health. Physicians as leaders in the health care system can play a role in ensuring equitable access to care for all Canadians.
Equitable Access to Health Care in Canada:
Equitable access can be defined as the opportunity for patients to obtain appropriate health care services based on their perceived need for care. This necessitates consideration of not only availability of services but quality of care as well.4
Due to burden of disease and therefore need, those with lower socio-economic status should be utilizing more services along the continuum.5 That, however, is not the case. Individuals living in lower income neighbourhoods, younger adults and men are less likely to have primary care physicians than their counterparts.6
Primary care physicians deliver the majority of mental illness treatment and they are the main source of referrals to psychiatrists or other specialists. However, much of the care for people with mental illnesses, especially on the lower socio-economic end of the scale, is delivered in emergency rooms, which is both costly and episodic. This is due not only to a lack of primary care access but to a lack of community mental health services.7
Those with higher socio-economic status are much more likely to have access to and utilize specialist services.8 Examples include greater likelihood of catheterization and shorter waits for angiography for patients with myocardial infarction9; and greater access to in-hospital physiotherapy, occupational therapy, and speech language therapy for those hospitalized with acute stroke10. Low income men and women with diabetes were just as likely to visit a specialist for treatment as high income individuals despite a significantly greater need for care.11
There is a correlation between higher income and access to day surgery.12 A Toronto study found that inpatient surgery patients were of much higher income than medical inpatients.13 Additionally, utilization of diagnostic imaging services is greater among those in higher socio-economic groups.14 Access to preventive and screening programs such as pap smears and mammography are lower among disadvantaged groups.15
Geography can cause barriers to access. In general rural Canadians have higher health care needs but less access to care.16 People in northern and rural communities typically have to travel great distances to obtain health services as many, especially specialist services, cannot be obtained in their home community.17 Those living in the most rural communities in Canada are the least likely to have a regular family doctor, or to have had a specialist physician visit.18 According to data from the Society of Rural Physicians of Canada, 21% of the Canadian population is rural while only 9.4% of family physicians and 3% of specialists are considered rural.19 This lack of access to specialists and other medically necessary services can lead to delays in treatment and harm to health including unnecessary pain and permanent disability.20 Further, travel for necessary treatment often comes with a significant financial cost.21
It is not just access to insured services that is a problem in Canada. Many Canadians do not have access to needed pharmaceuticals. Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.22 The use of appropriate diabetes preventative services, medication, and blood glucose testing, has been shown to be dependent on out of pocket expenditures.23
Rehabilitation services are difficult for some Canadians to access as well. Services such as physiotherapy and occupational therapy are often not covered unless they are provided in-hospital or to people on certain disability support programs. This leads to long wait times for services that are covered or no access at all.24 Adding to these inequities is the fact that different programs are covered in different provinces and territories.25
Access to mental health services is a major challenge for Canadians. According to data from Statistics Canada, more than half a million Canadians who had a perceived need for mental health care services, reported that their needs were unmet. Access to counselling services was the most frequent unmet need reported.26 A number of important mental health professionals - notably psychologists and counsellors - are not funded through provincial health budgets, or are funded only on a very limited basis. Access to psychologists is largely limited to people who can pay for them, through private insurance or out of their own pockets.27,2
Access to subsidized residential care, long-term care, home care and end-of-life care is problematic as well. Those with means can access high quality long-term care services within their community, while those with inadequate resources are placed in lower quality facilities sometimes hours away from family and friends.28 Even with expansions promised by governments, home care will not be able to meet the needs of underserved groups such as those living in rural and remote areas.29 Finally, only a fraction of patients have access to or receive palliative and end-of-life care. Those living in rural or remote areas or living with disabilities have severely limited access to formal palliative care.30
Difficulties in access are particularly acute for Canada's Aboriginal peoples. Many live in communities with limited access to health care services, sometimes having to travel hundreds of miles to access care.31 Additionally, there are jurisdictional challenges; many fall through the cracks between the provincial and federal health systems. While geography is a significant barrier for Aboriginal peoples, it is not the only one. Aboriginals living in Canada's urban centres also face difficulties. Poverty, social exclusion and discrimination can be barriers to needed health care. Of all federal spending on Aboriginal programs and services only 10% is allocated to urban Aboriginals. This means that Aboriginals living in urban areas are unable to access programs such as Aboriginal head start, or alcohol and drug services, which would be available if they were living on reserve.32 Further, even when care is available it may not be culturally appropriate. Finally, Canada's Aboriginal peoples tend to be over-represented in populations most at risk and with the greatest need for care, making the lack of access a much greater issue for their health status.33
However, these examples are only part of the story as accessing care which is inappropriate cannot be considered equitable access.34 Those of lower socio-economic status are more likely to use inpatient services; show an increased use of family physician services once initial contact is made;35 and have consistently higher hospitalization rates; 36 This could be due to the higher burden of need or could demonstrate that the services that are received are not addressing the health care needs of those lower on the socio-economic scale.37
Women and men from low-income neighbourhoods are more likely to report difficulties making appointments with their family doctors for urgent non-emergent health problems. They were also more likely to report unmet health care needs.38 In terms of hospitalizations, people with lower socio-economic status were much more likely to be hospitalized for ambulatory care sensitive conditions (ACSC) and mental health39; admissions which could potentially be avoided with appropriate primary care.40 They were also found to have on average longer lengths of stay.41 According to a study of hospitals in the Toronto Central Local Health Integration Network, patients considered to be Alternate Level of Care were more likely to have a low-income profile.42
Further, people with ACSC in low-income groups, those living in rural areas, or those with multiple chronic conditions were twice as likely to report the use of emergency department services for care that could have been provided by a primary care provider.43
There is a financial cost to this disparity. According to a 2011 report, low-income residents in Saskatoon alone consume an additional $179 million in health care costs than middle income earners.44 A 2010 study by CIHI found increased costs for avoidable hospitalizations for ambulatory care sensitive conditions were $89 million for males and $71 million for females with an additional $248 million in extra costs related to excess hospitalizations for mental health reasons.45
Areas for Action:
As the background suggests, equitable access is about more than just utilization of services. There are patient characteristics as well as complex factors within the health system which determine whether equitable access is achieved. Recent work has categorized access as having considerations on the supply of services and demand of patients for care. On the demand or patient side we must consider: ability to perceive; ability to seek, ability to reach, ability to pay, and ability to engage. On the supply side or health system considerations include: approachability; acceptability, availability and accommodation, affordability, and appropriateness. 46 The following table highlights some of the current barriers to equitable access.
(See PDF for correct display of table)
Demand Side or Patient Barriers
Supply Side or System Barriers
Services not located in areas of need
Cultural beliefs and norms
Patients lack family physicians
Lack of management of chronic disease
Cost of transportation
Long waits for service
Time off work for appointments
Payment models which don't account for complexity of patients
Access to child care
Coordination between primary care and speciality care and between health care and community services
Payment for medications or other medical devices/treatments
Standardization of referral and access to specialists and social services
Immobility- due to physical disabilities, and/or mental health barriers
Lack of needs based planning to ensure that population has necessary services
Cognitive issues, ie. Dementia, that adversely affect ability to access and comply with care
Attitudes of health care workers
Patient based actions for improving equitable access:
Low health literacy can lead to difficulties for some Canadians in perceiving a need for care.47 Evidence suggests that more than half of Canadian adults (60%), lack the capacity to obtain, understand and act upon health information and services in order to make health decisions on their own.48 Many physicians are undertaking strategies to minimize this lack of health literacy among their patients. Examples include plain language resources as well as teach-back exercises which allow physicians to determine whether patients have fully understood the information provided.49 These efforts should continue to be supported.
Understanding how the health system works and where to access services can be a problem for some individuals.50 Beliefs about the need and value for certain services can also undermine the ability of patients in seeking care.51 Work needs to be done to ensure that disadvantaged groups are aware of the services that are available to them and the benefits of taking preventative steps in their health.
Low-income Canadians are ten times more likely to report unmet needs of health care due to the cost of transportation.52 Other barriers include a lack of child care, and ability to get time off work to attend necessary health appointments.53 Strategies that provide patients with transportation to appointments or subsidies for such travel have seen some success. Extended office hours and evening appointments can increase access for those unable to take time off work. Additionally, programs that provide patients with home visits from health care providers can help to eliminate this barrier. Further support and expansion of these programs should be explored.
There is also the inability to pay for services not covered by provincial plans such as pharmaceuticals, physiotherapy and other rehabilitation services.54 According to a 2005 report on diabetes in Canada, affordability and access to medical supplies was the biggest challenge for those Canadians living with diabetes.55 Access to services such as mental health counselling, subsidized residential care, and long-term care are also hindered by the inability to pay.
