Health equity is created when individuals have the opportunity to achieve their full health potential; equity is undermined when preventable and avoidable systematic conditions constrain life choices.1 These conditions are known as the social determinants of health. The World Health Organization (WHO) defines the social determinants of health as the circumstances in which people are born, develop, live and age.2 In 2002, researchers and policy experts at a York University conference identified the following list: income and income distribution; early life; education; housing; food security; employment and working conditions; unemployment and job security; social safety net; social inclusion/exclusion; and health services. 3
Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.4 Any actions to improve health and tackle health inequity must address the social determinants and their impact on daily life.5
THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH STATUS
Social status is one of the strongest predictors of health at the population level. There is a social gradient of health such that those with higher social status experience greater health than those with lower social status. The social gradient is evident not only when comparing the most disadvantaged to the most advantaged; within each strata, even among those holding stable middle-class jobs, those at the lowest end fare less well than those at the higher end. The Whitehall study of civil servants in the United Kingdom found that lower ranking staff have a greater disease burden and shorter life expectancy than higher-ranking staff.6 Differences in medical care did not account for the differences in mortality.7 This gradient has been demonstrated for just about any health condition.8
Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.9 In 2001, people in the neighbourhoods with the highest 20% income lived about three years longer than those in the poorest 20% neighbourhoods (four years for men; two years for women).10 Dietary deficiencies, common in food insecure households, can lead to an increased chance of chronic disease and greater difficulty in disease management. It is estimated that about 1.1 million households in Canada experience food insecurity, with the risk increasing in single-parent households and in families on social assistance.11
Studies suggest that adverse socio-economic conditions in childhood can be a greater predictor of cardiovascular disease and diabetes in adults than later life circumstances and behavioural choices.12 Effective early childhood development offers the best opportunity to reduce the social gradient and improve the social determinants of health,13 and offers the greatest return on investment.14
Low income contributes not only to material deprivation but social isolation as well. Without financial resources, it is more difficult for individuals to participate in cultural, educational and recreational activities or to benefit from tax incentives. Suicide rates in the lowest income neighbourhoods are almost twice as high as in the wealthiest neighbourhoods.15 This social isolation and its effects are most striking in Canada's homeless population. Being homeless is correlated with higher rates of physical and mental illness. In Canada, premature death is eight to 10 times higher among the homeless.16
The gradient in other social determinants can have an adverse impact as well. A study conducted in the Netherlands estimated that average morbidity and mortality in the overall population could be reduced 25-50% if men with lower levels of education had the same mortality and morbidity levels as those men with a university education.17 Employment status also follows this gradient, such that having a job is better than being unemployed. 18 Unemployment is correlated with increased blood pressure, self-reported ill health, drug abuse, and reductions in normal activity due to illness or injury.19 Unemployment is associated with increases in domestic violence, family breakups and crime. Finally, job security is relevant.20 Mortality rates are higher among temporary rather than permanent workers.21
Canada's Aboriginal people face the greatest health consequences as a result of the social determinants of health. Poverty, inadequate or substandard housing, unemployment, lack of access to health services, and low levels of education characterize a disproportionately large number of Aboriginal peoples.22 The crude mortality rate for First Nations is higher and life expectancy lower than the Canadian average.23 Aboriginal peoples experience higher rates of chronic disease, addictions, mental illness and childhood abuse.24 Aboriginal peoples have higher rates of suicide, with suicide being the leading cause of potential years of life lost in both the First Nations and Inuit populations.25
THE SOCIAL DETERMINANTS OF HEALTH AND CANADA'S HEALTH SYSTEM
These differences in health outcomes have an impact on the health care system. Most major diseases including heart disease and mental illness follow a social gradient with those in lowest socio-economic groups having the greatest burden of illness.26 Those within the lowest socio-economic status are 1.4 times more likely to have a chronic disease, and 1.9 times more likely to be hospitalized for care of that disease.27 Chronic diseases such as diabetes account for 67% of direct health care costs and 60% indirect costs.28
Research has shown that Canadians with low incomes are higher users of general practitioner, mental health, and hospital services.29 People in the lowest income group were almost twice as likely as those in the highest income group to visit the emergency department for treatment. 30 Part of this may be caused by differences in access to care. Low-income Canadians are more likely to report that they have not received needed health care in the past 12 months.31 Those in the lowest income groups are 50% less likely than those in the highest income group to see a specialist or get care in the evenings or on weekends, and 40% more likely to wait more than five days for a doctor's appointment.32
Barriers to health care access are not the only issue. Research in the U.K.33 and U.S.34 has found that compliance with medical treatment tends to be lower in disadvantaged groups, leading to pain, missed appointments, increased use of family practice services and increased emergency department visits, and corresponding increases in cost. In the U.S., non-adherence has been attributed to 100,000 deaths annually.35 Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.36
These differences have financial costs. In Manitoba for example, research conducted in 1994 showed that those in the lowest income decile used services totaling $216 million (12.2%). In the same year, those in the highest income decile consumed $97 million (5.5%) of expenditures. If expenditures for the bottom half of the population by income had been the same as the median, Manitoba would have saved $319 million or 23.1% of their health care budget. 37 According to a 2011 report, low-income residents in Saskatoon consume an additional $179 million in health care costs than middle income earners.38
To reduce the burden of illness and therefore system costs, Canada needs to improve the underlying social and economic determinants of health of Canadians. However, until these changes have time to improve the health status of the population, there will still be a large burden of illness correlated to these underlying deficiencies. As a result, the health system will need to be adequately resourced to address the consequences of the social determinants of health.
AREAS FOR ACTION
The WHO Commission on the Social Determinants of Health identified four categories through which actions on social determinants can be taken. These include:
* reducing social stratification by reducing inequalities in power, prestige, and income linked to socio-economic position;
* decreasing the exposure of individuals and populations to the health-damaging factors they may face;
* reducing the vulnerability of people to the health damaging conditions they face; and
* intervening through health care to reduce the consequences of ill health caused by the underlying determinants.39
All of these areas offer possibilities for action by the physician community. The following section provides suggestions for action by the medical profession through: CMA and national level initiatives; medical education; leadership and research; and clinical practice.
CMA and national level initiatives
Despite the strong relationship between the social determinants of health and health, little in the way of effective action has resulted. CMA and its partners can and should, advocate for research and push for informed healthy public policy, including health impact assessments for government policies. Additionally, targeted population health programs aimed at addressing the underlying determinants should be supported.
All Canadians need a better understanding of the health trends and the impacts of various social and economic indicators. Information about the differences in specific health indicators, collected over time,40 is essential to the task of describing underlying health trends and the impacts of social and economic interventions. Data within primary care practices could be assembled into (anonymous) community-wide health information databases, to address this need.
CMA recommends that:
1. The federal government recognize the relationship of the social determinants of health on the demands of the health care system and that it implement a requirement for all cabinet decision-making to include a Health Impact Assessment.
2. Options be examined for minimizing financial barriers to necessary medical care including pharmaceuticals and medical devices necessary for health.
3. Federal and provincial/territorial governments examine ways to improve the social and economic circumstances of all Canadians.
4. Efforts be made to educate the public about the effect of social determinants on individual and population health.
5. Appropriate data be collected and reported on annually. This data should be locally usable, nationally comparable and based on milestones across the life course.
Medical education is an effective means to provide physicians with the information and tools they require to understand the impact of social determinants on the health of their patients and deal with them accordingly.41 In 2001, Health Canada published a report in which they stated that the primary goal of medical education should be the preparation of graduates who know how to reduce the burden of illness and improve the health of the communities in which they practice.42 Among the report's recommendations was a call for greater integration of the social determinants in medical curricula.43 Although the CanMEDS framework has been a part of the Royal College of Physicians and Surgeons of Canada's accreditation process since 2005, challenges to the integration of these competencies remain.44
The report called for a greater emphasis on providing medical students with firsthand experiences in the community and with distinct populations (service learning),45 which addresses the difficulties in teaching the social aspects of medicine within a traditional classroom or hospital setting.46 Many such programs exist across the country.47 However, these programs are still limited and there is a need to increase the availability of longitudinal programs which allow students to build on the skills they develop throughout medical school.
Increasingly residency programs which focus on the social determinants of health are being offered.48 These programs are a means of providing physicians with the proper tools to communicate with patients from diverse backgrounds49 and reduce behaviours that marginalized patients have identified as barriers to health services.50 It also provides residents with physician role models who are active in the community. However, medical residents note a lack of opportunities to participate in advocacy during residency.51 Further, while experiential programs are effective in helping to reduce barriers between physicians and patients from disadvantaged backgrounds, greater recruitment of medical students from these marginalized populations should also be explored and encouraged.
Finally, physicians in practice need to be kept up to date on new literature and interventions regarding the social determinants. Innovations which help address health equity in practice should be shared with interested physicians. In particular, there is a need for accredited continuing medical education (CME) and a means to encourage uptake.52
CMA recommends that:
6. Greater integration of information on the social determinants and health inequity be provided in medical school to support the CanMEDS health advocate role
7. All medical schools and residency programs offer service learning programs, to provide students with an opportunity to work with diverse populations in inner city, rural and remote settings, and to improve their skills in managing the impact of the social determinants on their patients.
8. CME on the social determinants of health and the physician role in health equity be offered and incentivized for practising physicians.
Leadership and research
Within many communities in Canada, there are physicians who are working to address social determinants and health equity within the patient populations they serve. This is done in many cases through collaboration with partners within and outside of the health care system. Providing these local physician leaders with the tools they need to build these partnerships, and influence the policies and programs that affect their communities is a strategy that needs to be explored.
Evidence-based research about health equity, the clinical setting and the role of physicians is underdeveloped. Interested physicians may wish to participate in research about practice level innovations, as a means of contributing to the evidence base for 'health equity' interventions or simply to share best practices with interested colleagues. Further, physicians can provide the medical support to encourage the adoption of early childhood development practices for example, which support later adult health. In time, research will contribute to training, continuing medical education and potentially to clinical practice guidelines.
Physicians can provide leadership in health impact assessments and equity audits within the health care system as well. Data is essential to identify health equity challenges within a program, to propose and test measures that address the issues underlying the disparities. Formal audits and good measurement are essential to develop evidence-based policy improvements.53 Innovative programs such as those within the Saskatoon Health Region and the Centre for Addiction and Mental Health in Toronto are examples of using these tools to improve access and reduce inequities.
CMA recommends that:
9. Physicians who undertake leadership and advocacy roles should be protected from repercussions in the workplace, e.g., the loss of hospital privileges.
10. Physician leaders explore opportunities to strengthen the primary care public health interface within their communities by working with existing agencies and community resources.
11. Physician leaders work with their local health organizations and systems to conduct health equity impact assessments in order to identify challenges and find solutions to improve access and quality of care.
12. Physicians be encouraged to participate in or support research on best practices for the social determinants of health and health equity. Once identified, information sharing should be established in Canada and internationally.
In consultation with identified health equity physician champions, a number of clinical interventions have been identified which are being undertaken by physicians across the country. These interventions could be undertaken in many practice settings given the right supports, and could be carried out by various members of the collaborative care team.1
First, a comprehensive social history is essential to understand how to provide care for each patient in the context of their life.54 There are a number of tools that can be used for such a consultation and more are in development.55 However, consolidation of the best ideas into a tool that is suitable for the majority of health care settings is needed. There is some concern that asking these questions is outside of the physician role. The CanMEDS health advocate role clearly sees these types of activities as part of the physician role.56 The 'Four Principles of Family Medicine' defined by the College of Family Physicians of Canada, affirms this role for physicians as well.57
Community knowledge was identified as a strategy for helping patients. Physicians who were aware of community programs and services were able to refer patients if/when social issues arose.58 Many communities and some health providers have developed community resource guides.59 For some physicians, developing a network of community resources was the best way to understand the supports available.
As a corollary, physicians noted their work in helping their patients become aware of and apply for the various social programs to which they are entitled. The programs vary by community and province/territory, and include disability, nutritional supports and many others. Most if not all of these programs require physicians to complete a form in order for the individual to qualify. Resources are available for some of these programs,60 but more centralized supports for physicians regardless of practice location or province/territory are needed.
Physicians advocate on behalf of their patients by writing letters confirming the medical limitations of various health conditions or the medical harm of certain exposures.61 For example, a letter confirming the role of mold in triggering asthma may lead to improvements in the community housing of an asthmatic. Additionally, letters might help patients get the health care services and referrals that they require. As identified leaders within the community, support from a physician may be a 'game-changer' for patients.
Finally, the design of the clinic, such as hours of operation or location, will influence the ability of people to reach care.62
CMA recommends that:
13. Tools be provided for physicians to assess their patients for social and economic causes of ill health and to determine the impact of these factors on treatment design.
14. Local databases of community services and programs (health and social) be developed and provided to physicians. Where possible, targeted guides should be developed for the health sector.
15. Collaborative team-based practice be supported and encouraged.
16. Resources or services be made available to physicians so that they can help their patients identify the provincial/territorial and federal programs for which they may qualify.
17. Physicians be cognizant of equity considerations when considering their practice design and patient resources.
18. All patients be treated equitably and have reasonable access to appropriate care, regardless of the funding model of their physician.
Socio-economic factors play a larger role in creating (or damaging) health than either biological factors or the health care system. Health equity is increasingly recognized as a necessary means by which we will make gains in the health status of all Canadians and retain a sustainable publicly funded health care system. Addressing inequalities in health is a pillar of CMA's Health Care Transformation initiative. Physicians as clinicians, learners, teachers, leaders and as a profession can take steps to address the problems on behalf of their patients.
1 A full review of the consultations is provided in the companion paper The Physician and Health Equity: Opportunities in Practice.
1 Khalema, N. Ernest (2005) Who's Healthy? Who's Not? A Social Justice Perspective on Health Inequities. Available at: http://www.uofaweb.ualberta.ca/chps/crosslinks_march05.cfm
2 World Health Organization (2008) Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Available at: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf
3 Public Health Agency of Canada (N.D.) The Social Determinants of Health: An Overview of the Implications for Policy and the Role of the Health Sector. Available at: http://www.phac-aspc.gc.ca/ph-sp/oi-ar/pdf/01_overview_e.pdf
4 Keon, Wilbert J. & Lucie Pépin (2008) Population Health Policy: Issues and Options. Available at: http://www.parl.gc.ca/Content/SEN/Committee/392/soci/rep/rep10apr08-e.pdf
5 Friel, Sharon (2009) Health equity in Australia: A policy framework based on action on the social determinants of obesity, alcohol and tobacco. The National Preventative Health Taskforce. Available at: http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/0FBE203C1C547A82CA257529000231BF/$File/commpaper-hlth-equity-friel.pdf
6 Wilkinson, Richard & Michael Marmot eds. (2003) Social Determinants of Health: The Solid Facts: Second Edition. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf
7 Khalema, N. Ernest (2005) Who's Healthy?...
8 Dunn, James R. (2002) The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Available at: http://www.opha.on.ca/our_voice/collaborations/makeconnxn/HDP-proj-full.pdf
10 Wilkins, Russ; Berthelot, Jean-Marie; and Ng E. . Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996. Health Reports 13 [Supplement]: pp. 45-71
11 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health: The Canadian Facts. Available at: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf
12 Raphael, Dennis (2003) "Addressing The Social Determinants of Health In Canada: Bridging The Gap Between Research Findings and Public Policy." Policy Options. March 2003 pp.35-40.
13 World Health Organization (2008) Closing the gap in a generation...
14 Hay, David I. (2006) Economic Arguments for Action on the Social Determinants of Health. Canadian Policy Research Networks. Available at: http://www.cprn.org/documents/46128_en.pdf
15 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
17 Whitehead, Margaret & Goran Dahlgren (2006) Concepts and principles for tackling social inequities in health: Levelling up Part 1. World Health Organization Europe. Available at: http://www.euro.who.int/__data/assets/pdf_file/0010/74737/E89383.pdf
18 Wilkinson, Richard & Michael Marmot eds. (2003) "Social Determinants of Health...
19 Ferrie, Jane E. (1999) "Health consequences of job insecurity." In Labour Market Changes and Job Security: A Challenge for Social Welfare and Health Promotion. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98411/E66205.pdf
20 Marmot, Michael (2010) Fair Society Healthy Lives: The Marmot Review: Executive Summary. Available at: http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLivesExecSummary.pdf
21 World Health Organization (2008) Closing the gap in a generation...
22 Aboriginal Healing Foundation, Frequently Asked Questions (Ottawa: Canadian Government Publishing Directorate, 2009) Available at: http://www.ahf.ca/faq
23Health Council of Canada, "The Health Status Of Canada's First Nations, Métis And Inuit Peoples", 2005, Available at:http://healthcouncilcanada.ca.c9.previewyoursite.com/docs/papers/2005/BkgrdHealthyCdnsENG.pdf
24 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
25Health Council of Canada, (2005)"The Health Status Of Canada's First Nations, Métis And Inuit Peoples...
26 Dunn, James R. (2002) The Health Determinants Partnership...
27 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions. http://secure.cihi.ca/cihiweb/products/PHC_Experiences_AiB2012_E.pdf
28 Munro, Daniel (2008) "Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health." The Conference Board of Canada. Available at: http://www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb
29 Williamson, Deanna L. et.al. (2006) "Low-income Canadians' experiences with health-related services: Implications for health care reform." Health Policy. 76(2006) pp. 106-121.
30 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians...
31 Williamson, Deanna L. et.al. (2006) "Low-income Canadians'...
32 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
33 Neal, Richard D. et.al. (2001) "Missed appointments in general practice: retrospective data analysis from four practices." British Journal of General Practice. 51 pp.830-832.
34 Kennedy, Jae & Christopher Erb (2002) "Prescription Noncompliance due to Cost Among Adults with Disabilities in the United States." American Journal of Public Health. Vol.92 No.7 pp. 1120-1124.
35 Bibbins-Domingo, Kirsten & M. Robin DiMatteo. Chapter 8: Assessing and Promoting Medication Adherence. pp. 81-90 in King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients...
36 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health...
37 Dunn, James R. (2002) The Health Determinants Partnership...
38 Saskatoon Poverty Reduction Partnership (2011) from poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Available at: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf
39 World Health Organization (2005) Action On The Social Determinants Of Health: Learning From Previous Experiences. Available at: http://www.who.int/social_determinants/resources/action_sd.pdf
40 Braveman, Paula (2003) "Monitoring Equity in Health and Healthcare: A Conceptual Framework."Journal of Health, Population and Nutrition. Sep;21(3):181-192.
41 Royal College of Physicians (2010) How doctors can close the gap: Tackling the social determinants of health through culture change, advocacy and education. Available at: http://www.marmotreview.org/AssetLibrary/resources/new%20external%20reports/RCP-report-how-doctors-can-close-the-gap.pdf
42 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools. Available at: http://www.medicine.usask.ca/leadership/social-accountability/pdfs%20and%20powerpoint/SA%20-%20A%20vision%20for%20Canadian%20Medical%20Schools%20-%20Health%20Canada.pdf
44 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate: Translating the Quest for Social Responsibility into Medical Education and Practice." Academic Medicine. Vol.86 No.9 pp.1108-1113.
45 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools...
46 Meili, Ryan; Fuller, Daniel; & Jessica Lydiate. (2011) "Teaching social accountability by making the links: Qualitative evaluation of student experiences in a service-learning project." Medical Teacher. 33; 659-666.
47 Ford-Jones, Lee; Levin, Leo; Schneider, Rayfel; & Denis Daneman (2012) "A New Social Pediatrics Elective-A Tool for Moving to Life Course Developmental Health." The Journal of Pediatrics. V.160 Iss. 3 pp.357-358; Meili, Ryan; Ganem-Cuenca, Alejandra; Wing-sea Leung, Jannie; & Donna Zaleschuk (2011) "The CARE Model of Social Accountability: Promoting Cultural Change." Academic Medicine. Vol.86 No.9 pp.1114-1119.
48 Cuthbertson, Lana "U of A helps doctors understand way of life in the inner city." Edmonton Journal Dec 22, 2010. Available at: http://www2.canada.com/edmontonjournal/news/cityplus/story.html?id=943d7dc3-927b-4429-878b-09b6e00595e1
49 Willems, S.; Maesschalck De, S.; Deveugele, M.; Derese, A. & J. De Maeseneer (2005) "Socio-economic status of the patient and doctor-patient communication: does it make a difference?" Patient Education and Counseling. 56 pp. 139-146.
50 Bloch, Gary; Rozmovits, Linda & Broden Giambone (2011) "Barriers to primary care responsiveness to poverty as a risk factor for health." BioMed Central Family Practice. Available at: http://www.biomedcentral.com/content/pdf/1471-2296-12-62.pdf; Schillinger, Dean; Villela, Theresa J. & George William Saba. Chapter 6: Creating a Context for Effective Intervention in the Clinical Care of Vulnerable Patients. pp.59-67. In King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients.
51 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate...
52 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
53 Meili, Ryan (2012) A Healthy Society: How A Focus On Health Can Revive Canadian Democracy. Saskatoon: Canada. Purich Publishing Limited. pp.36
54 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
55 Bloch, Gary (2011) "Poverty: A clinical tool for primary care "Family & Community Medicine, University of Toronto. Available at: http://www.healthprovidersagainstpoverty.ca/system/files/Poverty%20A%20Clinical%20Tool%20for%20Primary%20Care%20%28version%20with%20References%29_0.pdf ; Bricic, Vanessa; Eberdt, Caroline & Janusz Kaczorowski (2011) "Development of a Tool to Identify Poverty in a Family Practice Setting: A Pilot Study." International Journal of Family Medicine. Available at: http://www.hindawi.com/journals/ijfm/2011/812182/ ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, female health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, male health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders
56 Frank, Dr. Jason R. ed. (2005) "The CanMEDS 2005 Physician Competency Framework: Better standards. Better physicians. Better Care." Office of Education: The Royal College of Physicians and Surgeons of Canada. Available at: http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf
57 Tannenbaum, David et.al. (2011) "Triple C Competency-based Curriculum: Report of the Working Group on Postgraduate Curriculum Review-Part 1
58 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
59 Doyle-Trace L, Labuda S. Community Resources in Cote-des-Neiges. Montreal: St Mary's Hospital Family Medicine Centre, 2011. (This guide was developed by medical residents Lara Doyle-Trace and Suzan Labuda at McGill University.); Mobile Outreach Street Health (N.D.) Pocket MOSH: a little MOSH for your pocket: A Practitioners Guide to MOSH and the Community We Serve. Available at: http://www.cdha.nshealth.ca/mobile-outreach-street-health
60 Health Providers Against Poverty (N.D.) Tools and Resources. Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders
61 Meili, Ryan (2012) A Healthy Society: How A Focus...pp.61; UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities...
62 Rachlis, Michael (2008) Operationalizing Health Equity: How Ontario's Health Services Can Contribute to Reducing Health Disparities. Wellesley Institute. Available at: http://wellesleyinstitute.com/files/OperationalizingHealthEquity.pdf
Restricting Marketing of Unhealthy Foods and Beverages to Children and Youth in Canada: A Canadian Health Care and Scientific Organization Policy Consensus Statement
Federal government to immediately
begin a legislative process to restrict all
marketing targeted to children under the
age of 13 of foods and beverages high in
saturated fats, trans-fatty acids, free
sugars or sodium and that in the interim
the food industry immediately ceases
marketing of such food to children.
PURPOSE OF STATEMENT
This policy consensus statement was developed to
reflect the growing body of evidence linking the
promotion and consumption of diets high in
saturated fats, trans-fatty acids, free sugars or
sodium1 to cardiovascular and chronic disease
(hypertension, dyslipidemia, diabetes mellitus,
obesity, cancer, and heart disease and stroke)—
leading preventable risk factors and causes of death
and disability within Canada and worldwide. (1-3)
(1) For the remainder of the document, reference to foods
high in saturated fats, trans-fatty acids, free sugars or
sodium will be framed as foods high in fats, sugars or
The current generation of Canadian children is
expected to live shorter, less healthy lives as a
result of unhealthy eating. (4) Canadians’
overconsumption of fat, sodium and sugar, rising
rates of childhood obesity, growing numbers of
people with cancer, heart disease and stroke, and
the combined strain they exert on the health care
system and quality of life for Canadians necessitates
immediate action for Canadian governments and
policy-makers. Restricting the marketing of
unhealthy foods and beverages directed at children
is gaining increasing international attention as a
cost-effective, population-based intervention to
reduce the prevalence and the burden of chronic
and cardiovascular diseases through reducing
children’s exposure to, and consumption of,
disease-causing foods. (2,5,6)
In May 2010, the World Health Organization (WHO
released a set of recommendations on the
marketing of foods and non-alcoholic beverages to
children (5) and called on governments worldwide
to reduce the exposure of children to advertising
messages that promote foods high in saturated fats,
trans-fatty acids, free sugars or sodium and to
reduce the use of powerful marketing techniques. In
June 2012, the follow-up document, A Framework
for Implementing the Set of Recommendations on
the Marketing of Foods and Non-Alcoholic
Beverages to Children, (7) was released.
The policy aim should be to reduce the impact
on children of marketing of foods high in
saturated fats, trans-fatty acids, free sugars,
WHO (2010): Recommendation 1
What this policy consensus statement offers is the
perspective of many major national health care
professional and scientific organizations to guide
Canadian governments and non-government
organizations on actions that need to be taken to
protect the health of our future generations, in part
by restricting the adverse influence of marketing of
foods high in fat, sugar or sodium to Canadian
children and youth.
SUMMARY OF EVIDENCE AND RATIONALE
-Young children lack the cognitive ability to
understand the persuasive intent of marketing
or assess commercial claims critically. (8) in
1989 the Supreme Court of Canada ruled that
“advertisers should not be able to capitalize
upon children’s credulity” and “advertising
directed at young children is per se
-The marketing and advertising of information or
products known to be injurious to children’s
health and wellbeing is unethical and infringes
on the UN Convention on the Rights of the Child
which stipulates that, “In all actions concerning
children … the best interests of the child shall
be a primary consideration.” (9)
- Unhealthy food advertising during children’s
television programs in Canada is higher than in
many countries, with children being exposed to
advertisements for unhealthy foods and
beverages up to 6 times per hour. (10)
- Unhealthy food and beverage advertising
influences children’s food preferences,
purchase requests and consumption patterns
and has been shown to be a probable cause of
childhood overweight and obesity by the WHO.