Even if patients are able to obtain care they may not be able to fully engage. Language difficulties, low health literacy, cognitive challenges (ie. Dementia), cultural mores and norms, and discrimination or insensitivity of health care workers, may all act as barriers to full participation in care.56 Efforts should be made to develop teaching methods to improve engagement of patients and their families/caregivers from disadvantaged groups.57 Strategies to remove or minimize the barriers created by a lack of health literacy should be developed and shared with physicians and other health care providers. Further, programs which facilitate access to services including interpretation and translation of key health information should be supported.58
Finally, an understanding of a patient's cultural and social context is important. The Royal College of Physicians and Surgeons of Canada and the Association of Faculties of Medicine of Canada have developed training modules for physicians who will be working with Canada's Aboriginal peoples.59 Similar programs have been developed by the Canadian Paediatric Society, and the Society of Obstetricians and Gynaecologists of Canada. More of this training is needed and should focus on groups who are likely to experience disadvantage in health care access and appropriateness.
Recommendations for action:
CMA and National Level Initiatives
The CMA recommends that:
1. Governments develop a national strategy for improving the health literacy of Canadians which takes into account the special needs of different cultures.
2. Governments provide accessible and affordable transportation options for patients requiring medical services when such services are unavailable locally.
3. Governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies.
4. Governments examine methods to ensure that low-income and other disadvantaged Canadians have greater access to needed medical interventions such as rehabilitation services, mental health, home care, and end-of-life care.
5. Governments explore options to provide funding for long-term care services for all Canadians.
6. Governments ensure that necessary interpretation and translation services are provided at all points of care.
Physicians in Practice
The CMA recommends that
7. Physicians be supported in addressing the health literacy of their patients and their families/caregivers.
8. Physician education programs continue to emphasize the important cultural and social contexts in which their patients live.
System based actions for improving equitable access:
On the system side there are two main areas that need to be addressed: making sure that people can access the services that they need (approachability, availability and accommodation, and affordability); and ensuring that once they have accessed the system that services are appropriate for their health needs (acceptability and appropriateness). Strategies for action include: patient-centred primary care which focuses on chronic disease management; better care coordination and greater access to necessary medical services along the continuum; quality improvement initiatives which incorporate equity as part of their mandate; and health system planning and assessment which prioritizes equitable access to care.
1. Patient-centred primary care which focuses on chronic disease management and which includes programs to increase access to those most at need.
Comprehensive primary care offers the biggest possibility for increasing equitable access and reducing health disparities. Data from a large population study in Ontario indicates that inequities in access to primary care and appropriate chronic disease management are much larger than inequities in the treatment of acute conditions.60
Currently many primary care services are located outside of the neighbourhoods with the greatest need for care. While some are accessible through public transportation, there is still a need for more convenient access for these communities. Community health centres (CHC) offer a good model for addressing this challenge through location in disadvantaged neighbourhoods and the provision of culturally appropriate care.61 Additionally, CHCs offer a number of different health, and sometimes social services, under one roof making access to many different types of care more convenient for patients.
More work needs to be done to to reduce barriers in access to Canadians living in rural and remote communities. Telemedicine is one strategy that has increased access for rural Canadians. The Ontario Telemedicine Network is one example of this innovative approach. Patients in rural communities can have access to specialists in urban centres through their local health providers. Examples include cardiac rehab follow-up, tele-homecare to support lifestyle changes, and psychiatric or mental health consultations.62
Programs which encourage recruitment and training of health professionals from rural and disadvantaged populations have been found to increase access as these individuals are more likely to return to their home communities to practice.63
Medical schools have been attempting to increase the diversity in their schools for a number of years. However, work still needs to be done. Data from the 2012 student component of the National Physician Survey shows that 278 of the 2000 students who responded to the survey (13.9%) come from families considered to be in the top 1% of earners in Canada. This is compared to only 46 (2.3%) of students whose family incomes place them in the bottom quintile of earners. 64
One of the suggested strategies for increasing diversity in medical schools is increasing the knowledge about the medical profession among rural and disadvantaged young people. An innovative program in Alberta called Mini Docs allows children between the ages of six and 12 to learn about being a doctor and how to stay healthy. The children get to wear medical scrubs for the day and use harmless medical tools such as stethoscopes and bandages. The day long program is run by medical students.65
Strategies to remove financial barriers to access, such as scholarships, should be expanded. Further, there is a need to modify the admissions process to recognize the differences in access to programs such as MCAT preps and overseas volunteer experiences based on the availability of financial resources as well as the necessity of employment for some students while in medical school. This necessary employment may limit the time available for volunteer and community service.66
Another strategy that can be effective in increasing access is programs that seek to link primary care providers with unattached and underserved patients. Programs such as Health Care Connect in Ontario and the GP and Me program in British Columbia actively seek to link sometimes hard to serve patients to appropriate primary care.
The College of Family Physicians of Canada has developed a blueprint for comprehensive primary care for Canadians. The concept, a 'patient's medical home' seeks to link Canadians with a comprehensive health care team led by a family physician. These medical homes will take many forms but will be designed to increase both access and the patient-centredness of care.67
Another barrier to access is timeliness of service. Many patients are forced to use walk in clinics or emergency departments as they cannot receive the required care from their primary care providers. Use of walk-in clinics or emergency departments for primary care may lead to lost opportunities for prevention and health promotion.68 Advanced access programs can help to improve equitable access to care by facilitating timely appointments for all patients.69 The AIM (Access improvement measures) program in Alberta uses a system designed by the Institute for Healthcare Improvement to redesign practice to focus on same day appointments and elimination of unnecessary delays.70
Primary care which prioritizes chronic disease management offers the greatest potential for increasing appropriateness of care and reducing system costs. Those most likely to have chronic diseases are also those who face the biggest barriers to equitable access.71 Currently many people with ACSC do not receive the appropriate tests to monitor their conditions, management of their medications, or supports to self-manage their disease.72 Some programs do exist to encourage more effective management of chronic disease. The Champlain Local Health Integration Network (LHIN) in Ontario has developed a cardiovascular disease prevention network to improve care through the use of evidence based practices and better integration between all areas of the health care continuum.73 Primary Care networks in Alberta have similar goals designed to connect multiple physicians, clinics and regions together to support the health needs of the population.74
Further work is necessary to expand these types of programs and to provide appropriate compensation models for complex patients. Payment models in some jurisdictions undermine access by failing to take morbidity and co-morbidity into consideration in designing rates such as equal capitation.75
Finally, there is a need to encourage greater self-management of disease. Practice support programs in British Columbia are providing training to support physicians in increasing patient self-management and health literacy.76 Additional programs of this nature are necessary in all jurisdictions.
2. Better care coordination and greater access to necessary medical services along the continuum of care.
Patient-centred care which integrates care across the continuum and which includes community services will be necessary to ensure not only greater access but greater acceptability of care.77 Innovative programs focused on increasing the coordination in terms of transition from hospital to home have shown some success in preventing readmissions particularly when vulnerable populations are targeted.78 Health Links in Ontario aims to reduce costs, based on the assumption that much of the utilization of high cost services, such as emergency department visits, could be prevented with better coordinated care. One of the pilot sites in Guelph aims to assign one person in primary care, likely a doctor or a nurse, to be the primary contact for patients deemed high need and to intervene on behalf of these patients to ensure better care coordination.79
Further work is needed to ensure greater coordination in speciality care. As the evidence demonstrates, access to specialist services are skewed in favour of high-income patients. To reduce this inequity it may be necessary to standardize the referral process and facilitate the coordination of care from the primary care providers' perspective.80 A new program in British Columbia is designed to reduce some of these barriers by providing funding and support to rapid access programs which allow family physicians to access specialist care through a designated hotline. If no specialist is available immediately there is a commitment that the call will be returned within two hours. Specialists available through this program include cardiology, endocrinology, nephrology, psychiatry, and internal medicine among others.81 Similar programs in other jurisdictions could help to increase coordination between primary and speciality care.
Care coordination is only part of the problem, however. There is also a need to increase the access to services that are medically necessary across the care continuum. These include a lifetime prevention schedule82, diagnostic testing, specialty services, and access to appropriate rehabilitation services, mental health, long-term care and end of life care.
3. Quality improvement initiatives which incorporate considerations of equity as part of their mandate.
Equity has become a key component of many quality improvement initiatives around the world. The Health Quality Council Ontario identified nine attributes of a high-performing health system: safe, effective, patient-centred, accessible, efficient, equitable, integrated, appropriately resourced, and focused on population health.83
The POWER study, a large study of Ontario residents found that where there were targeted programs for quality improvement fewer inequities were observed. In particular they referred to the actions of Cancer Care Ontario and the Ontario Stroke Network. Both of these groups had undergone large quality improvement initiatives to standardize care and increase coordination of services through evidence-based guidelines and ongoing performance measurement. Considerations of accessibility and equity were specifically included. As a result of these efforts, the POWER study found that acute cancer and stroke care in Ontario were quite equitable.84
Similar efforts are underway in other jurisdictions. The Towards Optimized Practice initiative in Alberta supports efforts in medical offices to increase the use of clinical practice guidelines for care as well as quality improvement initiatives.85 Encouraging more health services and programs to undertake such quality improvement initiatives could help to reduce the inequities in access for all Canadians.