- The vast majority of Canadians (82%) want
government intervention to place limits on
advertising unhealthy foods and beverages to
- The regulation of food marketing to children is
an effective and cost-saving population-based
intervention to improve health and prevent
- Several bills have been introduced into the
House of Commons to amend the Competition
Act and the Food and Drug Act to restrict
commercial advertising, including food, to
children under 13 years of age. None have yet
been passed. (15)
- Canada’s current approach to restricting
advertising to children is not effective and is not
in line with the 2010 WHO recommendations on
the marketing of foods and beverages to
children, nor is it keeping pace with the direction
of policies being adopted internationally, which
ban or restrict unhealthy food and beverage
marketing targeted to children. (16,17)
The Supreme Court of Canada concluded
that “advertising directed at young
children is per se manipulative”
Irwin Toy Ltd. v. Québec (AG), 1989
FOOD MARKETING TO CHILDREN: A TIMELY
OPPORTUNITY FOR CANADA
Childhood obesity and chronic disease prevention
are collective priorities for action of federal,
provincial and territorial (F/P/T) governments.
Strategy 2.3b of the 2011 Federal, Provincial and
Territorial Framework for Action to Promote Healthy
Weights stipulates “looking at ways to decrease the
marketing of foods and beverages high in fat, sugar
and/or sodium to children. “(5, p. 31)
The 2010 Sodium Reduction Strategy for Canada
has also identified the need to “continue to explore
options to reduce the exposure of children to
marketing for foods that are high in sodium" as a
key activity for F/P/T governments to consider. (19,
In their 2010 set of recommendations, the WHO
stipulated that governments are best positioned to
lead and ensure effective policy development,
implementation and evaluation. (6)
To date, there has been no substantive movement
by the federal government to develop coordinated
national-level policies that change the way
unhealthy foods and beverages are produced,
marketed and sold. Current federal, provincial and
industry-led self-regulatory codes are inconsistent
in their scope and remain ineffective in their ability
to sufficiently reduce children’s exposure to
unhealthy food marketing, nor have they been
adequately updated to address the influx of new
marketing mediums to which children and youth in
Canada are increasingly subjected.
Quebec implemented regulations in 1980 restricting
all commercial advertising. (20) Although the ban
has received international recognition and is viewed
as world leading, several limitations remain, in part
due exposure of Quebec children to marketing from
outside Quebec, weak enforcement of the
regulations and narrow application of its provisions.
Accordingly, the undersigned are calling on the
federal government to provide strong leadership
and establish a legislative process for the
development of regulations that restrict all
commercial marketing of foods and beverages high
in saturated fats, trans-fatty acids, free sugars or
sodium to children.
Strong federal government action and commitment
are required to change the trajectory of chronic
diseases in Canada and institute lasting changes in
public health. Specifically:
Efforts must be made to ensure that
children…are protected against the impact
of marketing [of foods with a high content
of fat, sugar and sodium] and given the
opportunity to grow and develop in an
enabling food environment — one that
fosters and encourages healthy dietary
choices and promotes the maintenance of
healthy weight. (7, p. 6)
Such efforts to protect the health of children must
go beyond the realm of federal responsibility and
involve engagement, dialogue, leadership and
advocacy by all relevant stakeholders, including all
elected officials, the food and marketing sector,
public health, health care professional and scientific
organizations, and most importantly civil society.
The undersigned support the development of
policies that are regulatory in nature to create
national and/or regional uniformity in
implementation and compliance by industry.
“Realizing the responsibility of governments
both to protect the health of children and to
set definitions in policy according to public
health goals and challenges — as well as to
ensure policy is legally enforced — statutory
regulation has the greatest potential to achieve
the intended or desired policy impact.”
WHO (2012), p. 33
The following outline key definitions and
components of an effective and comprehensive
policy on unhealthy food and beverage marketing
to children and should be used to guide national
policy scope and impact.
- Age of Child: In the context of broadcast
regulations, the definition of “age of child”
typically ranges from under 13 years to under
16 years. In Canada, Quebec’s Consumer
Protection Act (20) applies to children under
13 years of age. Consistent with existing
legislation, this report recommends that policies
restricting marketing of unhealthy foods and
beverages be directed to children less than
13 years of age at a minimum.
While the science on the impact of marketing on
children over 13 is less extensive, emerging
research reveals that older children still require
protection and may be more vulnerable to newer
forms of marketing (i.e., digital media ), in which
food and beverage companies are playing an
increasingly prominent role. (21-23) Strong
consideration should be given to extending the
age of restricting the marketing of unhealthy
food and beverage to age 16.
- Unhealthy Food and Beverages: In the absence
of a national standardized definition for “healthy”
or “unhealthy” foods, this document defines
unhealthy foods broadly as foods with a high
content of saturated fats, trans-fatty acids, free
sugars or sodium, as per the WHO
recommendations. (5) It is recommended that a
robust and comprehensive definition be
developed by an interdisciplinary stakeholder
- Focus on Marketing: Marketing is more than
advertising and involves:
…any form of commercial communication or
message that is designed to, or has the
effect of, increasing the recognition, appeal
and/ or consumption of particular products
and services. It comprises anything that acts
to advertise or otherwise promote a product
or service. (6, p. 9)
This definition goes beyond the current legal
definition of advertisement outlined in the Food
and Drug Act as “any representation by any
means whatever for the purpose of promoting
directly or indirectly the sale or disposal of any
food, drug, cosmetic or device.” (24)
- Marketing Techniques, Communication Channels
and Locations: Legislation restricting unhealthy
food marketing needs to be sufficiently
comprehensive to address the broad scope of
marketing and advertising techniques that have a
particularly powerful effect on children and
youth. This includes, but is not limited to, the
. Direct electronic marketing (email, SMS)
. Mobile phones
. Video and adver-games
. Characters, brand mascots and/or celebrities,
including those that are advertiser-generated
. Product placement
. Point-of-purchase displays
. Cinemas and theatres
. Competitions and premiums (free toys)
. Children’s institutions, services, events and
activities (schools, event sponsorship)
. “Viral and buzz marketing” (25,26)
. Directed to Children: The criteria used by the
Quebec Consumer Protection Act (20) to
determine whether an advertisement is “directed
at children” offers a starting point in developing
national legislation regarding child-directed
media. The loopholes in the Quebec Consumer
Protection Act criteria, namely allowing
advertising of unhealthy foods and beverages
directed at adults during children’s programming,
will necessitate the development of an
alternative approach or set of criteria that
reflects the range of media to which children are
exposed and when they are exposed, in addition
to the proportion of the audience that is made up
Quebec Consumer Protection Act
To determine whether or not an
advertisement is directed at persons under
thirteen years of age, account must be taken
of the context of its presentation, and in
a)the nature and intended purpose of the
b)the manner of presenting such
c)the time and place it is shown.
1. Federal Government Leadership
1.1 Immediately and publicly operationalize the
WHO set of recommendations on the marketing
of foods and non-alcoholic beverages to
In working toward the implementation of the
WHO recommendations, the federal
government is strongly urged to accelerate
implementation of the WHO Framework for
Implementing the Set of Recommendations on
the Marketing of Foods and Beverages to
Children. To this end, the Government of
Canada is urged to:
1.2 Convene a Federal, Provincial and Territorial
Working Group on Food Marketing to Children
to develop, implement and monitor policies to
restrict unhealthy food and beverage marketing
to children. As stipulated within the WHO
The government-led working group should
ultimately reach consensus on the priorities
for intervention, identify the available policy
measures and decide how they best can be
implemented. (7, p.13)
1.3 In developing policies, it is recommended that
the working group:
- Develop standardized criteria and an
operational definition to distinguish and
classify “unhealthy” foods. Definitions
should be developed using objective,
evidence-based methods and should be
developed and approved independent of
- Develop a set of definitions/specifications
that will guide policy scope and
implementation. Consistent with the WHO
recommendations, the working group is
encouraged to apply the policy
specifications identified above.
- Set measurable outcomes, targets and
timelines for achievement of targets for
industry and broadcasters to restrict
unhealthy food marketing to children in all
forms and settings. It is recommended that
policies be implemented as soon as possible
and within a 3-year time frame.
- Establish mechanisms for close monitoring
and enforcement through defined rewards
and/or penalties by an independent
regulatory agency that has the power and
infrastructure to evaluate questionable
advertisements and enforce penalties for
(2) Such an infrastructure could be supported
though the Canadian Radio-television and
Telecommunications Commission (CRTC), similar
to the authority of the US Federal Trade
Commission (FTC), the Canadian Food
Inspection Agency or the Food and Drug Act via
the development of an advertising investigation
The nature and extent of penalties imposed should be sufficiently
stringent to deter violations. Enforcement
mechanisms should be explicit, and infringing
companies should be exposed publicly.
- Develop evaluation mechanisms to assess
process, impact and outcomes of food
marketing restriction policies. Components
should include scheduled reviews (5 years or
as agreed upon) to update policies and/or
strategies. To showcase accountability,
evaluation findings should be publicly
1.4 Provide adequate funding to support the
successful implementation and monitoring of
the food marketing restriction policies.
1.5 Collaborate with the Canadian Institutes of
Health Research and other granting councils to
fund research to generate baseline data and
address gaps related to the impact of marketing
in all media on children and how to most
effectively restrict advertising unhealthy foods
to children. (27)
1.6 Fund and commission a Canadian economic
modeling study to assess the cost-effectiveness
and the relative strength of the effect of
marketing in comparison to other influences on
children’s diets and diet-related health
outcomes. Similar studies have been
undertaken elsewhere and highlight cost–
benefit savings from restricting unhealthy food
1.7 Call on industry to immediately stop marketing
foods to children that are high in fats, sugar or
2. Provincial, Territorial and Municipal
2.1 Wherever possible, incorporate strategies to
reduce the impact of unhealthy food and
beverage marketing to children into provincial
and local (public) health or related strategic
action plans, and consider all settings that are
frequented by children.
2.2 Pass and/or amend policies and legislation
restricting unhealthy food and beverage
marketing to children that go beyond
limitations stipulated in federal legislation and
regulations and industry voluntary codes.
2.3 Until federal legislation is in place, strike a P/T
Steering Committee on Unhealthy Food
Marketing to Children to establish
interprovincial consistency related to key
definitions and criteria and mechanisms for
enforcement, as proposed above.
2.4 Collaborate with local health authorities, non-
governmental organizations and other
stakeholders to develop and implement
education and awareness programs on the
harmful impacts of marketing, including but not
limited to unhealthy food and beverage
2.5 Call on industry to immediately stop marketing
foods to children that are high in fats, sugar or
3. Non-governmental Organizations
(NGOs), Health Care Organizations,
Health Care Professionals
3.1 Publicly endorse this position statement and
advocate to all Canadian governments to
restrict marketing of unhealthy foods to
children and youth in Canada.
3.2 Collaborate with governments at all levels to
facilitate implementation and enforcement of
federal/provincial/municipal regulations or
3.3 Wherever possible, incorporate and address
the need for restrictions on unhealthy food
and beverage marketing to children into
position papers, strategic plans, conferences,
programs and other communication mediums.
3.4 Support, fund and/or commission research to
address identified research gaps, including the
changing contexts and modes of marketing
and their implications on the nutritional status,
health and well-being of children and youth
3.5 Call on industry to immediately stop the
marketing of foods high in fat, sugar or
4. Marketing and Commercial Industry
4.1 Immediately cease marketing foods high in fats,
sugar or sodium.
4.2 Amend the Canadian Children’s Food and
Beverage Advertising Initiative (CAI) nutrition
criteria used to re-define “better-for-you
products” to be consistent with currently
available international standards that are
healthier and with Canadian nutrient profiling
standards, once developed.
BACKGROUND AND EVIDENCE BASE
Non-communicable diseases (diabetes, stroke,
heart attack, cancer, chronic respiratory disease)
are a leading cause of death worldwide and are
linked by several common risk factors including high
blood pressure, high blood cholesterol, obesity,
unhealthy diets and physical inactivity. (1,2,3 28)
The WHO has predicted that premature death from
chronic disease will increase by 17% over the next
decade if the roots of the problem are not
Diet-related chronic disease risk stems from long-
term dietary patterns which start in childhood
(8,28). Canadian statistics reveal children, consume
too much fat, sodium and sugars (foods that cause
chronic disease) and eat too little fiber, fruits and
vegetables (foods that prevent chronic disease). (3)
There is evidence that (television) advertising of
foods high in fat, sugar or sodium is associated with
childhood overweight and obesity. (6,11) Children
and youth in Canada are exposed to a barrage of
marketing and promotion of unhealthy foods and
beverages through a variety of channels and
techniques – tactics which undermine and
contradict government, health care professional
and scientific recommendations for healthy eating.
Available research indicates that food marketing to
children influences their food preferences, beliefs,
purchase requests and food consumption patterns.
(8,29) A US study showed that children who were
exposed to food and beverage advertisements
consumed 45% more snacks than their unexposed
counterparts. (30) Similarly, preschoolers who were
exposed to commercials for vegetables (broccoli
and carrots) had a significantly higher preference
for these vegetables after multiple exposures (n=4)
compared to the control group. (31)
Economic modeling studies have shown that
restricting children’s exposure to food and beverage
advertising is a cost effective population based
approach to childhood obesity prevention, with the
largest overall gain in disability adjusted life years.
(13,14). Canada has yet to conduct a comparable
Marketing and Ethics
Foods and beverages high in fats, sugars or sodium
is one of many health compromising products
marketed to children. It has been argued that policy
approaches ought to extend beyond marketing of
unhealthy foods and beverages to one that restricts
marketing of all products to children, as practiced in
Quebec (7,26,32). Article 36 of the Convention on
the Rights of the Child, to which Canada is a
signatory, states that, “children should be protected
from any activity that takes advantage of them or
could harm their welfare and development.” (9)
Restricting marketing of all products has been
argued to be the most comprehensive policy option
in that it aims to protect children from any
commercial interest and is grounded in the
argument that children have the right to a
commercial-free childhood (7, 25,26,32). The focus
on restricting unhealthy food and beverage
marketing was based in consultations with national
health organizations whose mandates, at the time
of writing, were more aligned with a focus on
unhealthy foods and beverages.
This policy statement is not opposed to, and does
not preclude further policy enhancements to
protect children from all commercial marketing, and
therefore encourages further advocacy in this area.
In order to inform the debate and help underpin
future policy direction, further research is needed.
Canada’s Food and Beverage Marketing
Television remains a primary medium for children’s
exposure to advertising, with Canadian children
aged 2–11 watching an average of 18 hours of
television per week. (26) In the past two decades,
the food marketing and promotion environment has
expanded to include Internet marketing, product
placement in television programs, films and DVDs,
computer and video games, peer-to-peer or viral
marketing, supermarket sales promotions, cross-
promotions between films and television programs,
use of licensed characters and spokes-characters,
celebrity endorsements, advertising in children’s
magazines, outdoor advertising, print marketing,
sponsorship of school and sporting activities,
advertising on mobile phones, and branding on toys
and clothing. (25,26)
A systematic review of 41 international studies
looking at the content analysis of children’s food
commercials found that the majority advertised
unhealthy foods, namely pre-sugared cereals, soft
drinks, confectionary and savoury snacks and fast
food restaurants. (33) In an analysis of food
advertising on children’s television channels across
11 countries, Canada (Alberta sample) had the
second-highest rate of food and beverage
advertising (7 advertisements per hour), 80% of
which were for unhealthy foods and beverages
defined as “high in undesirable nutrients and/or
Illustrating the influence of food packaging in
supermarkets, two Canadian studies found that for
six food product categories 75% of the products
were directed solely at children through use of
colour, cartoon mascots, pointed appeals to parents
and/or cross-merchandising claims, games or
activities. Of the 63% of products with nutrition
claims, 89% were classified as being “of poor
nutritional quality” due to high levels of sugar, fat,
or sodium when judged against US-based nutrition
criteria. Less than 1% of food messages specifically
targeted to children were for fruits and vegetables.
Food is also unhealthily marketed in schools. A
recent study of 4,936 Canadian students from
grades 7 to 10 found that 62% reported the
presence of snack-vending machines in their
schools, and that this presence was associated with
students’ frequency of consuming vended goods.
(36) In another Canadian analysis, 28% of
elementary schools reported the presence of some
form of advertising in the school and 19% had an
exclusive marketing arrangement with Coke or
Pepsi. (37) Given children’s vulnerability, a key
tenant of the WHO recommendations on marketing
to children is that “settings where children gather
should be free from all forms of marketing of foods
high in saturated fats, trans-fatty acids, and free
sugars or sodium.” (6, p.9) and need to be included
in development of food marketing policies directed
The Canadian public wants government oversight in
restricting unhealthy food marketing to children. A
nation-wide survey of over 1200 Canadian adults
found 82% want limits placed on unhealthy food
and beverage advertising to children; 53% support
restricting all marketing of high-fat, high-sugar or
high-sodium foods aimed directly at children and
Canada’s Commercial Advertising Environment
Internationally, 26 countries have made explicit
statements on food marketing to children and 20
have, or are in the process of, developing policies in
the form of statutory measures, official guidelines
or approved forms of self-regulation. (38) The
differences in the nature and degree of these
restrictions is considerable, with significant
variation regarding definition of child, products
covered, communication and marketing strategies
permitted and expectations regarding
implementation, monitoring and evaluation. (38,39)
With the exception of Quebec, Canada’s advertising
policy environment is restricted to self-regulated
rather than legislative measures with little
monitoring and oversight in terms of measuring the
impact of regulations on the intensity and
frequency of advertising unhealthy foods and
beverages to children. (39)
Nationally, the Food and Drug Act and the
Competition Act provide overarching rules on
commercial advertising and (loosely) prohibit selling
or advertising in a manner that is considered false,
misleading or deceptive to consumers. These laws,
however, contain no provisions dealing specifically
with unhealthy food advertising or marketing to
children and youth. (26) The Consumer Package
and Labeling Act outlines federal requirements
concerning the packaging, labeling, sale,
importation and advertising of prepackaged non-
food consumer products. Packaging and labels,
however, are not included under the scope of
advertising and therefore not subject to the
administration and enforcement of the Act and
Such loopholes have prompted the introduction of
three private member's bills into the House of
Commons to amend both the Competition Act and
the Food and Drugs Act. Tabled in 2007, 2009 and
2012, respectively, none of the bills have, to date,
advanced past the First Reading. (15)
The Canadian Code of Advertising Standards (Code)
and the Broadcast Code for Advertising to Children
(BCAC) together cover Canadian broadcast and non-
broadcast advertising. (23) While both have explicit
provisions/clauses to cover advertising directed to
children (12 years and younger), neither address or
explicitly cover unhealthy food and beverage
advertising. Further excluded are other heavily
used and persuasive forms of marketing directed to
children, including in-store promotions, packaging,
logos, and advertising in schools or at events, as
well as foreign media. (40)
Formed in 2008, the Canadian Children’s Food and
Beverage Advertising Initiative (CAI) defines
marketing standards and criteria to identify the
products that are appropriate or not to advertise to
children under 12 years old. Under this initiative,
participating food companies (N=19) are
encouraged to direct 100% of their advertising to
children under 12 to “better-for-you” products. (41)
In 2010, the scope of CAI was expanded to include
other media forms, namely video games, child-
directed DVDs and mobile media.
Despite reportedly high compliance by CAI
participants, (41) several fundamental loopholes
undermine its level of protection and effectiveness,
- Participation is voluntary, exempting non-
participators such as President’s Choice,
Wendy’s and A&W, from committing to CAI core
- Companies are allowed to create their own
nutrient criteria for defining “better-for-you” or
“healthier dietary choice” products. (32) A 2010
analysis revealed that up to 62% of these
products would not be acceptable to promote to
children by other countries’ advertising nutrition
- Companies are able to adopt their own
definition of what constitutes “directed at
children” under 12 years. (32) Participants'
definitions of child audience composition
percentage range from 25% to 50%, significantly
more lenient than current Quebec legislation
and other international regulatory systems.
- The initiative excludes a number of marketing
and advertising techniques primarily directed at
children, namely advertiser-generated
characters (e.g., Tony the Tiger), product
packaging, displays of food and beverage
products, fundraising, public service messaging
and educational programs. (26,27)
The Quebec Consumer Protection Act states that
“no person may make use of commercial
advertising directed at persons under thirteen years
of age.” (26) Despite its merits, the effectiveness of
the Quebec ban has been compromised. In its
current form, the ban does not protect children
from cross-border leakage of child-directed
advertisements from other provinces. (40) One
study found that while the ban reduced fast food
consumption by US$88 million per year and
decreased purchase propensity by 13% per week,
the outcomes primarily affected French-speaking
households with children, not their English-speaking
counterparts. (44) A more recent study looking at
the ban’s impact on television advertising arrived at
similar conclusions and found that Quebec French
subjects were exposed to significantly fewer candy
and snack promotions (25.4%, p<0.001) compared
to the Ontario English (33.7%) and Quebec English
(39.8%) groups. (40)
The ban has further been criticized for having a
weak definition of “advertisement”, which allows
adult-targeted advertisements for unhealthy foods
during children’s programming (37) and having
weak regulatory and monitoring structures. (37,40)
In assessing the effectiveness of Quebec’s
legislation in reducing children’s exposure to
unhealthy food advertising, it is important to note
that the ban was not developed to target or reduce
the marketing of foods and beverages specifically,
but rather to reduce the commercialization of
Public Policy: The Way Forward
Several legislative approaches have been
undertaken internationally to restrict unhealthy
food and beverage marketing. (7,43,45) While
more research is needed with regards to the impact
of restricting unhealthy food and beverage
marketing on child health outcomes (i.e., obesity), a
US study estimated that between 14-33% of
instances of childhood obesity could be prevented
by eliminating television advertising for unhealthy
food. (46) An Australian study found that a
restriction on non-core-food advertisement
between 7am and 8:30pm could reduce children’s
exposure to unhealthy food advertising by almost
80%. (47) An evaluation of the UK regulations
which restricts television advertising of all foods
high in fat, sugar and sodium found that since its
introduction there has been a 37% reduction in
unhealthy food advertisement seen by children.
Restrictions on food marketing are being
increasingly advocated internationally. A 2011
International Policy Consensus Conference
identified regulating marketing to children as a key
policy strategy to prevent childhood obesity. (48) A
similar recommendation was made at the
September 2011 United Nations high-level meeting
on the prevention and control of non-
communicable diseases. Restrictions on television
advertising for less healthful foods has also been
identified as an effective (Class I; Grade B)
population-based strategy to improve dietary
behaviors in children by the American Heart
Within Canada, non-governmental and other health
organizations are assuming an equally active role.
Among others, the Chronic Disease Prevention
Alliance of Canada, the Dietitians of Canada, the
Alberta Policy Coalition for Chronic Disease
Prevention, the Simcoe Board of Health, the
Thunder Bay and District Board of Health and the
Kingston, Frontenac, Lennox and Addington Board
of Health have issued position papers or statements
urging the federal government to implement more
stringent regulations on food and beverage
marketing to children. (26,42,48)
The current voluntary, industry self-regulated and
ineffective system of restricting the marketing and
advertising of foods and beverages fails to protect
Canadian Children and thereby contributes to the
rising rates of childhood obesity and the likelihood
of premature death and disability in our children’s
and future generations. Strong federal government
leadership and nationwide action from other levels
of government and other key stakeholders are
needed. Regulation restricting unhealthy food
advertising is internationally supported, with a
growing evidence base for expanding such
regulation to all forms of food marketing.
This policy statement offer an integrated, pragmatic
and timely response to the national stated priorities
of childhood obesity and chronic disease prevention
in Canada and supports the F/P/T vision of making
Canada, “…a country that creates and maintains the
conditions for healthy weights so that children can
have the healthiest possible lives.” (4)
This policy statement was funded by The Heart and Stroke
Foundation of Canada (HSFC) and the Institute of
Circulatory and Respiratory Health (CIHR) Chair in
Hypertension Prevention and Control, prepared with the
assistance of an ad hoc Expert Scientific Working Group,
reviewed and approved by the Hypertension Advisory
Committee and endorsed by the undersigned national
HYPERTENSION ADVISORY COMMITTEE
Manuel Arango, Heart and Stroke Foundation of Canada
Norm Campbell, Canadian Society of Internal Medicine
Judi Farrell, Hypertension Canada
Mark Gelfer, College of Family Physicians of Canada
Dorothy Morris, Canadian Council of Cardiovascular Nurses
Rosana Pellizzari, Public Health Physicians of Canada
Andrew Pipe, Canadian Cardiovascular Society
Maura Rickets, Canadian Medical Association
Ross Tsuyuki, Canadian Pharmacists Association
Kevin Willis, Canadian Stroke Network
Norm Campbell, HSFC/CIHR Chair in Hypertension
Prevention and Control, Chair
Tara Duhaney, Policy Director, Hypertension Advisory
1. World Health Organization. Diet, Nutrition, and the
Prevention of Chronic Diseases. WHO Technical
Report Series No. 916. Geneva, WHO; 2003.
http://www.who.int/hpr/NPH/docs/who_fao_expert_report.pdf. Accessed December 2011
2. World Health Organization. 2008-2013 Action Plan
for the Global Strategy for the Prevention and
Control of Noncommunicable Diseases. Geneva:
WHO; 2008. Available at:
2008.pdf. Accessed December 2011
3. Public Health Agency of Canada. Tracking Heart
Disease and Stroke in Canada. Ottawa, 2009.