4. Health system planning and assessment which prioritizes equitable access to care
Considerations of equity must be built specifically into all planning considerations. Too often services are designed without adequate consideration of the specific needs of disadvantaged groups. Planners need to do a better job of understanding their practice populations and tailoring programs to those most in need of care.86 This planning should be done in consultation with other sectors that play a role in influencing the health of their practice populations.
Further, assessments of the equity and use of services is also needed. Some services may be designed in a way that is more appropriate for some than others, resulting in higher utilization among some groups and a lack of access for others.87 Innovative work is taking place in the Saskatoon Health Region to try and understand these barriers. Health care services are undergoing specific health equity assessments to ensure that all services meet the needs of diverse populations. This includes looking at the full spectrum of services from preventative care and education programs to tertiary level care such as dialysis. In Ontario, the local health integration networks (LHIN) have now been tasked with developing equity plans for their services. Clear goals and performance measurements are part of this work.88
One of the tools available to support this work is a health equity impact assessment tool developed by the Ontario Ministry of Health and Long-Term Care. This tool is intended for use by organizations within the health system as well as those outside the system who will impact on the health of Ontarians. The main focus of the tool is to reduce inequities that result from barriers in access to quality health services. Additionally, it is designed to identify unintended health impacts, both positive and negative, before a program or policy is implemented.89 Further work is needed to ensure that equity is included in the deliverables and performance management of health care organizations and provider groups across the country.90
To support these planning programs appropriate data will need to be collected. This data needs to be comprehensive for all services and needs to include specific data points which will allow planners as well as providers to understand the composition of their populations as well as measure and report on considerations of equity.91
Recommendations for action:
CMA and National Level Initiatives
The CMA recommends that:
9. Governments continue efforts to ensure that all Canadians have access to a family physician.
10. Appropriate compensation and incentive programs be established in all jurisdictions to support better management of chronic disease for all Canadians.
11. Governments provide funding and support to programs which facilitate greater integration between primary and speciality care.
12. With support from government, national medical organizations develop programs to increase standardization of care and the use of appropriate clinical practice guidelines.
13. Appropriate data collection and performance measurement systems be put in place to monitor equitable distribution of health services and greater appropriateness of care.
Health System Planners
The CMA recommends that:
14. Needs based planning be mandated for all health regions and health system planning. Equity impact assessment should be part of this planning to ensure that services meet the needs of all Canadians.
15. Chronic disease management and other supportive strategies for vulnerable patients at risk of frequent readmission to the acute care system be prioritized in all health systems.
16. Quality improvement initiatives be mandated in all care programs. These programs should include a specific focus on standardization of care and continuous quality improvement and should include equity of access as part of their mandate.
Physicians in Practice
The CMA recommends that:
17. Physicians be supported in efforts to offer timely access in primary care settings.
18. Physicians be supported in continued efforts to include all patients in decisions about their care and management of their illnesses.
19. Physicians be supported in continued efforts to standardize care and utilize evidence based clinical practice guidelines with a particular emphasis on the management of chronic disease.
20. Physicians be encouraged and adequately supported to participate in community-based interventions that target the social determinants of health.
Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. For those that are most vulnerable, this lack of access can serve to further exacerbate their already increased burden of illness and disease. The strategies discussed above offer some opportunities for the health sector and the medical profession to intervene and mitigate this inequity. By removing barriers on both the patient and system side it is hoped that greater access to appropriate care will follow. While these strategies offer some hope, these actions alone will not be sufficient to increase the overall health of the Canadian population. Action is still required to tackle the underlying social and economic factors which lead to the disparities in the health of Canadians.
1 This paper represents a focus on equitable access to care. For a more general policy statement on the role of physicians in addressing the social determinants of health please see: Canadian Medical Association. Health Equity and the Social Determinants of Health: A Role for the Medical Profession. Ottawa, ON; 2012. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD13-03.pdf
2 The Canadian Medical Association is currently developing a policy paper on access to mental health services in Canada. It is anticipated that this policy statement will be completed in 2014.
1 Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualising access at the interface of
health systems and populations. Int J Equity Health 2013. Available: http://www.equityhealthj.com/content/12/1/18 (accessed 2013Mar 12)
2 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2011 Jan 14).
3 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7).
4 Levesque JF, Harris M, Russell G. Patient-centred access to health care: conceptualising access at the interface of
health systems and populations. Int J Equity Health 2013. Available: http://www.equityhealthj.com/content/12/1/18 (accessed 2013Mar 12)
5 Oliver A, Mossialos E. Equity of access to health care: outlining the foundations for action. J Epidemiol Community Health 2004; 58: 655-658.
6 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter7-AccesstoHealthCareServices.pdf (accessed 2012 Dec 10).
7 Kirby M, Goldbloom D, Bradley L. Changing Directions, Changing Lives: The Mental Health Strategy for Canada.Ottawa (ON): Mental Health Commission of Canada; 2012. Available: http://strategy.mentalhealthcommission.ca/pdf/strategy-text-en.pdf (accessed 2013 Mar 12).
8 Allin S. Does Equity in Healthcare Use Vary...; Frolich N, Fransoo R, Roos N. Health Service Use in the Winnipeg Regional Health Authority: Variations Across Areas in Relation to Health and Socioeconomic status. Winnipeg (MB) Manitoba Centre for Health Policy. Available: http://mchp-appserv.cpe.umanitoba.ca/teaching/pdfs/hcm_forum_nf.pdf (accessed 2013 Feb 6); McGrail K. Income-related inequities: Cross-sectional analyses of the use of medicare services in British Columbia in 1992 and 2002. Open Medicine 2008; 2(4): E3-10; Van Doorslaer E, Masseria C. Income-Related Inequality in the Use... Veugelers PJ, Yip AM. Socioeconomic disparities in health care use: Does universal coverage reduce inequalities in health? J Epidemiol Community Health 2003; 57:424-428.
9 Alter DA, Naylor CD, Austin P, et al. Effects of Socioeconomic Status on Access to Invasive Cardiac Procedures And On Mortality After Acute Myocardial Infarction. NEJM 1999; 341(18):1359-1367.
10 Kapral MK, Wang H, Mamdani M, et al. Effect of socioeconomic Status on Treatment and Mortality After Stroke. JAHA 2002; 33: 268-275.
11 Booth GL, Lipscombe LL, Bhattacharyya O, et al. Ontario Women's Health Equity Report: Diabetes: Chapter 9 Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter9-Diabetes.pdf (accessed 2012 Dec 10).
12 McGrail K. Income-related inequities... Murphy K, Glazier R, Wang X, et al. Hospital Care for All: An equity report on differences in household income among patients at Toronto Central Local Health Integration Network (TC LHIN) Hospitals, 2008-2010. Toronto(ON): Centre for Research on Inner City Health. Available: http://www.stmichaelshospital.com/pdf/crich/hospital-care-for-all-report.pdf (accessed 2012 Dec 10).
13 Murphy K, Glazier R, Wang X, et al. Hospital Care for All...
14 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services...Demeter S, Reed M, Lix L, et al. Socioeconomic status and the utilization of diagnostic imaging in an urban setting. CMAJ 2005; 173(10): 1173-1177.
15 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2010. Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter12-SDOHandPopsatRisk.pdf (accessed 2012 Dec 10); Frolich N, Fransoo R, Roos N. Health Service Use in the Winnipeg... Wang L, Nie JX, Ross EG. Determining use of preventive health care in Ontario. Can Fam Physician 2009; 55: 178-179.e1-5; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences with health-related services: Implications for health care reform. Health Policy 2006; 76:106-121.
16 The Ontario Rural Council. TORC 2009 Rural Health Forum: Rethinking Rural Health Care: Innovations Making a Difference. Guelph, ON; 2009. Available: http://ruralontarioinstitute.ca/file.aspx?id=1fb3035d-7c0e-4bfa-a8d7-783891f5c5dc (accessed 2013 Sep 18).
17 Browne A. Issues Affecting Access to Health Services in Northern, Rural and Remote Regions of Canada. Available: http://www.unbc.ca/assets/northern_studies/northern/issues_affecting_access_to_health_services_in_northern.pdf (accessed 2013 Mar 13).
18 Sibley LM, Weiner JP. An evaluation of access to health care services along the rural-urban continuum in Canada. BMC Health Services Research. Toronto (ON); 2011. Available: http://www.biomedcentral.com/1472-6963/11/20 (accessed 2013 Mar 13).
19 Society of Rural Physicians of Canada. National Rural Health Strategy- summary. Shawville, QC; 2008. Available: http://www.srpc.ca/PDF/nrhsA.pdf (accessed 2013 Sep 18).
20 Health Charities Coalition of Canada. Position Statement: Access to Health Care. Ottawa, ON; 2013. Available: http://www.healthcharities.ca/media/23883/posstatement_accesshealthc_final_en.pdf (accessed 2013 Sep 18).
21 Society of Rural Physicians of Canada. Rural Canadians need and deserve equitable access to health care. Shawville, QC; 2006. Available: http://www.srpc.ca/PDF/September-20-2006.pdf (accessed 2013 Sep 18).