Available at: http://www.phac-
eng.pdf. Accessed January 2012
4. Olshansky SJ, Passaro DJ, Hershow RC et al. A
potential decline in life expectancy in the United
States in the 21st century. N Engl J Med. 2005;
5. Public Health Agency of Canada. Curbing Childhood
Obesity: A Federal, Provincial and Territorial
Framework for Action to Promote Healthy Weights.
Ottawa, PHAC; 2011 Available at: http://www.phac-
Accessed January 2012
6. World Health Organization. Set of recommendations
on the marketing of foods and non-alcoholic
beverages to children. Geneva: WHO; 2010.
http://www.who.int/dietphysicalactivity/publications/recsmarketing/en/index.html. Accessed December 2011
7. World Health Organization. A Framework for
Implementing the Set of Recommendations on the
Marketing of Foods and Non-Alcoholic Beverages to
Children. Geveva: WHO; 2012. Available at:
http://www.who.int/dietphysicalactivity/MarketingFramework2012.pdf. Accessed June 2012
8. Kunkel D, Wilcox B, Cantor J, Palmer E, Linn S,
Dowrick P. Report of the APA Taskforce on
Advertising and Children. Washington: American
Psychological Association; 2004. Available at:
http://www.apa.org/pi/families/resources/advertising-children.pdf. Accessed January 2012
9. United Nations. Convention on the Rights of the
Child. Geneva: United Nations, 2009 Available at:
Accessed February, 2012
10. Kelly B, Halford JCG, Boyland E, Chapman K, Bautista-
Castaño I, Berg C, et al. Television food advertising to
children: A global perspective. Am J Public Health.
2010;100:1730-5. Available at:
11. McGinnis JM, Gootman JA, Kraak VI (Eds.) Food
Marketing to Children and Youth: Threat or
Opportunity? Committee on Food Marketing and the
Diets of Children and Youth. Washington, DC: IOM;
12. Ipsos Reid. Canadians’ Perceptions of, and Support
for, Potential Measures to Prevent and Reduce
Childhood Obesity. Prepared for the Public Health
Agency of Canada. Ottawa, November 2011.
http://www.sportmatters.ca/files/Reports/Ipsos%20Obesity%202011.pdf. Accessed February 2012
13. Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-
Barron V, Chisholm D. Tackling of Unhealthy Diets,
physical inactivity, and obesity: Health effects and
cost-effectiveness. Lancet 2010; 376 (9754): 1775-
84 Available at:
14. Magnus A, Habby MM, Carter R, Swinburn B. The
cost-effectiveness of removing television advertising
of high fat and/or high sugar food and beverages to
Australian children. Int J Obes.2009; 33: 1094-1102.
15. Parliament of Canada. Private Member’s Bills.
Accessed April 2012
16. Conrad S. Innovations in Policy Evaluation:
Examining the food and beverages included in the
Canadian Children’s Food and Beverage Advertising
Initiative. Ottawa: Public Health Agency of Canada;
17. Alberta Policy Coalition for Cancer Prevention. Using
Public Policy to Promote Healthy Weights for
Canadian Children. Submission to the “Our Health,
Our Future – National Dialogue on Healthy Weights”
18. Public Health Agency of Canada. The integrated pan-
Canadian healthy living strategy. 2005. Available at:
strat/pdf/hls_e.pdf. Accessed January 2012
19. Health Canada. Sodium Reduction Strategy for
Canada: Recommendations of the Sodium Working
Group. Ottawa, Ontario, July 2010. Available at:
http://publications.gc.ca/collections/collection_2010/sc-hc/H164-121-2010-eng.pdf. Accessed December
20. Quebec Consumer Protection Office. The Consumer
Protection Act: Application Guide for Sections 248
and 249. Quebec, 1980
21. Montgomery K, Chester J. Interactive Food and
Beverage Marketing: Targeting Adolescents in the
Digital Age. J Adolesc Health. 2009: S18-S29.
22. Harris JL, Brownell KD, Bargh JA. The Food Marketing
Defense Model: Integrating Psychological Research
to Protect Youth and Inform Public Policy. Soc Issues
Policy Rev. 2009; 3(1): 211-271. Available at:
23. Pechman C, Levine L, Loughlin S, Leslie F. Impulsive
and Self-Conscious: Adolescents' Vulnerability to
Advertising and Promotion. Journal of Public Policy
and Marketing. 2005; 24 (2): 202-221. Available at:
24. Health Canada. Food and Drugs Act . R.S., c. F-27.
Ottawa: Health Canada; 1985. Available at:
Accessed February 2012
25. Mackay S, Antonopoulos N, Martin J, Swinburn B. A
comprehensive approach to protecting children from
unhealthy food advertising. Melbourne, Australia:
Obesity Policy Coalition; 2011. Available at:
email1%20final%2013.04.11.pdf. Accessed January
26. Cook B. Policy Options to Improve the Children’s
Advertising Environment in Canada. Report for the
Public Health Agency of Canada Health Portfolio Task
Group on Obesity and Marketing. Toronto; 2009.
27. Toronto Board of Health. Food and Beverage
Marketing to Children. Staff Report to the Board of
Health. Toronto: Board of Health; 2008. Available at:
http://www.toronto.ca/legdocs/mmis/2008/hl/bgrd/backgroundfile-11151.pdf. Accessed January 2012
28. The Conference Board of Canada. Improving Health
Outcomes: The Role of Food in Addressing Chronic
Diseases. Conference Board of Canada, 2010.
177_FoodandChronicDisease.pdf. Accessed June 2012
29. Cairns G, Angus K, Hastings G, Caraher M.
Systematic reviews of the evidence on the nature,
extent and effects of food marketing to children. A
retrospective summary. Appetite. 2012 (in press).
30. Harris JL, Bargh JA, Brownell KD. Priming Effects of
Television Food Advertising on Eating Behavior.
Health Psychol. 2009; 28(4):404-13. Available at:
31. Nicklas TA, Goh ET, Goodell LS et al. Impact of
commercials on food preferences of low-income,
minority preschoolers. J Nutr Educ Behav. 2011;
32. Elliott C. Marketing Foods to Children: Are We
Asking the Right Questions. Child Obes. 2012; 8(3):
33. Hastings G, Stead M, McDermott L, Forsyth A,
Mackintosh AM, Rayner M, Godfrey C, Caraher M,
Angus K. Review of research on the effects of food
promotion to children. Final Report to the UK Food
Standards Agency. Glasgow, Scotland: University of
Strathclyde Centre for Social Marketing; 2003.
http://www.food.gov.uk/multimedia/pdfs/promofoodchildrenexec.pdf. Accessed February 2012
34. Elliott C. Marketing fun foods: A profile and analysis
of supermarket food messages targeted at children.
Can Public Policy. 2008; 34:259-73
35. Elliott C. Assessing fun foods: Nutritional content
and analysis of supermarket foods targeted at
children. Obes Rev. 2008; 9: 368-377. Available at:
36. Minaker LM, Storey KE, Raine KD, Spence JC, Forbes
LE, Plotnikoff RC, McCargar LJ. Associations between
the perceived presence of vending machines and
food and beverage logos in schools and adolescents'
diet and weight status. Public Health Nutr. 2011;
37. Cook B. Marketing to Children in Canada: Summary
of Key Issues. Report for the Public Health Agency of
Canada. 2007. Available at:
Accessed January 2012
38. Hawkes C, Lobstein T. Regulating the
commercial promotion of food to children: a
survey of actions worldwide. Int J Pediatr
Obes. 2011; 6(2):83-94.
39. Hawkes C, Harris J. An analysis of the content of
food industry pledges on marketing to children.
Public Health Nutr. 2011; 14:1403-1414. Available
40. Potvin-Kent M, Dubois, L, Wanless A. Food
marketing on children's television in two
different policy environments. Int J of Pediatr
Obes. 2011; 6(2): e433-e441. Available at:
41. Advertising Standards Canada. Canadian children’s
food and beverage advertising initiative: 2010
compliance report. Available at:
2010ComplianceReport.pdf. Accessed March 2012
42. Dietitians of Canada. Advertising of Food and
Beverage to Children. Position of Dietitians of
Canada. 2010. Available at:
paper.aspx. Accessed January 2012
43. Hawkes C. Marketing food to children: a global
regulatory environment. World Health Organization.
2004(b). Available at:
http://whqlibdoc.who.int/publications/2004/9241591579.pdf. Accessed February 2012
44. Dhar T, Baylis K. Fast-food Consumption and the Ban
on Advertising Targeting Children: The Quebec
Experience. Journal of Marketing Research. 2011; 48
(5): 799-813. Available at:
45. World Health Organization. Marketing of Food and
Non-Alcoholic Beverages of Children. Report of a
WHO Forum and Technical Meeting. Geneva: WHO;
2006. Available at:
pdf. Accessed January 2012
46. Veerman JL, Van Beeck, Barendregt JJ, Mackenbach
JP. By how much would limiting TV food advertising
reduce childhood obesity? Eur J Public Health. 2009;
19(4): 365-9. Available at:
47. Kelly B, King L, Mauman A, Smith BJ, Flood V. The
effects of different regulation systems on television
food advertising to children. Aust N Z J Public
Health. 2007; 31(4): 340-343.
48. Alberta Policy Coalition for Chronic Disease
Prevention. Canadian Obesity Network -
International Consensus: Take Action to Prevent
Childhood Obesity (Press Release). 2011. Available
49. Mozaffarian D, Afshin A, Benowitz NL et al.
Population Approaches to Improve Diet, Physical
Activity, and Smoking Habits: A Scientific Statement
From the American Heart Association. Circulation.
This paper discusses the current state of the professional relationship between physicians and the health care system. A review of the concept of medical professionalism, and the tensions that can arise between the care of individual patients and a consideration of the broader needs of society, provides some basic groundwork. Our understanding of what it means to be a physician has evolved significantly over the years, and the medical profession is now being challenged to clarify the role it is willing to play in order to achieve transformation of our health care system.
We have arrived at this point due to a convergence of several factors. Regionalization of health care has led to a change in the leadership roles played by practising physicians and to the opportunities they have for meaningful input into system change. Physicians are now also less likely to be involved in hospital-based care, which has resulted in a loss of collegiality and interactions with peers. Changing models of physician engagement status and changing physician demographics have also presented new and unique issues and challenges over the past few years.
The Canadian Medical Association (CMA) suggests that its physician members and other stakeholders employ a "AAA" lens to examine the challenges and opportunities currently facing Canadian physicians as they attempt to engage with the health care system: Autonomy, Advocacy and Accountability. These important concepts are all underpinned by strong physician leadership. Leadership skills are fundamentally necessary to allow physicians to be able to participate actively in conversations aimed at meaningful system transformation.
KEY CMA RECOMMENDATIONS ARE AS FOLLOWS:
Physicians should be provided with the leadership tools they need, and the support required, to enable them to participate individually and collectively in discussions on the transformation of Canada's health care system.
Physicians need to be provided with meaningful opportunities for input at all levels of decision-making, with committed and reliable partners, and must be included as valued collaborators in the decision-making process.
Physicians have to recognize and acknowledge their individual and collective obligations (as one member of the health care team and as members of a profession) and accountabilities to their patients, to their colleagues and to the health care system and society.
Physicians must be able to freely advocate when necessary on behalf of their patients in a way that respects the views of others and is likely to bring about meaningful change that will benefit their patients and the health care system.
Physicians should participate on a regular and ongoing basis in well-designed and validated quality improvement initiatives that are educational in nature and will provide them with the feedback and skills they need to optimize patient care and outcomes.
Patient care should be team based and interdisciplinary with smooth transition from one care setting to the next and funding and other models need to be in place to allow physicians and other health care providers to practise within the full scope of their professional activities.
The concept of medical professionalism, at its core, has always been defined by the nature and primacy of the individual doctor-patient relationship, and the fiduciary obligation of physicians within this relationship. The central obligation of the physician is succinctly stated in the first tenet of the CMA Code of Ethics:
Consider first the well-being of the patient.1
Since the latter half of the 20th century, however, there has been a growing emphasis on the need for physicians to also consider the collective needs of society, in addition to those of their individual patients. As stated in the CMA Code of Ethics:
Consider the well-being of society in matters affecting health.
This shift in thinking has happened for at least two reasons. First, there have been tremendous advances in medical science that now enable physicians to do much more to extend the length and quality of life of their patients, but these advances inevitably come at a cost which is ultimately borne by society as a whole. Second, since World War II, Canadian governments have been increasingly involved in the financing of health care through taxation revenues. As a result, there have been growing calls for physicians to be prudent in their use of health care resources, and to be increasingly accountable in the way these resources are employed.
The 2002 American Board of Internal Medicine (ABIM) Foundation Charter on Medical Professionalism calls for physician commitment to a just distribution of finite resources: "While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources."2 This has also been described as civic professionalism.
Lesser et al have put forward a systems view of professionalism that radiates out from the patient-physician relationship to broader interactions with members of the health care team, the training environment and to the external environment, dealing with payers and regulators and also addressing the socio-economic determinants of health.3 Understandably, given that the resources available for health care are finite, tensions will arise between the care of individual patients and the collective needs of society, and these tensions can at times be very difficult to resolve for individual medical practitioners.
As stated in the CMA policy Medical Professionalism (Update 2005):
Medical professionalism includes both the relationship between a physician and a patient and a social contract between physicians and society. Society grants the profession privileges, including exclusive or primary responsibility for the provision of certain services and a high degree of self-regulation. In return, the profession agrees to use these privileges primarily for the benefit of others and only secondarily for its own benefit. 4
Over time the delivery, management and governance of health care have become more complex, and as a result the health care sector now accounts for roughly one in 10 jobs in Canada. There are more than two dozen regulated health professions across Canada, as well as numerous professional managers employed in various capacities, many of whom have had little or no exposure to the everyday realities of the practice of clinical medicine. Notwithstanding the acknowledgement of the very real and important need for inter-professional collaboration and teamwork, inevitably this creates competition for influence in the health care system.
The CMA 2005 update of its policy on medical professionalism acknowledges the need for change.
While maintaining responsibility for care of the patient as a whole, physicians must be able to interact constructively with other health care providers within an interdisciplinary team setting. The relationship of physicians with their colleagues must be strengthened and reinforced. Patient care benefits when all health care practitioners work together towards a common goal, in an atmosphere of support and collegiality.
Now, physicians are being challenged to clarify exactly what it is that they are prepared to do in order to advance the much-needed transformation of our health care system, and how they will partner with patients, other care providers and the system in order to achieve this common goal. This provides a significant opportunity for physicians to continue their leadership role in the health care transformation initiative in the interests of their patients, while at the same time redefining their relationship with the system (understood in this context as health care administrators, governments and their representatives, health districts, health care facilities and similar organizations) in order to ensure that they have a meaningful and valued seat at the decision-making table, now and in the future.
The common refrain among health administrators, health ministry officials and health policy analysts for the past decade and longer has been that physicians are "not part of the health care system", that they are independent contractors and not employees, and that they are too often part of the problem and not the solution.
Over this period of time, several developments have resulted in a diminished role of physicians in clinical governance in Canada and have, to varying degrees, transformed the professional and collegial relationship between physicians and their health regions, health care facilities and communities to one that is increasingly governed by legislative fiat or regulation.
Beginning with New Brunswick in 1992, all jurisdictions except Ontario, the Yukon Territory and Nunavut have adopted a regional governance model. This change has eliminated all hospital and community services boards within a geographic region and replaced them with a single regional board. Clinical governance is now administered through a regional medical advisory committee (MAC). Some provinces such as Saskatchewan recognize the role of the district (regional) medical staff association. This has had a profound impact in reducing the number of physicians engaged in the clinical governance of health care institutions.
Another by-product of regionalization is that in virtually all jurisdictions, physicians no longer sit on governing boards. While physicians continue to serve as department heads and section chiefs within regions and/or individual hospital facilities, the level of support and financial compensation to do so varies greatly, particularly outside major regions and institutions, and there has been a lack of physician interest in such positions in some places.
In addition to a diminished presence in clinical governance, physicians are less likely to be actively involved in hospitals than they were previously. Anecdotally, many physicians, particularly in larger urban communities, describe having been "pushed out" of the hospital setting, and of feeling increasingly marginalized from the decision-making process in these institutions. Another result of the diminished engagement with hospitals has been the loss of the professional collegiality that used to be fostered through interaction in the medical staff lounge or through informal corridor consultations.
In the community setting, there have been some positive developments in terms of physician leadership and clinical governance. Ontario and Alberta have implemented new primary care funding and delivery models that promote physician leadership of multidisciplinary teams, and at least two-thirds of the family physicians in each of these jurisdictions have signed on. British Columbia has established Divisions of Family Practice, an initiative of the General Practice Services Committee (a joint committee of the BC Ministry of Health and the BC Medical Association), in which groups of family physicians organize at the local and regional levels and work in partnership with the Health Authority and the Ministry of Health to address common health care goals.
Looking ahead, regionalization is also likely to affect physicians in community-based practice. There is a clear trend across Canada to require all physicians within a region to have an appointment with the health region if they want to access public resources such as laboratory and radiology services. In the future this may also result in actions such as mandated quality improvement activities which may be of variable effectiveness and will not necessarily be aligned with the learning needs of physicians.
Physician engagement status
Traditionally physicians have interfaced with hospitals through a privileges model. This model, which has generally worked well, aims to provide the physician with the freedom to reasonably advocate for the interests of the patient.5 In this model, legislation and regulations also require that there are minimum procedures in place for renewing, restricting, and terminating privileges, and that procedures are set out to ensure that this takes place within a fair and structured framework. The hospital's MAC generally reviews physician privileges applications and recommends appointment and reappointment. The MAC thus plays an integral role in ensuring the safety of care within the region or hospital.5
There has been increasing attention recently on engaging in other types of physician-hospital relationships, including employment or contractual arrangements. This type of arrangement can vary from an employment contract, similar to that used by other professional staff such as nurses and therapists, to a services agreement whereby the physician provides medical services to the hospital as an independent contractor.5 However, there are concerns, expressed by the Canadian Medical Protective Association (CMPA) and others, that many of the procedural frameworks and safeguards found in hospital bylaws pertaining to the privileges model may not necessarily extend to other arrangements, and that physicians entering into these contractual agreements may, in some cases, find their appointment at the hospital or facility terminated without recourse. Under such arrangements the procedural fairness and the right of appeal available under the privilege model may not be available to physicians.
One relatively new approach is the appointment model, which aims to combine many of the protections associated with the privileges model with the advantages of predictability and specificity of the employment model. It generally applies the processes used to grant or renew privileges to the resolution of physician performance-related issues.5
It has been argued that changes in appointment status and relationship models can have a detrimental impact on the relationship between practitioners and health care facilities.6 While this has been reported specifically within the context of Diagnostic Imaging, the same may hold true for other specialties as well.
It should also be noted that the issues raised in this paper are applicable to all members of the profession, regardless of their current or future practice arrangements or locations.
Changing physician demographics and practice patterns
It is well recognized that physician demographics and practice patterns have changed significantly over the past several years. Much has been written about the potential impact of these changes on medicine, and their impact on patient care, on waiting lists and on the ability of patients to access clinical services.7 It is also acknowledged that "lifestyle factors," that is to say the attempt by many physicians to achieve a healthier work-life balance, may play a role in determining the type and nature of clinical practice chosen by new medical graduates, the hours they will work and the number of patients they will see.
All of these changes mean that clinical practices may have smaller numbers of patients and may be open shorter hours than in the past. Physicians are being increasingly challenged to outline their understanding of their commitment to ensuring that all patients have timely access to high quality health care within the Canadian public system, while balancing this with their ability to make personal choices that are in their best interests.
Put another way, how can we assist physicians in adjusting their clinical practices, at least to some extent, based on the needs of the population?
While there are clearly challenges and barriers to physician participation in meaningful transformation of the health care system, there are also opportunities for engagement and dialogue, particularly when the doctors of Canada show themselves to be willing and committed partners in the process. Health care transformation cannot be deferred just because it involves difficult decisions and changes to the status quo. Regardless of how we have reached the current situation, relationships between physicians and other parties must evolve to meet future needs. Physicians need to be assisted in their efforts in this regard, both by local health boards and facilities, and by organizations such as the CMA and its provincial and territorial counterparts.
Physicians, individually and collectively, need to demonstrate what they are willing to do to assist in the process and what they are willing to contribute as we move forward, and they need to commit to having the medical profession be an important part of the solution to the challenges currently facing the Canadian system.
We examine some of these challenges through the "AAA" lens of Autonomy, Advocacy and Accountability, which are underpinned by the concept of Physician Leadership.
To a large extent, physicians continue to enjoy a significant degree of what is commonly termed clinical or professional autonomy, meaning that they are able to make decisions for their individual patients based on the specific facts of the clinical encounter. In order to ensure that this autonomy is maintained, physicians need to continue to embrace the concept of clinical standards and minimization of inter-practice variations, where appropriate, while also recognizing the absolute need to allow for individual differences in care based on the requirements of specific patients. Professional autonomy plays a vital role in clinical decision-making, and it is at the heart of the physician-patient relationship. Patients need to feel that physicians are making decisions that are in the best interest of the patient, and that physicians are not unduly limited by external or system constraints. As part of this decision-making, physicians may also need to consider carefully the appropriate balance between individual patient needs and the broader societal good.
In recent years, governments have sometimes made use of the "legislative hammer" to force physicians to conform to the needs of the health system, thus undermining physicians' individual or personal autonomy. Historically, physicians have organized themselves to provide 24-hour coverage of the emergency room and other critical hospital services. This has proven increasingly challenging in recent years, particularly in the case of small hospitals that serve sparsely populated areas where there are few physicians.
Physicians need to continue to make sure that they do not confuse personal with professional autonomy and that they continue to ensure that health care is truly patient-centred. Physicians have rights but also obligations in this regard and they need to make sure that they continue to use a collaborative approach to leadership and decision-making. This includes an ongoing commitment to the concept of professionally-led regulation and meaningful physician engagement and participation in this system.
While physicians will continue to value and protect their clinical and professional autonomy, and rightly so as it is also in the best interests of their patients, they may need to consider which aspects of personal and individual autonomy they may be willing to concede for the greater good.
For example, physicians may need to work together and collaboratively with administrators and with the system to ensure that call coverage is arranged and maintained so that it need not be legislatively mandated, or imposed by regions or institutions. They may need to consider changing the way they practice in order to serve a larger patient population so that patients in need of a primary care physician do not go wanting, and so that the overall patient care load is more evenly balanced amongst colleagues. New primary care models established in Ontario and Alberta over the past decade that provide greater out-of-hours coverage are one example of such an initiative.
By working collaboratively, both individually and collectively, physicians are finding creative ways to balance their very important personal autonomy with the needs of the system and of their patients. These efforts provide a solid foundation upon which to build as the profession demonstrates its willingness to substantively engage with others to transform the system.
To paraphrase from the discussion at the CMA's General Council meeting in August 2011: Physicians need to carefully examine their individual and collective consciences and show governments and other partners that we are willing to play our part in system reform and that we are credible partners in the process.
All parties in the discussion, not only physicians, must be able to agree upon an appropriate understanding of professional autonomy if the health care system is to meet the current and future needs of Canadians.
Physician advocacy has been defined as follows:
Action by a physician to promote those social, economic, educational and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.8
This can consist of advocacy for a single patient to assist them in accessing needed funding for medications, or lobbying the government for changes at a system level. How and when individual physicians choose to undertake advocacy initiatives depends entirely on that individual practitioner, but physicians as a collective have long recognized their obligation to advocate on behalf of their individual patients, on behalf of groups of patients, and at a societal level for changes such as fairer distribution of resources and adequate pandemic planning.
Traditionally, physicians have served as advocates for their patients in a number of arenas; however, various factors such as provincial/territorial legislation, regulatory authorities, and hospital contracts have combined to make them more reluctant to take on this important role and as a result overall patient care may suffer and the patient-physician relationship may be threatened. Increasingly, hospital bylaws urge or require physicians to consult with their institution or health region before going public with any advocacy statements, and in at least one health region physicians are required to sign a confidentiality agreement. Because of this, many physicians fear reprisal when they decide to act as an advocate.
The ability to undertake advocacy initiatives is a fundamental concept and principle for Canadian physicians. Indeed, the CMA Code of Ethics encourages physicians to advocate on behalf of the profession and the public. Patients need to feel that their concerns are heard, and physicians need to feel safe from retribution in bringing those concerns forward.
A well-functioning and respectful advocacy environment is essential to health care planning. Health care is about making choices every day. Governments struggling to balance budgets should be aware that the public can accept that hard choices must and will get made - but they are less likely to be supportive if physicians and their patients do not feel that their opinions are sought and considered as part of the process.
Frontline health care providers, many of whom work in relative isolation in an office or community setting, also need to feel that they have a voice. The CMA supports the need for a forum where primary care physicians can speak with one voice (and make sure that this voice is heard and respected) in a community setting.
In addition to advocating for issues related directly to patient care, physicians, as community leaders, may also be called upon to advocate for other issues of societal importance, such as protection of the environment or social determinants of health. These advocacy undertakings can also be of great importance.
There can be a fine line between advocacy that is appropriate and is likely to affect important and meaningful change, and advocacy that others will perceive as being obstructive or counterproductive in nature. To further complicate matters, what might be seen as appropriate advocacy in one circumstance might not be in a different setting. Physicians should be clear on whose behalf they are speaking and whether they have been authorized to do so. If they have any questions about the possible medicolegal implications of their advocacy activities, they may also wish to contact their professional liability protection provider (e.g., CMPA) for advice in these instances.
Depending on the facts of the individual circumstances, physicians may need to consider other factors as well when deciding if, when and how to undertake advocacy activities. They should also be aware that their representative medical organizations, such as national specialty societies, provincial and territorial medical associations and the CMA, may be able to assist them with their initiatives in certain situations.
Physicians should not feel alone when advocating for their patients, particularly when this is done in a reasonable manner and in a way that is likely to effect meaningful and important change.
Physician accountability can be seen to occur at three levels: accountability to the patients they serve, to society and the health care system and to colleagues and peers.