22 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts....
23 Kwan J, Razzaq A, Leiter LA, et al. Low Socioeconomic Status and Absence of Supplemental Health Insurance as Barriers to Diabetes Care Access and Utilization. CJD 2008; 32(3) : 174-181.
24 Barnes S, Dolan LA, Gardner B, et al. Equitable Access to Rehabilitation : Realizing Potential, Promising Practices, and Policy Directions. Toronto (ON) Wellesley Institute; 2012. Available : http://www.wellesleyinstitute.com/wp-content/uploads/2012/06/Equitable-Access-to-Rehabilitation-Discussion-Paper1.pdf (accessed 2013 Feb 6).
25 Bowen, S. Access to Health Services for Underserved Populations in Canada. In Certain Circumstances: Issues in Equity and Responsiveness in Access to Health Care in Canada: A collection of papers and reports prepared for Health Canada. Ottawa (ON) Health Canada; 2000. Available: http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2001-certain-equit-acces/2001-certain-equit-acces-eng.pdf (accessed 2013 Feb 6).
26 Statistics Canada. Canadian Community Health Survey: Mental Health, 2012. Ottawa, ON; 2013. Available: http://www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.pdf (accessed 2013 Sep 18).
27 Kirby M, Goldbloom D, Bradley L. Changing Directions, Changing Lives...
28 EMC News. CCAC publishes long-term care waitlists monthly. Brockville (ON); 2013. Available: http://www.emcstlawrence.ca/20130404/news/CCAC+publishes+long-term+care+waitlists+monthly (accessed 2013 Apr 11).
29 Health Charities Coalition of Canada. Position Statement on Access to Home Care Revised for Approval Ottawa (ON); 2011. Available: http://www.healthcharities.ca/media/2720/HomeCarePos_statmnt_Sep22_11_Final_EN.pdf (accessed 2013 Mar 12)
30 Canadian Hospice Palliative Care Association. Fact Sheet: Hospice Palliative Care in Canada. Ottawa(ON); 2012. Available: http://www.chpca.net/media/7622/fact_sheet_hpc_in_canada_may_2012_final.pdf (accessed 2013 Mar 25).
31 Bowen, S. Access to Health Services for Underserved Populations.....
32 Place J. The Health of Aboriginal People Residing in Urban Areas. National Collaborating Centre for Aboriginal Health. Prince George, BC; 2012. Available: http://www.nccah-ccnsa.ca/Publications/Lists/Publications/Attachments/53/Urban_Aboriginal_Health_EN_web.pdf (accessed 2013 Sep 18).
33 National Collaborating Centre for Aboriginal Health. Access to Health Services As A Social Determinant of First Nations, Inuit And Metis Health. Prince George (BC) National Collaborating Centre for Aboriginal Health; 2011. Available: http://www.nccah-ccnsa.ca/docs/fact%20sheets/social%20determinates/Access%20to%20Health%20Services_Eng%202010.pdf (accessed 2013 Feb 6).
34 Levesque JF, Harris M, Russell G. Patient-centred access to health care...
35 Allin S. Does Equity in Healthcare Use Vary...; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences...
36 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status for Males and Females. Ottawa(ON); 2010. Available: https://secure.cihi.ca/free_products/disparities_in_hospitalization_by_sex2010_e.pdf (accessed 2013 Feb 6); Van Doorslaer E, Masseria C. Income-Related Inequality...
37 Allin S. Does Equity in Healthcare Use Vary...
38 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12...;Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences...
39 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status...
40 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status... ;Roos LL, Walld R, Uhanova J, et al. Physician Visits, Hospitalizations, and Socioeconomic Status: Ambulatory Care Sensitive Conditions in a Canadian Setting. HSR 2005; 40(4): 1167-1185.
41 Curtis LJ, MacMinn WJ. Health-Care Utilization in Canada: 25 Years of Evidence: SEDAP Research Paper No. 190. Hamilton (ON) Social and Economic Dimensions of an Aging Population Research Program; 2007. Available: http://catalogue.iugm.qc.ca/GEIDEFile/23002.PDF?Archive=102297992047&File=23002_PDF (accessed 2013 Feb 14).
42 Murphy K, Glazier R, Wang X, et al. Hospital Care for All...
43 Canadian Institute for Health Research. Disparities in Primary Health Care Experiences Among Canadians With Ambulatory Care Sensitive Conditions. Ottawa(ON); 2012. Available: https://secure.cihi.ca/free_products/PHC_Experiences_AiB2012_E.pdf (accessed 2013 Feb 14).
44 Saskatoon Poverty Reduction Partnership. From poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Saskatoon (SK): Saskatoon Poverty Reduction Partnership; 2011.Available: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf (accessed 2012 Mar 13)
45 Canadian Institute for Health Information. Hospitalization Disparities...
46 Levesque JF, Harris M, Russell G. Patient-centred access to health care...
47 Bowen, S. Access to Health Services for Underserved Populations...
48 Canadian Council on Learning. Health Literacy in Canada: Initial Results for the International Adult Literacy and Skills Survey. Ottawa (ON); 2007. Available: http://www.ccl-cca.ca/pdfs/HealthLiteracy/HealthLiteracyinCanada.pdf (accessed 2013 Apr 19).
49 Parnell TA, Turner J. IHI 14th Annual International Summit. Health Literacy: Partnering for Patient-Centred Care. April 9, 2013.
50 Bowen, S. Access to Health Services for Underserved Populations...
51 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7....
52 Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences...
53 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7...; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences...
54 Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences...
55 Chiu S, Hwang SW. Barriers to healthcare among homeless people with diabetes. Diabetes Voice 2006; 51(4): 9-12. Available: http://www.idf.org/sites/default/files/attachments/article_473_en.pdf (2011 Feb 20),
56 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7.... Willems S, De Maesschalck S, Deveugele M, et al. Socio-economic status of the patient and doctor-patient communication: does it make a difference? Patient Educ Couns 2004; 56: 139-146; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians' experiences...
57 Willems S, De Maesschalck S, Deveugele M, et al. Socio-economic status of the patient...
58 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7...
59 Indigenous Physicians of Canada and the Association of Faculties of Medicine Canada, "First Nations, Inuit, Métis Health, Core Competencies: A Curriculum Framework for Undergraduate Medical Education"
Updated April 2009, online: http://www.afmc.ca/pdf/CoreCompetenciesEng.pdf (accessed October 20, 2010).
60 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13. Toronto (ON) Project for and Ontario Women's Health Evidence-Based Report; 2012.Available: http://powerstudy.ca/wp-content/uploads/downloads/2012/10/Chapter13-AchievingHealthEquityinOntario.pdf (accessed 2013 Feb 6).
61 Bierman AS, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7... ;Bowen, S. Access to Health Services for Underserved Populations.....
62 Williams, R. Telemedicine in Ontario: Fact not Fiction: How to enhance your practice and enrich the patient experience. Ontario Telemedicine Network: Toronto, ON; 2013. Available: http://otn.ca/sites/default/files/telemedicine_in_ontario-_fact_not_fiction_02-26.pdf (accessed 2013 Sep 19).
63 Bowen, S. Access to Health Services for Underserved Populations...
64 National Physician Survey- 2012 student component
65 Alberta Medical Association. Mini Docs. Edmonton (AB); 2012. Available: https://www.albertadoctors.org/about/awards/health-promo-grant/2011-12-recipients/mini-docs (accessed 2013 Apr 18).
66 Dhalla IA, Kwong JC, Streiner DL et al. Characteristics of first-year students in Canadian...
67 The College of Family Physicians of Canada . A Vision for Canada: Family Practice: The Patient's Medical Home. Toronto, ON; 2011. Available: http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf (accessed 2012 Mar 15).
68 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7...
70 Access Improvement Measures. Edmonton (AB): Alberta Primary Care Initiative. Available at: http://www.albertapci.ca/AboutPCI/RelatedPrograms/AIM/Pages/default.aspx (accessed 2013 Mar 12).
71 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7...
72 Canadian Institute for Health Research. Disparities in Primary Health Care Experiences...
73 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13...
74 About Primary Care Networks. Edmonton (AB): Alberta Primary Care Initiative. Available at: http://www.albertapci.ca/AboutPCNs/Pages/default.aspx (accessed 2013 Mar 12).
75 Glazier RH. Balancing Equity Issues in Health Systems: Perspectives of Primary Healthcare. Healthcare Papers 2007; 8(Sp):35-45.
76 General Practice Services Committee. Learning Modules-Practice Management. Vancouver (BC): Government of British Columbia & British Columbia Medical Association. Available: http://www.gpscbc.ca/psp/learning/practice-management (accessed 2013 Mar 12).
77 Bierman A, Angus J, Ahmad F, et al. Ontario Women's Health Equity Report : Access to Health Care Services : Chapter 7...
78 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13...
79 Improving Care for High-Needs Patients: McGuinty Government Linking Health Providers, Offering Patients More Co-ordinated Care. Toronto (ON) Ontario Ministry of Health and Long-Term Care; December 6, 2012. Available: http://news.ontario.ca/mohltc/en/2012/12/improving-care-for-high-needs-patients.html (accessed 2012 Dec 10).
80 Curtis LJ, MacMinn WJ. Health-Care Utilization in Canada: 25 Years of Evidence...
81 Shared Care Partners in Care Annual Report 2011/12. Vancouver (BC): Government of British Columbia & British Columbia Medical Association. Available: https://www.bcma.org/files/SC_annual_report_2011-12.pdf (accessed 2013 Mar 12).
82 British Columbia Medical Association. Partners in Prevention: Implementing a Lifetime Prevention Plan. Vancouver, BC; 2010. Available: https://www.bcma.org/files/Prevention_Jun2010.pdf (accessed 2013 Sep 18).
83 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13...
85 Toward Optimized Practice. Edmonton (AB). Available at: http://www.topalbertadoctors.org/index.php (accessed 2013 Mar 12).
86 Ali A, Wright N, Rae M ed. Addressing Health Inequalities: A guide for general practitioners. London (UK); 2008. Available: http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z%20policy/Health%20Inequalities%20Text%20FINAL.ashx (accessed 2012 Jan 16); Gardner, B. Health Equity Road Map Overview. Toronto (ON): Wellesley Institute, 2012. Available: http://www.wellesleyinstitute.com/wp-content/uploads/2012/09/HER_Systemic-Health-Inequities_Aug_2012.pdf (accessed 2013 Feb 6).
87 Bowen, S. Access to Health Services for Underserved Populations...
88 Gardner B. Health Equity Into Action: Planning and Other Resources for LHINs. Toronto(ON) Wellesley Institute; 2010. Available: http://www.wellesleyinstitute.com/wp-content/uploads/2010/09/Health_Equity_Resources_for_LHINs_1.pdf (accessed 2013 Feb 6).
89 Ontario Ministry of Health and Long-Term Care. Health Equity Impact Assessment (HEIA) Workbook. Toronto, ON; 2012. Available: http://www.health.gov.on.ca/en/pro/programs/heia/docs/workbook.pdf (accessed 2013 Sep 30).
90 Bierman AS, Johns A, Hyndman B, et al. Ontario Women's Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12...; Gardner, B. Health Equity Road Map...; Glazier RH. Balancing Equity Issues in Health Systems...
91 Bierman AS, Shack AR, Johns A. Ontario Women's Health Equity Report : Achieving Health Equity in Ontario: Opportunities for Intervention and Improvement: Chapter 13...
The Built Environment is part of the overall ecosystem of our earth. It encompasses all the buildings, spaces and products that are created, or at least significantly modified by people. It includes our homes, schools and workplaces, parks, business areas and roads. It extends overhead in the form of electric transmission lines, underground in the form of waste disposal sites and subway trains and across the country in the form of highways (Health Canada, 1997)."
The built environment affects every one of us every day, and mounting evidence suggests that it can play a significant role in our state of health and well-being. This policy statement provides the perspective of the Canadian Medical Association on how the built environment can influence health, and what all sectors in society might do to ensure that community design and development takes the health of residents into consideration.
In the 19th century, the industrial revolution attracted hordes of people into cities. Congestion, squalid living conditions, and lack of clean water, clean air, and proper sewage systems led to outbreaks of diseases such as cholera and tuberculosis. These events, coupled with the development of the germ theory, served as a catalyst for public and professional awareness of how the built environment has direct health impacts; clean water, fresh air, uncongested living conditions, and proper housing were all recognized as constituents of good health.
During the past three decades, the 'Healthy Cities' movement has brought a renewed interest to the health implications of the built environment by focusing on disease prevention through community design. Over the years this idea has proliferated, and a body of literature has grown revealing the large scope of health risk factors that may be influenced by the built environment. The literature indicates that the following connections between the built environment and public health are possible:
o Decreased physical activity
o Increased prevalence of obesity
o Increased prevalence of asthma and other respiratory diseases
o Injuries and unintended fatalities
o Heat exposure. (Frank , Kavage S, & Devlin A, 2012) (Franks, Kavage & Devlin, 2012; Health Canada 2013)
There is also mounting evidence that these factors may be compounded for vulnerable populations such as children, the elderly, and those living in poverty.
Smart Growth is an urban planning and transportation theory that became popular almost two decades ago. Though different organizations may differ slightly in their view of what smart growth means, its general aims are to build compact accessible cities that avoid urban sprawl and mitigate auto-dependence. The 'Smart Growth' movement contains tenets that research supports in creating healthy built environments such as mixed land uses, providing transportation alternatives like walking and bicycle infrastructure and public transit, and creating walkable neighbourhoods. (Smart Growth BC, 2012)(See definitions)
What the Research Is Telling Us
Canada's physical activity guidelines recommend that children from 5 to 11 should be active for at least 60 minutes a day; those 18 and over should be active for at least 150 minutes per week. (Canadian Society of Exercise Physiology, 2011). Participation in regular physical activity bestows substantial health benefits; it can lengthen and improve quality of life and reduce the risk for many physical and mental health conditions. Physical activity can improve overall fitness, lower risk for heart disease, stroke, and high blood pressure, lower risk for non-insulin dependent diabetes and the risk of overweight. (Dannenberg, Frumkin, & Jackson, 2011) Physical activity includes more than exercise and leisure time activity, it also includes active transportation such as walking to school, work or errands as part of daily living.
One of the most important determinants of physical activity is a person's neighbourhood. (Jackson & Kochtotzky) Research shows that urban sprawl, access to parks and recreation/fitness facilities, and neighbourhood walkability all may have an impact on physical activity levels (Cutts, Darby, Boone, & Brewis, 2009; Ewing, Schmid, Killingsworth, Zlot, & Raudenbush, 2003).
Individuals living in walkable neighbourhood with a mix of land uses and interconnected street networks were found to be 2-4 times more likely to achieve 30 minutes moderate physical activity a day. Urban design characteristics associated with higher physical activity rates include pedestrian-oriented street and site design, parks, trails, playgrounds and other recreational facilities within walking distance and sidewalks. (Frank , Kavage S, & Devlin A, 2012)
A barrier to physical activity can be the perception of the lack of a safe place to be active. Safety concerns keep 1 in 5 Canadians from walking or bicycling. Urban design that encourages walking and cycling can improve perceived neighbourhood safety. (Heart and Stroke Foundation of Canada, 2011)
There are unique barriers to active modes of transportation in rural communities. Rural environments often lack pedestrian facilities and bike lanes; stores, schools, jobs, and services are sometimes located far apart from homes; and parks and recreation facilities are rare. Understanding these barriers is the first step towards finding opportunities to remove them. (Active Living Research and the Public Health Institute, 2013)
CMA' policy on Active Transportation recommends that all sectors (government, business and the public) work together, as a matter of priority, to create a culture in their communities that supports and encourages active transportation and physical activity.
Increased prevalence of obesity
Obesity has almost doubled in the past 3 decades; in 1978 the measured obesity rate was 13.8% and in 2008 the measured obesity rate was 25.4% (PHAC/CIHI, 2011). Obesity is associated with high blood pressure, stroke, and heart disease, which are among the leading causes of disability and death (Statistics Canada, 2008). Mental health conditions, type II diabetes, several types of cancer, among many other diseases, are also linked to obesity (Guh, Zhang, Bansback, Amarsi, Birmingham, & Anis, 2009). The combined cost of obesity and these related conditions was estimated to be $4.3 billion dollars in 2005 (Public Health Agency of Canada, 2012).
There are many factors involved in this increase, but a causal indicator is the decline in physical activity among Canadians: In 2005, 47% of Canadians were reported as being 'inactive' (Human Resource and Skills Development Canada, 2006).
Urban design that encourages sedentary living habits such as work, home, school and shopping separated by distances that discourage walking, parking lots built as close as possible to final destinations not only discourage walking but encourage automobile usage. (Jackson, Kochtitzky, CDC) Less walkable, auto dependent built environments have been correlated with higher body weights and obesity. (Frank , Kavage S, & Devlin A, 2012)
Furthermore, research indicates that the food environment that we live in, and the amount of healthy food choices we have access to, can affect the chance of becoming obese as well. For example, neighbourhoods with a high density of fast food restaurants or neighbourhoods with poor access to grocery stores (food deserts) have both been correlated with obesity (Larsen & Gilliland, 2008; Cummins & Macintyre, 2006; Frank L. D., 2009).
Increased prevalence of asthma and other respiratory diseases
In August 2008, the CMA released a report estimating that the effects of air pollution would result in 11,000 hospital admissions and 21,000 deaths Canada wide, totaling a financial cost of close to $8.1 billion dollar (Canadian Medical Association, 2008). Carbon monoxide, sulfur and nitrogen oxides, volatile organic compounds, ozone, and lead, among other toxins, are emitted into the air every day from industrial processes and car exhaust. These air-borne chemicals are associated with heart disease, cancer, acute respiratory illness, and the aggravation of other respiratory illnesses such as asthma (Frank L. D., 2009). While the built environment does not directly produce these chemicals, it has a role to play in where those chemicals are emitted, where they are concentrated, and, in the case of vehicles, how much of them are produced.