Accountability to patients
The physician-patient relationship is a unique one. Based on, optimally, absolute trust and openness, this relationship allows for a free exchange of information from patient to physician and back again. Physicians often see patients at their most vulnerable, when they are struggling with illness and disease. While other health care providers make essential contributions to patient care, none maintain the unique fiduciary relationships that are at the heart of the physician's role and which are recognized by law.
Physicians are accountable to their individual patients in a number of important ways. They provide clinical services to their patients and optimize their availability so that patients can be seen and their needs addressed in a timely fashion. They follow up on test results. They facilitate consultations with other physicians and care providers and follow up on the results of these consultations when needed. They ensure that patients have access to after hours and emergency care when they are not personally available.
Physicians can also fulfill their obligation to be accountable to patients in other ways. They can participate in accreditation undertakings to ensure that their practices meet accepted standards. They can ensure, through lifelong learning and maintenance of competency activities, that they are making clinical decisions based on the best available evidence. They can undertake reviews of their prescribing profiles to ensure that they are consistent with best current standards. All of these activities can also be used to maximize consistencies within and between practices and minimize inter-practice variability where appropriate.
Accountability to society and the health care system
Physician accountability at this level is understandably more complex. In general, society and the health care system in Canada provide physicians with financial compensation, with a significant degree of clinical autonomy as reflected by professionally-led regulation, and with a high level of trust. In some cases, physicians are also provided with a facility in which to practice and with access to necessary resources such as MRIs and operating rooms.
In return, physicians agree to make their own individual interests secondary in order to focus on those of their patients, and they agree to provide necessary medical services. Accountability then can be examined based on the extent that these necessary services are provided (i.e. patients have reasonable access to these services) and also the level of quality of those services. Clearly, neither access nor quality can be considered in isolation of the system as a whole, but for the purposes of this paper the focus will be on the role of the physician.
The issue of level and comprehensiveness of service provision has been considered to some extent above under the concept of physician autonomy. Physicians as individuals and as a collective need to ensure that patients have access to timely medical care and follow up. They also need to make sure that the transition from one type of care to another (for example, from the hospital to the community setting) is as seamless as possible, within the current limitations of the system.
Collectively and individually, physicians also have an obligation to make sure that the quality of the care they provide is of the highest standard possible. They should strive for a "just culture of safety", which encourages learning from adverse events and close calls to strengthen the system, and where appropriate, supports and educates health care providers and patients to help prevent similar events in the future.9
Thousands of articles and hundreds of books have been published on the subjects of quality assurance and quality improvement. From a physician perspective, we want to be able to have access to processes and resources that will provide us with timely feedback on the level of quality of our clinical care in a way that will help us optimize patient outcomes and will be seen as educational in nature rather than punitive. As a self-regulated profession, medicine already has strong accountability mechanisms in place to ensure the appropriate standards of care are maintained.
To ensure that physicians are able to meet their obligation to be accountable to the health care system for high quality care, the CMA has developed a series of recommendations for Continuous Quality Improvement (CQI) activities (see box below).
Physicians need to take ownership of the quality agenda. New medical graduates are entering practice having come from training systems where they have access to constant feedback on their performance, only to find themselves in a situation where feedback is non-existent or of insufficient quality to assist them in caring for their patients. While regulators and health care facilities have a legitimate interest in measuring and improving physician performance, ultimately physicians themselves must take responsibility for ensuring that they are providing their patients with the highest possible standard of care, and that mechanisms are in place to ensure that this is in fact the case.
Accountability to colleagues
Physicians are also accountable to their physician peers and to other health care providers. While much of this accountability is captured by the concept of "collegiality," or the cooperative relationship of colleagues, there are other aspects as well.
Anecdotal evidence suggests strongly that many physician leaders find themselves marginalized by their peers. They describe being seen as having "gone over to the other side" when they decide to curtail or forego their clinical practices in order to participate in administrative and leadership activities. Physicians should instead value, encourage and support their peers who are dedicating their time to important undertakings such as these. As well, physicians should actively engage with their administrative colleagues when they have concerns or suggestions for improvement. Collaboration is absolutely vital to the delivery of safe and quality care.
Physicians also need to make sure that they do everything they can to contribute to a "safe" environment where advocacy and CQI activities can be undertaken. This can mean encouraging physician colleagues to participate in these initiatives, as well as serving as a role model to peers by participating voluntarily in CQI undertakings.
Physicians are also accountable to ensure that transition of care from one physician to another occurs in as seamless a manner as possible. This includes participating in initiatives to improve the quality and timeliness of both consultation requests and results, as well as ensuring professional and collegial communications with other physicians and with all team members.
Finally, physicians need to support each other in matters of individual health and well-being. This can include support and care for colleagues suffering from physical or psychological illness, as well as assisting with accommodation and coverage for duty hours and professional responsibilities for physicians who are no longer able to meet the demands of full-time practice for whatever reason.
"You will not find a high performing health system anywhere in the world that does not have strong physician leadership."
Dan Florizone, Deputy Minister of Saskatchewan Health
As we can see from the discussion above, having strong physician leaders is absolutely critical to ensuring that the relationship between physicians and the health care system is one of mutual benefit. Physicians as a collective have an obligation to make sure that they support both the training required to produce strong physician leaders, as well as providing support for their colleagues who elect to undertake this increasingly important role.
Physicians are well-positioned to assume leadership positions within the health care system. They have a unique expertise and experience with both the individual care of patients, as well as with the system as a whole. As a profession, they have committed to placing the needs of their patients above those of their own, and this enhances the credibility of physicians at the leadership level as long as they stay committed to this important value. Leadership is not just about enhancing the working life of physicians, but is about helping to ensure the highest possible standard of patient care within an efficient and well-functioning system.
As part of their leadership activities, physicians need to ensure that they are consistently engaged with high quality and reliable partners, who will deliver on their promises and commitments, and that their input is carefully considered and used in the decision-making process. These partners can include those at the highest level of government, and must also include others such as medical regulators and senior managers. Without ensuring that they are speaking with the right people, physicians cannot optimize their leadership initiatives.
Physician leadership activities must be properly supported and encouraged. Many physicians feel increasingly marginalized when important meetings or training opportunities are scheduled when they are engaged in direct patient care activities. Non-clinician administrators have time set aside for these activities and are paid to participate, but physicians must either miss these discussions in order to attend to the needs of their patients, or cancel clinics or operating room times. This means that patient care is negatively impacted, and it presents a (sometimes significant) financial disincentive for physicians to participate. Some jurisdictions have recognized this as a concern and are ensuring that physicians are compensated for their participation.
Patients want their physicians to be more involved in policy-making decisions and this must be enabled through the use of proper funding mechanisms, reflective learning activities, continuing professional development credits for administrative training and participation, assisting in the appropriate selection of spokespersons including guidelines on how to select them, and guidelines for spokespersons on how to provide meaningful representation of the profession's views.
Physician leadership training must take place throughout the continuum of medical education, from the early days of medical school through to continuing professional development activities for those in clinical practice. Physicians with an interest in and aptitude for leadership positions should ideally be identified early on in their careers and encouraged to pursue leadership activities and training through means such as mentorship programs and support from their institutions to attend training courses and meetings where they will be able to enhance and refine their leadership skills.
There has been action on several fronts to support the organized professional development of physicians in leadership roles. Since the 1990s the Royal College of Physicians and Surgeons of Canada (RCPSC) has been implementing its CanMEDs framework of roles and competencies in the postgraduate medical training programs across Canada, and this has also been adopted by the College of Family Physicians of Canada (CFPC). The CanMEDs framework sets out seven core roles for physicians. Two that are most pertinent to the relationship between physicians and the health care system are those of manager and health advocate.10 These roles highlight the importance of physician involvement in leadership and system engagement activities, and are relevant for physicians in training as well as those in practice.
As managers, physicians are integral participants in health care organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system.
As health advocates, physicians responsibly use their expertise and influence to advance the health of individual patients, communities and populations.
A number of key enabling competencies have been identified for each role, and the RCPSC has developed a variety of resource materials to support the framework.
For almost 30 years, the CMA has been offering the Physician Manager Institute (PMI) program in order to provide training for physicians pursuing leadership and management positions. PMI is offered in "open enrolment" format in major cities across Canada, and also "in house" through longstanding associations with hospitals and health regions (e.g., Calgary zone of Alberta Health Services [AHS]). In 2010 the CMA and the Canadian Society of Physician Executives introduced the Canadian Certified Physician Executive (CCPE) Program. The CCPE is a peer-assessed credential that can be attained either through an academic route that is based on completion of PMI courses or through a practice-eligibility route based on formal leadership experience.11
The CMA also partners with several provincial and territorial medical associations to provide leadership training. Currently CMA has agreements with the Saskatchewan, Ontario and Quebec medical associations and this will extend to the four Atlantic medical associations and the Alberta Medical Association/AHS in 2012.
In addition, a number of university business schools have developed executive program offerings for health leaders. During the past decade, a number of physicians have taken up CEO positions in Canada's major academic health organizations.
Internationally, it has been recognized that physician leadership is critical to the success of efforts to improve health services.12, 13
Having well trained and qualified physicians in leadership roles is critical in making sure that physicians continue to play a central role in the transformation of the Canadian health care system. The CMA and its membership unreservedly support our physician colleagues who dedicate their time and energies to these leadership activities and the CMA will continue to play an integral part in supporting and training the physician leaders of the future.
CONCLUSION: THE CMA'S VISION OF THE NEW PROFESSIONAL RELATIONSHIP BETWEEN CANADIAN PHYSICIANS AND OUR HEALTH CARE SYSTEM
We have explored the factors that have brought us to this point, as well as the issues that must be examined and addressed to enable us to move forward. It is now time for the physicians of Canada to commit to meaningful participation in the process of transforming our health care system. This can only be achieved through the concerted efforts of all parties, including governments, health authorities, health care facilities, physicians and other health care providers. It will not be easy, and it is not likely that this transformation will take place without commitment and sacrifice on our part.
However, now is the time for physicians to demonstrate to their patients, to their colleagues and to society that they are willing to do their share and play their role in this critically important process, at this critically important time. Doing so will help them to achieve the CMA's vision of the new professional relationship between Canadian physicians and the health care system.
In this vision:
Physicians are provided with the leadership tools they need, and the support required, to enable them to participate individually and collectively in discussions on the transformation of Canada's health care system.
Physicians are provided with meaningful opportunities for input at all levels of decision-making, with committed and reliable partners, and are included as valued collaborators in the decision-making process.
Physicians recognize and acknowledge their individual and collective obligations (as one member of the health care team and as members of a profession) and accountabilities to their patients, to their colleagues and to the health care system and society.
Physicians are able to freely advocate when necessary on behalf of their patients in a way that respects the views of others and is likely to bring about meaningful change that will benefit their patients and the health care system.
Physicians participate on a regular and ongoing basis in well-designed and validated quality improvement initiatives that are educational in nature and will provide them with the feedback and skills they need to optimize patient care and outcomes.
Patient care is team based and interdisciplinary with seamless transition from one care setting to the next and funding and other models are in place to allow physicians and other health care providers to practise within the full scope of their professional activities.
1. Canadian Medical Association. CMA Code of Ethics. http://policybase.cma.ca/PolicyPDF/PD04-06.pdf. Accessed 05/20/11.
2. ABIM Foundation. Medical professionalism in the new millennium: a physician charter. Annals of Internal Medicine 2002; 136(3): 243-6.
3. Lesser C, Lucey C, Egener B, Braddock C, Linas S, Levinson W. A behavioral and systems view of professionalism. JAMA 2010; 304(24): 2732-7.
4. Canadian Medical Association. Medical professionalism 2005 update. http://policybase.cma.ca/dbtw-wpd/Policypdf/PD06-02.pdf. Accessed 06/03/11.
5. Canadian Medical Protective Association. Changing physician : hospital relationships. Managing the medico-legal implications of change. 2011. https://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/com_2011_changing_physician-e.cfm. Accessed 02/07/12.
6. Thrall JH. Changing relationship between radiologists and hospitals Part 1: Background and major issues. Radiology 2007; 245: 633-637.
7. Reichenbach L, Brown H. Gender and academic medicine: impact on the health workforce. BMJ. 2004; 329: 792-795.
8. Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: what is it and how do we do it? Acad Med 2010 Jan; 85(1): 63-7.
9. Canadian Medical Protective Association. Learning from adverse events: Fostering a just culture of safety in Canadian hospitals and health care institutions. 2009. http://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/com_learning_from_adverse_events-e.cfm. Accessed 02/07/12.
10. Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 Framework. http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf. Accessed 05/20/11.
11. Canadian Society of Physician Executives and Canadian Medical Association. Canadian Certifies Physician Executive. Candidate Handbook. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Leadership/CCPE/2012CCPE-Handbook_en.pdf. Accessed 05/20/11.
12. Ham C. Improving the performance of health services: the role of clinical leadership. Lancet 2003; 361: 1978-80.
13. Imison C, Giordano R. Doctors as leaders. BMJ 2009; 338: 979-80.
Vision for e-Prescribing: a joint statement by the Canadian Medical Association and the Canadian Pharmacists Association
By 2015, e-prescribing will be the means by which prescriptions are generated for Canadians.
e-Prescribing is the secure electronic creation and transmission of a prescription between an authorized prescriber and a patient's pharmacy of choice, using clinical Electronic Medical Record (EMR) and pharmacy management software.