Urban sprawl has been tied to longer commute times and higher total vehicle miles traveled per person. Neighbourhood design and walkability have been identified as factors that can affect number of vehicle trips taken and transportation mode choice, and increased mixed land use has been identified as a factor that could further decrease emission rates (Newman & Kenworthy, 1989; Frank, Sallis, Conway, Chapman, Saelens, & Bachman, 2006).
Injuries and unintentional fatalities
Transport-related injuries accounted for a total of $3.7 billion dollars in healthcare costs in Canada in 2009 (SmartRisk, 2009). The majority of this financial burden was related to motor vehicle, pedestrian, and cycling accidents. Death and injuries from these types of incidents typically happen at a younger age which both
increases the years of life lost due to death or disability and the financial burden of continuing care (SmartRisk, 2009).
The built environment perhaps has the most identifiable and direct correlation to this category of impacts. Designs of auto-oriented environments that promote high traffic volume, high traffic speed, and low accessibility for pedestrians and cyclists lead to increased incidence of injuries and fatalities (Surface Transportation Policy Partnership, 2002).
Increased prevalence of illness and death related to heat exposure
The 'urban heat island effect' is a phenomenon correlated with urban environments that are primarily asphalt and concrete and lack vegetation and green space. Such environments have been estimated to have anywhere from 1oC to 12oC higher surface level temperatures in comparison to rural areas (United States Environmental Protection Agency, 2012). This can be especially dangerous for elderly individuals in the summertime and studies have demonstrated increased mortality amongst these populations during hot summers (Centers for Disease Control and Prevention, 2009). This is not only an issue of building materials and the balance of green space but has to do with isolation as well: If elderly residents have poor access to public transportation they may not be able to reach air-conditioned facilities.
Noise - be it from transport, industry, neighbours, or construction - is a prominent feature of the urban environment. Prolonged exposure to environmental noise has been directly linked to physical and psychosocial health outcomes, including hypertension, high blood pressure and heart disease, hearing impairment, stress levels, and sleep. There is some evidence linking noise to reduced ability to concentrate and more aggressive behavior. (Stansfeld SA, 2003)
In general, denser neighbourhoods have higher levels of ambient noise through the concentration of more people, traffic, and activities. However, as with air pollution, noise exposure is extremely site-specific and not necessarily exclusive to walkable or auto-oriented neighbourhoods. (Frank , Kavage S, & Devlin A, 2012) Canadian noise mapping data would assist researchers in assessing how environmental noise affects health and assist communities to proactively manage noise pollution.
The research shows that certain built environment characteristics may affect specific populations such as children, the elderly, low-income populations.
Children: Overweight and obesity is an issue for Canadians nationwide, but particularly so for children. Between 1978 to 2004 there was a 70% increase in overweight and obese children aged 12-17 (Statistics Canada, 2006). Obesity in children can lead to health issues such as hypertension, glucose intolerance, and orthopedic complications (Statistics Canada, 2006). Furthermore obesity in childhood has a high likelihood of carrying over into adulthood and may result in further health problems such as diabetes and heart disease (Statistics Canada, 2006). With this in mind, environments that promote physical activity are especially important for this segment of the population. Living in mixed use communities with walkable destinations, parks and recreational facilities is related to greater physical activity. (Dannenburg, Frumkin & Jackson, 2011)
Elderly: The elderly population is generally less physically robust and more prone to chronic illnesses, which make them especially vulnerable to air pollution and heat exposure. Physical activity is an important aspect of daily life for this age group as it has been shown to reduce the negative health impacts of aging (Vogel, Brechat, Lepetre, Kaltenbach, Berthel, & Lonsdorfer, 2009). Being physically active however, requires accessible and safe streets that cater to the needs of individuals with mobility issues. Special consideration is required when constructing the built environment to ensure the needs of this growing population.
CMA's policy on Health and Health Care Principles for an Aging Population recommends that communities take the needs and potential limitations of older Canadians into account when designing buildings, walkways, transportation systems or other aspects of the built environment.
Low Income Populations: Low income populations are at higher risk for chronic illnesses such as high blood pressure and diabetes, and have a lower overall survivability for major heart attacks (Centre for Chronic Disease Prevention and Control. , 2002; Statistics Canada, 1996-97). They are also more likely to smoke, be overweight or obese, and are less likely to be physically active (Creatore, Gozdyra, Booth, & Glazier, 2007). Many of these factors may be due to limited access to stable housing, housing location (normally close to highways or industrial zones with high pollution exposure), neighbourhood safety, and lack of access to or affordability of healthy food options.
Planning and public health combined efforts in the 19th century to improve living conditions. Today there is a need for health care practitioners, particularly those in the public health field, and community planners to work together, to share their expertise and efforts, to improve the health and well-being of Canadians. By designing communities that encourage and support healthy living - physical activity, healthy weights, access to healthy foods - we can address some of the risk factors for many chronic diseases and create supportive, active communities.
Health Care Associations can:
o Advocate for health supportive environments by increasing the public and policy makers' understanding of the impact of the built environment on health.
o Advocate for the contribution that public health professionals can make to urban planning and development to ensure that population health impacts are recognized and mitigated.
o Provide community planners with strong public health arguments and health data to support healthy communities.
Health Care Professionals can:
o Incorporate an awareness of a patient's built environment (such as housing, access to transportation and healthy foods) into treatment programs and health counseling.
o Encourage your community to adopt policies and design principles that build healthy supportive environments.
Federal, Provincial and Local Governments can:
o Integrate concepts of population health into urban planning.
o Promote multidisciplinary planning teams, including professionals in medicine, public health and community design to ensure that all stakeholders take health impacts into account.
o Incorporate health impact assessments into community planning and development initiatives in the public sector.
o Encourage the private sector to provide infrastructure and amenities in developments that promote healthy living.
The Public can:
o Learn more about the connection between the built environment and health and advocate for positive change.
o Become involved in public consultations regarding local community planning and development.
o Develop research projects at the Federal level on the impact of the built environment on health to inform and help coordinate programs and initiatives at the provincial and local levels.
o Focus on creating a standardized set of health indicators that can be uniformly applied to assess the status of a community's built environment.
o Research into the effectiveness of policy options on various communities (urban, suburban, rural).
It is important that we acknowledge how our surroundings can affect our lives and health, and work together to create positive change. The CMA is willing to work with other people and organizations to ensure that the influence of the built environment on health receives the attention that it warrants with the ultimate goal of building or re-inventing healthy communities for all Canadians.
In order of appearance
Inactive: "Respondents are classified as active, moderately active or inactive based on an index of average daily physical activity over the past 3 months. For each leisure time physical activity engaged in by the respondent, an average daily energy expenditure is calculated by multiplying the number of times the activity was performed by the average duration of the activity by the energy cost (kilocalories per kilogram of body weight per hour) of the activity. The index is calculated as the sum of the average daily energy expenditures of all activities. Respondents are classified as follows: 3.0 kcal/kg/day or more = physically active; 1.5 to 2.9 kcal/kg/day = moderately active; less than 1.5 kcal/kg/day = inactive". (Human Resource and Skills Development Canada, 2006).
Urban Sprawl: "A particular type of suburban development characterized by very low-density settlements, both residential and non-residential; dominance of movement by use of private automobiles, unlimited outward expansion of new subdivisions and leap-frog developments of these subdivisions; and segregation of land uses by activity." (United States Department of Housing and Urban Development, 1999)
Walkability: Walkability refers to the ease with which pedestrians can move within and between environments. The literature gives varied definitions but the main variable to consider are the following: mixed land use (defined below), proximity to destinations (accessibility and convenience), pedestrian facilities (sidewalks, urban furniture etc...), street connectivity (short block lengths, availability of multiple alternate routes etc...), aesthetics (landscape, vegetation, architecture), presences of public spaces (parks, plazas, etc...), presence of traffic calming measures (lower speed limits, street narrowing, speed bumps etc...), and access to transit. (Shay, Spoon, & Khattak, 2003)
Transportation Mode Choice: Transportation mode choice refers to an individuals decision regarding how to get from one destination to another. The theory behind mode choice is complex and involves characteristics of the built environment, socio-demographic and socioeconomic variables, benefit-cost analysis, and personal preference. (Cervero, Built Environments and Mode Choice: Toward a Normative Framework, 2002)
Mixed Land Use: "Land use mix is the composition of uses within a given geographic area." (Cervero, Land Use Mixing and Suburban Mobility, 1998) The uses referred to can be restaurants, offices, studios, shops, or any variety of business, institution, natural space, or recreation site. In the literature there are various indices and equations used to measure the degree of 'mixed land use' in an area.
Urban Heat Island Effect: The urban heat island effect occurs when the sun significantly heats urban surfaces (concrete, asphalt, etc...) to significantly higher temperatures than the surroundings air (can be upwards of 27-50oC). Comparatively shaded or more moist regions (such as rural areas with lots of vegetation) stay much closer to the surrounding air temperature. This heat imbalance between urban surfaces and surrounding air causes heat to transfer from those surfaces to the air, elevated the temperature above what it normally would be. This happens both at a surface and an atmospheric level. (United States Environmental Protection Agency, 2012)
Smart Growth: Smart Growth is an urban planning and transportation theory that became popular almost two decades ago. Though different organization's may differ slightly in their view of what smart growth means, it's general aims are to build compact accessible cities that avoid urban sprawl and mitigate auto-dependence. Some of the principles of this movement are as follows:
1). Incorporate mixed land uses into community designs
2). Build compact, accessible neighbourhoods close to jobs and amenities
3). Provide alternative modes of public transportation
4). Diversify housing to meet the needs of people from all socioeconomic classes
5). Maintain and protect natural open spaces
6). Build within existing communities instead of developing beyond community boundaries
7). Preserve agricultural land
8). Use new, sustainable technology in infrastructure and buildings
9). Develop community identity
10). Encourage active citizens to remain engaged in their communities
(Smart Growth BC, 2012)
Human Resource and Skills Development Canada. (2006). Retrieved July 15, 2012, from Indicators of Well-Being in Canada: Physical Activity: http://www4.hrsdc.gc.ca/.3ndic.1t.4r@-eng.jsp?iid=8
Active Living Research and the Public Health Institute. (2013). Where the Rubber Meets the Road: Promoting Active Transportation in Rural Areas.. Retrieved September 2013, from Active Living Research : http://activelivingresearch.org/where-rubber-meets-road-promoting-active-transportation-rural-areas
Canadian Medical Association. (2008). No Breathing Room: National Illness Cost of Air Pollution. Ottawa: CMA.
Canadian Society of Exercise Physiology. (2011). Canadian Physical Activity Guidelines. Canadian Society of Exercise Physiology.
Centers for Disease Control and Prevention. (2009, May 31). Extreme Heat: A Prevention Guide to Promote Your Personal Health and Safety. Retrieved July 15, 2012, from CDC: http://www.bt.cdc.gov/disasters/extremeheat/heat_guide.asp
Centre for Chronic Disease Prevention and Control. . (2002). Diabetes in Canada, 2nd Edition. Ottawa: Health Canada.
Cervero, R. (1998). Land Use Mixing and Suburban Mobility. Transportation Quarterly, 42(3).
Cervero, R. (2002). Built Environments and Mode Choice: Toward a Normative Framework. Transportation Research Part D: Transport and Environment , 7(4), 265-284.
Creatore, M., Gozdyra, P., Booth, G., & Glazier, R. (2007). Chapter 1: Setting the Context. In M. Creatore, P. Gozdyra, G. Booth, R. Glazier, & M. Tynan, Neighbourhood Environments and Resources for Healthy Living - A Focus on Diabetes in Toronto: ICES Atlas. Toronto: Institute for Clinical Evaluative Sciences.
Cummins, S., & Macintyre, S. (2006). Food Environments and Obesity - Neighbourhood or Nation. International Journal of Epidemiology, 35(1), 100-104.
Cutts, B., Darby, K., Boone, C., & Brewis, A. (2009). City Structure, Obesity, and Environmental Justice: An Integrated Analysis of Physical and Social Barriers to Walkable Streets and Park Access. Social Science and Medicine, 69(9), 1314-1322.
Dennenberg, A. L., Howard, F., & J, J. R. (Eds.). (2011). Making Healthy Places Designing and Building for Health, Well-being and Sustainability . Washington: Island Press.
Department of Health and Human Resources. (2004, August 20). National Institute of Health. Retrieved July 30, 2012, from Obesity and the Built Environment: http://grants.nih.gov/grants/guide/rfa-files/rfa-es-04-003.html
Ewing, R., Schmid, T., Killingsworth, R., Zlot, A., & Raudenbush, S. (2003). Relationship Between Urban Sprawl and Physical Activity, Obesity, and Morbidity. The Science of Health Promotion, 18(1), 47-57.
Frank , L., Kavage S, & Devlin A. (2012). Health and the Built Environment: A Review. World Medical Association.
Frank, L. D. (2009, January). Final Report on Health Assessment Tool Development for Peel Region by Larry Frank. Retrieved July 15, 2012, from Peel Region: http://www.peelregion.ca/health/urban/pdf/Peel-Lit-Review-Final-11072008-submitted.pdf
Frank, L., Sallis, J., Conway, T., Chapman, J., Saelens, B., & Bachman, W. (2006). Many Pathways from Land Use to Health: Associations Between Neighborhood Walkability and Active Tranportation, Body Mass Index, and Air Quality. Journal of the American Planning Association, 72(1), 75-87.
Guh, D., Zhang, W., Bansback, N., Amarsi, Z., Birmingham, C., & Anis, A. (2009). The Incidence of Co-morbidities Related to Obesity and Overweight: A Systematic Review and Meta-Analysis. Public Health, 9(88), 1-20.
Heart and Stroke Foundation of Canada. (2011). Position Statements: Community Design,Physical Activity, Heart Disease and Stroke. Retrieved June 2012, from Heart and Stroke Foundation of Canada: http://www.heartandstroke.com/site/c.iklQLcMWJtE/b.3820627/
Jackson, R. J., & Kochtotzky, C. (n.d.). Creating a Healthy Enviroment: The Impact of the Built Environment on Public Health. Retrieved April 2012, from Sprawl Watch Clearinghouse Monograph Series: http://www.sprawlwatch.org/health.pdf
Larsen, K., & Gilliland, J. (2008). Mapping the Evolution of 'Food Deserts" in a Canadian City: Supermarket Accessibility in London, Ontario, 1961-2005. International Journal of Health Geographics, 7(16), 1-16.
Newman, P., & Kenworthy, J. (1989). Gasoline Consumption and Cities. Journal of the American Planning Association , 55(1), 24-37.
PHAC/CIHI. (2011). Obesity in Canada. Ottawa: Public Health Agency of Canada.
Public Health Agency of Canada. (2012, July 18). Obestiy in Canada: Snapshot. Retrieved July 29, 2012, from Public Health Agency of Canada: http://www.phac-aspc.gc.ca/publicat/2009/oc/index-eng.php
Shay, E., Spoon, S., & Khattak, A. (2003). Walkable Environments and Walking Activity. Carolina Transportation Program, Department of City and Regional Planning. North Carolina: Carolina Transportation Program.
Smart Growth BC. (2012). 10 Smart Growth Principles. Retrieved 30 July, 2012, from Smart Growth BC: http://www.smartgrowth.bc.ca/Default.aspx?tabid=133
SmartRisk. (2009). The Economic Burden of Injury in Canada. Toronto: SmartRisk.
Stansfeld SA, M. M. (2003). Noise pollution: non-auditory effects on health. . British Medical Bulletin,, 68, 243-257.
Statistics Canada. (1996-97, May 29). National Population Health Survey, Cycle 2. Canada: The Daily.
Statistics Canada. (2006, June 28). Childhood Obesity: A Troubling Situation. Retrieved July 15, 2012, from StatsCan: http://www41.statcan.ca/2006/2966/ceb2966_004-eng.htm
Statistics Canada. (2008). Mortality, Summary List of Causes. Health Statistics Division . Ottawa: Statistics Canada.
Surface Transportation Policy Partnership. (2002). Mean Streets 2002. Washington, DC: STPP.
United States Department of Housing and Urban Development. (1999). The State of the cities 1999: Third Annual Report. Washington, DC: USHUD.
United States Environmental Protection Agency. (2012, July 13). Heat Island Effect. Retrieved July 29, 2012, from United States Environmental Protection Agency: http://www.epa.gov/hiri/
United States Environmental Protection Agency. (2012, June 21). Heat Island Effect: Basic Information. Retrieved July 15, 2012, from United States Environmental Protection Agency: http://www.epa.gov/hiri/resources/pdf/BasicsCompendium.pdf
Vogel, T., Brechat, P., Lepetre, P., Kaltenbach, G., Berthel, M., & Lonsdorfer, J. (2009). Health Benefits of Physical Activity in Older Patients: A Review. The International Journal of Clinical Practice, 63(2), 303-320.
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
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
Position Statement on Prescription Drug Shortages in Canada
The escalation in shortages of prescription drugs in the past few years and the ongoing disruptions to supply experienced in Canada and globally are matters of grave concern to the Canadian Medical Association (CMA) and its members. Drug shortages are having a detrimental impact on the delivery of patient care and treatment and the availability of health care services across the country.
CMA has advocated for a thorough examination of the drug supply system to identify points where we in Canada can influence supply problems. Solutions will have to involve the various players in the drug supply chain, from manufacturers through to healthcare providers and levels of government.
Drug shortages are not a problem confined to Canada. In the United States the number of drug shortages from 2006 to 2010 grew by more than 200 per cent.1 In 2011, 251 shortages were reported to the FDA. 2 Canada has not had an accurate record of the number of drugs in short supply over past years but in April 2013 253 drugs were listed on the industry sponsored Canadian Drug Shortage Website.3
Factors that influence the occurrence of a drug shortage can occur at any stage of the drug supply chain and any disruptions can ripple through the system.
Figure 1 Drug supply chain in Canada4 [See PDF]
There are many causes that can lead to a drug shortage. Disruptions in the supply of an active or key ingredient contribute to drug shortages and this is exacerbated when the active ingredient is produced by a single raw material supplier. If the supplier is unable to meet demand than all manufacturers relying on that supply become vulnerable to disruptions. The sourcing of raw materials from outside of North America, primarily China and India, whose safety and regulatory standards may not be stringently enforced can result in regulatory authorities closing down facilities thereby impacting supply of active ingredients or necessitating a lengthy search for a new supplier.
Additional manufacturing issues contributing to shortages can include complex manufacturing processes like those used to make sterile injectables, changes in product formulations, problems in the production process or regulatory enforcement of good manufacturing processes, limited capacity, an unexpected surge in demand, regulatory delays in product approvals and business decisions. 5
Shortages may also be due to factors outside the manufacturers control such as various interruptions in the normal delivery of medicines through the pharmacy supply chain and distribution network6. Just in time inventory management practices can lead to a reduction of available drug inventories. In addition procurement strategies that lead to sole source contracts for bulk purchases has been identified as the single most avoidable cause of drug shortages. 7
Disruptions in the supply of medications have the potential to impact patient care, patient health and the efficiency of the overall health care system.
Among the impacts of drug shortages are:
- delays in access to needed medication;
- delays or disruptions to clinical treatment;
- delayed or cancelled surgeries,
- loss of therapeutic effectiveness when an appropriate alternate therapy is not available;
- increased risk of side effects;
- increased non-compliance when changes in medication make it confusing and harder to comply with a new medication regime particularly for those on long term therapy.8
Any and all of these situations can result in a disruption to clinical stability and deterioration, particularly in patients with complex problems. Drug substitution can also result in unintended consequences. In 2010 an Institute of Safe Medication Practices survey of 1800 US health professionals revealed that in one year drug shortages caused over 1000 incidents involving negative side effects or medical errors. 9 In many instances shortages can lead to an increase in the use of the health care system, be it in physician or emergency room visits or treatments.
A CMA survey of physicians in September 2012 found that 66% of respondents indicated that drug shortages have gotten worse since 2010 and 64% stated that the shortages have had consequences for their patients or practice. Similarly, the results of the 2012 Canadian Pharmacists Association (CPhA) survey of pharmacists found that over 91% of pharmacists indicated that patients had been inconvenienced by shortages and 51% indicated that patients' care had been compromised.10
Drug shortages also have an impact on the practices of physicians and pharmacists. Sixty seven percent of the respondents to the CMA survey stated that drug shortages do have an impact on their practice most notably by increasing time spent on research or consultation with health professional colleagues to source alternative medicine, increase in length of patient visits due to medication substitution concerns, and increase in time spent on forms such as insurance claims. Seventy six percent of hospital pharmacists and 76 percent of community pharmacists also report an impact on their workload and practice.11
Since as early as 2005, the CMA has supported a comprehensive strategy and adequately resourced system for monitoring domestic drug supply. In response to a Health Canada consultation in October 2005 on a report entitled "Developing a Drug Supply Network" CMA recommended that Canada needs such a system to identify shortages and respond quickly to remedy them, and to ensure that policy and regulatory decisions are founded on accurate and reliable knowledge.
In March 2011 this position was reinforced in communication with the Government of Canada stating that Canada needs a sustainable, adequately resourced process to identify shortages, rapidly communicate them to health professionals and respond quickly to resolve them.
1. The Canadian Medical Association supports an investigation into the underlying causes of prescription drug shortages in Canada.
2. The Canadian Medical Association recommends the creation of a monitoring unit to track drug production disruptions in Canada and abroad.
The communication of information to health professionals once a shortage occurs, or is expected, is critical to their ability to make patient centered decisions and provide continuity of optimum care. CMA has participated on a Multi Stakeholder Working Group on Drug Shortages that has had the pharmaceutical industry and health professional organizations working together to establish a national drug shortage reporting website. CMA provided key input on the needs of needs of physicians to ensure that information required to provide optimum care when managing a drug shortage such as product information including name, manufacturer, formulation, strength, package size, expected duration of shortage, notification that shortage is resolved as well as automatic alerts and search and sort functionality was included on the website.
The establishment of the Canadian drug shortage website marks an improvement in the management of drug shortages but significant issues remain. Of great concern are drugs that are 'single sourced'. When there are shortages of single sourced medications there are no clear substitutes. Related to this are the unintended consequences of sole sourcing products from one manufacturer to secure a lower price. This introduces a vulnerability to the marketplace if the sole supplier experiences production disruptions. The 2011 production stoppage at a Sandoz facility in Quebec due to regulatory compliance issues and a subsequent fire in the plant resulted in a scramble to find alternate sources of many essential medications. The CMA supports the development of strategies at the provincial/territorial and federal level to discourage single source purchasing decisions. The inclusion of incentives or penalties for guaranteed supplies, or a contingency plan for supply disruptions should be inserted into purchase contracts. We must be extremely careful not to exacerbate supply problems while trying to address cost issues.
3. The Canadian Medical Association calls for a review of the supply processes in place for drugs and equipment considered essential for medical practice.
4. The Canadian Medical Association supports strategies to discourage single-source purchasing decisions for prescription medications.
Advance notice, by manufacturers to Health Canada, of expected drug shortages can provide a window of opportunity for the manufacturer and regulators to work together to resolve production problems or identify alternate supply. We are encouraged by recent initiatives by Health Canada to collect information on planned discontinuances from manufacturers.
5. The Canadian Medical Association calls for the establishment of a legislative framework requiring pharmaceutical companies to provide advance notice of production stoppages and any forecast disruptions in the drug supply.
Because of the complexity of the drug supply system, to effectively identify the situations that lead to drug shortages and find Canadian based solutions that can decrease the incidence of shortages or mitigate their impact requires the involvement and cooperation of all players in the process. CMA has consistently asked the government of Canada to work with the provinces and territories, the private sector and health professionals to address this potentially dangerous threat to the lives of Canadian patients.
6. The CMA supports the provinces and territories in their efforts to prevent drug shortages.
We are heartened by actions of Health Canada in 2012 to bring together representatives of industry, federal, provincial and territorial governments and health professional associations in a Multi Stakeholder Steering Committee on Drug Shortages to respond to the need for the mitigation of drug shortages. We trust that processes can be put in place and supported by key players to allow Canada to respond in a coordinated, transparent and accountable fashion to future or actual drug shortages.
Drug Shortages represent an ongoing worry for physicians. The impact on patients, health professionals and the health care system can be significant. Substantial progress has been made since 2011 in terms of gathering and sharing drug shortage information and improving our understanding of the drug supply processes but much still remains to be done. Although complex and challenging, ongoing attention to the issue is required to ensure that Canadians can count on a secure supply of medication into the future.
The CMA will continue to represent the best interests of patients and physicians to ensure that Canada's health care system delivers on patient-centered care.
1 DRUG SHORTAGES FDA's Ability to Respond Should be Strengthened, Statement of Marcie Cross, Director, Health Care, United States Government Accountability Office, Testimony before the Committee on Health, Education, Labor, and Pensions, U.S. Senate, December 15, 2011.
2 FDA is asking the public to send in ideas for combatting drug shortages, FDA Voice, Feb. 13, 2013, U.S. Food and Drug Administration, available at http://blogs.fda.gov/fdavoice/index.php/tag/drug-shortages/ (accessed 2013 April 2).
3 Canadian Drug Shortages Database available at http://www.drugshortages.ca/drugshortages.asp (accessed 2013 April 5).
4 Drug Supply In Canada: A Multi-stakeholder Responsibility, Report of the Standing Committee on Health, 41st Parliament, First session, June 2012.
5 Drug Supply Disruptions, Environmental Scan, Canadian Agency for Drugs and Technologies in Health, Issue 17, March 2011.
6 Canadian Drug Shortages Database available at http://www.drugshortages.ca/drugshortages.asp (accessed 2013April 5).
7 Drug Supply In Canada: A Multi-stakeholder Responsibility, Report of the Standing Committee on Health, 41st Parliament, First session, June 2012.
8 Prescription Drug Shortages, E Panel Survey, Canadian Medical Association, December 2010.
9 Drug Shortages, Recommendations of the Working Group on Drug Shortages, Ordre des Pharmaciens du Québec, March 2012.
10 Impact of Drug Shortages, Member survey, Canadian Pharmacists Association, October 2012.
11 BACKGROUNDER - DRUG SHORTAGES SURVEY, Canadian Pharmacists Association, Canadian Society of Hospital Pharmacists, Canadian Medical Association, January 2013, available at http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2013/Backgrounder-Drug-shortages_en.pdf ( assessed 2013 April 2).