Health Information Technology (HIT) is an enabler to support clinicians in the delivery of health care services to patients. The Canadian Medical Association (CMA) and the Canadian Pharmacists Association (CPhA) each have identified e-prescribing as a key tool to deliver better value to patients. The integration of HIT into clinics and health care facilities where physicians and pharmacists provide care is a priority for both associations1.
As part of its Health Care Transformation initiative, the CMA highlighted the need to accelerate the introduction of e-prescribing in Canada to make it the main method of prescribing. In its policy on optimal prescribing the CMA noted that one of the key elements was the introduction of electronic prescribing. The CPhA, as part of its Blueprint for Pharmacy Implementation Plan, highlights information and communication technology, which includes e-prescribing, as one of five priority areas.
We applaud the ongoing efforts of Canada Health Infoway, provinces and territories to establish Drug Information Systems (DIS) and the supporting infrastructure to enable e-prescribing. We urge governments to maintain e-prescribing as a priority and take additional measures to accelerate their investments in this area.
It is our joint position that e-prescribing will improve patient care and safety. e-Prescribing, when integrated with DIS, supports enhanced clinical decision-making, prescribing and medication management, and integrates additional information available at the point of care into the clinical workflow.
The following principles should guide our collective efforts to build e-prescribing capability in all jurisdictions:
* Patient confidentiality and security must be maintained
* Patient choice must be protected
* Clinicians must have access to best practice information and drug cost and formulary data
* Work processes must be streamlined and e-prescribing systems must be able to integrate with clinical and practice management software and DIS
* Guidelines must be in place for data sharing among health professionals and for any other use or disclosure of data
* The authenticity and accuracy of the prescription must be verifiable
* The process must prevent prescription forgeries and diversion
* Pan-Canadian standards must be set for electronic signatures
Benefits of e-Prescribing
A number of these benefits will be realized when e-prescribing is integrated with jurisdictional Drug Information Systems (DIS).
o Improves patient safety and overall quality of care
o Increases convenience for dispensing of new and refill prescriptions
o Supports collaborative, team-based care
o Supports a safer and more efficient method of prescribing and authorizing refills by replacing outdated phone, fax and paper-based prescriptions
o Eliminates re-transcription and decreases risk of errors and liability, as a prescription is written only once at the point-of-care
o Supports electronic communications between providers and reduces phone calls and call-backs to/from pharmacies for clarification
o Provides Warning and Alert systems at the point of prescribing, supporting clinician response to potential contraindications, drug interactions and allergies
o Facilitates informed decision-making by making medication history, drug, therapeutic, formulary and cost information available at the point of prescribing
* Health Care System:
o Improves efficiency and safety of prescribing, dispensing and monitoring of medication therapy
o Supports access to a common, comprehensive medication profile, enhancing clinical decision-making and patient adherence
o Increases cost-effective medication use, through improved evidence-based prescribing, formulary adherence, awareness of drug costs and medication management
o Improves reporting and drug use evaluation
While evidence of the value of e-prescribing is established in the literature, its existence has not fostered broad implementation and adoption. In Canada, there are a number of common and inter-related challenges to e-prescribing's implementation and adoption. These include:
* Improving access to relevant and complete information to support decision-making
* Increasing the level of the adoption of technology at the point of care
* Focusing on systems-based planning to ensure continuum-wide value
* Integrating e-prescribing into work processes to gain support from physicians, pharmacists and other prescribers
* Increasing leadership commitment to communicate the need for change, remove barriers and ensure progress
* Updating legislation and regulation to support e-prescribing
Enabling e-Prescribing in Canada
CMA and CPhA believe that we can achieve the vision that is set out in this document and address the aforementioned challenges by working collectively on five fronts:
* Health care leadership in all jurisdictions and clinical organizations must commit to make e-prescribing a reality by 2015
* Provinces and territories, with Canada Health Infoway, must complete the building blocks to support e-prescribing by increasing Electronic Medical Record (EMR) adoption at the point of care, finishing the work on the Drug Information Systems (DIS) in all jurisdictions and building the connectivity among the points of care and the DIS systems
* Pharmacist and medical organizations in conjunction with provinces, territories and Canada Health Infoway must identify clear benefits for clinicians (enhancing the effectiveness of care delivery and in efficiencies in changing workflows) to adopt e-prescribing and focus their efforts on achieving these benefits in the next three years
* Provinces, territories and regulatory organizations must create a policy/regulatory environment that supports e-prescribing which facilitates the role of clinicians in providing health care to their patients
* Provinces and territories must harmonize the business rules and e-health standards to simplify implementation and conformance by software vendors and allow more investment in innovation.
1 Health Care Transformation in Canada, Canadian Medical Association, June 2010; Blueprint for Pharmacy Implementation Plan, Canadian Pharmacists Association, September 2009
What do we mean by "personal information"?
Throughout this policy, we discuss "personal information," and it is important from the outset to set out what we mean by this term. "Personal information" is information that reveals a distinctive trait about yourself and helps others identify you. Some personal information such as your business address may be found in the public domain by accessing publications like telephone or professional directories. The focus of this policy is personal information collected, used and disclosed by the CMA that is NOT in the public domain.
What types of personal information does the CMA collect and use?
Primarily, the CMA collects and uses personal information about its members. CMA also has personal information about individuals who purchase CMA products and services, attend CMA sponsored events and seminars and submit manuscripts to CMA publications. The CMA assigns a personal identifier called a "CMA ID" to each member or purchaser of a CMA product or service so that you can use this number when contacting the CMA, ordering CMA products and publications or registering for the cma.ca Web site.
The CMA collects personal information directly from individuals or receives it from one of its provincial or territorial medical associations ("PTMAs") or subsidiaries, the CMA group of subsidiary companies, including our primary financial services company, MD Physician Services Inc.
-If you are a CMA member, you might have provided on an application form or will provide to the CMA or a PTMA or a CMA subsidiary, personal information like your home address, date of birth and gender. If you are both a client of one or more of CMA's financial subsidiaries and a CMA member, the fact of your client status, but not detailed financial information, will be known to CMA. A circumscribed and limited number of CMA employees, all of whom receive enhanced privacy training and sign specific undertakings, will have access to more detailed MD PS information such as frequency of meetings about your MD client status (but still not specific financial transactional details) in order to perform statistical analysis.
- If you have attended an event organized through CMA's Meetings and Travel Department, you might have provided us with credit card data as well as information about certain travel preferences and food sensitivities.
- If you have purchased a CMA product (e.g., classified advertising) or attended a CMA seminar (e.g., Physician Manager Institute), you provided us with personal contact information such as your name and address. We might also have collected credit card information if you chose to pay for the product or service by this method.
- If you have submitted a manuscript for publication in a CMA journal, you provided us with contact information, financial disclosure and competing interests data and the manuscript itself.
Why does the CMA collect and use personal information?
The CMA will collect and use only the personal information necessary to achieve the following purposes or one consistent with them:
1. to determine an individual's eligibility for membership in the CMA or to serve as a potential contributor to a CMA publication
2. to determine an individual's eligibility to benefit from the services of one of CMA's subsidiaries or its preferred third-party suppliers
3. to provide and to communicate information about CMA member benefits and services (e.g., the delivery of publications and travel reservations, financial services, advocacy, etc.)
4. to develop and to market products and services tailored to the interests of CMA members and the purchasers of CMA products and services
5. to update contact information in the CMA database
6. to assist the CMA PTMAs and CMA's subsidiaries with the maintenance of their membership and client contact information
7. to provide individuals with the opportunity to benefit from supporting the Canadian Medical Foundation which provides CMA members and others with valuable educational programs and services
8. to conduct surveys and research studies of the physician population in order to analyze for statistical and research purposes such issues as the demographics of physician human resources
9.to engage members and physicians in CMA's policy development process
10.to broadcast urgent health alerts of national significance
When and to whom does the CMA disclose personal information?
The CMA does not sell personal information. The CMA will only disclose your personal information to an organization for a purpose outlined in this policy, unless we obtain your consent for a new purpose. For example, one purpose identified above is maintaining up-to-date membership and client contact information. The CMA and its subsidiariesshare a core data field for the purposes of updating addresses and confirming membership status.
In addition to a core data field for the purposes of updating addresses and confirming membership status, CMA shares with its wholly owned subsidiary, MDPS, information about a member's participation in CMA activities and products such as Physician Manager Institute events. MDPS, as the most highly rated provider of CMA products and services, is seeking to have a better understanding and appreciation of physicians' relationship and interaction with CMA. Knowledge of an individual's participation in CMA events and activities provides this complete or "integrated" picture. If a CMA member objects, a note will be entered in the database.
If you are both a CMA member and a client of a CMA subsidiary company, when you inform us of an address change, with your permission, this information will be changed for both organizations.
The CMA might also disclose personal information to third parties or to organizations or companies that are not CMA-affiliated companies or Divisions if these organizations have contracted or partnered with the CMA to help us provide products and services or do research. For example, the CMA might out-source the mailing list function for one of its publications or work with the Canadian Post-MD Education Registry to study physician resource planning.
We may, in certain instances, contract with a third party service provider located in other countries such as the United States. Your information may be processed and stored in the United States and the United States governments, courts or law enforcement or regulatory agencies may be able to obtain disclosure of your information under a lawful order made in that country. If you would like more information about the jurisdictions in which we our service providers may operate please contact us as noted in the What if you have a question... section of this policy.
Within the CMA itself, your personal information in the form of interactions with the CMA will be shared amongst CMA departments. This will enable CMA to have a better understanding of your interests and activities such that CMA might tailor its product and service offerings to your interests. For example, if a member has completed a number of Physician Manager Institute courses, we might send him or her information about our Physician Leadership Credential Program. If a member objects to a particular disclosure of an activity, for instance a particular CME course, a note will be entered into the database
What if you object to CMA's collection, use or disclosure of personal information?
The CMA seeks to respect and honour your privacy and communication preferences. For instance, if you indicate to the CMA that you do not wish to receive certain publications, participate in surveys or receive information about new or specific benefits and services such as communications from CMA's subsidiaries, your preference will be noted and you will no longer receive correspondence from us on these issues. Please contact the CMA Member Service Centre at 888-855-2555 to make such a request.
You may also at any time, subject to restrictions required by law, object to the CMA's collection, use or disclosure of personal information. You need only provide the CMA with reasonable notice in writing of your intention and the details of your objection. For instance, if you do not wish to have contact and demographic information shared with the Canadian Medical Foundation, we will respect your choice.
Please note, however, that your objection to the disclosure of other information might mean that the CMA is unable to continue to provide you with some products or services. For example, if you object to the sharing of your CMA membership status with CMA's financial subsidiaries, then you will not be eligible to benefit from their products or services. MD Physician Services has to confirm your CMA membership status in order to offer you financial services.
It is your responsibility to contact the CMA in order to determine how an objection to the collection, use and disclosure of personal information might affect the services supplied.
How accurate is the personal information held by the CMA?
The CMA makes every reasonable effort to ensure the accuracy and currency of your personal information so that we might fulfill the purposes for which it was first collected. Your personal information is subject to change so please advise us accordingly of such changes so that we might better meet your needs.
How do you access the personal information held by the CMA?
You may send a written request to the attention of the Chief Privacy Officer at 1867 Alta Vista Drive, Ottawa, Ontario, K1G 5W8or to firstname.lastname@example.org to obtain the personal information held about you by the CMA. Within a reasonable time frame, the CMA will then advise you in writing whether it has such personal information and the nature of this information unless there is the rare occurrence that the release of such information is legally prohibited. If the CMA cannot release the personal information, we will provide you with the reasons for denying access.
You may challenge the accuracy and completeness of the personal information that is maintained by the CMA. The CMA will amend personal information when an individual successfully demonstrates inaccuracy or incompleteness.
How secure is your personal information?
The CMA makes every reasonable effort to protect your personal information by implementing security safeguards against loss or theft, as well as unauthorized access, disclosure, copying, use or modification. The CMA uses physical, organizational and technological measures as methods of protection. For instance, only a limited number of staff have access to such sensitive information as credit card numbers. Moreover, the CMA will ensure that employees are aware of the importance of maintaining the confidentiality of personal information.
How long does the CMA retain personal information?
The CMA keeps personal information as long as it is needed to fulfill the purposes identified above. When personal information is no longer required to fulfill the identified purposes, it will be safely and securely destroyed. Moreover, the CMA will retain personal information that is the subject of an access request for as long as is necessary to allow an individual to exhaust any legal remedy that is provided for in applicable federal or provincial/territorial privacy legislation.
The Canadian Medical Association (CMA) submission to the House of Commons Standing Committee on Finance discusses the important role of the federal government in ensuring Canada's health care system is cost-effective, accountable and accessible across the country in order to support the country's economic advantage. Investing in health and health care is required to generate wealth. As in other leading industrialized countries, the federal government needs to play a stewardship role in the effective allocation of health-related resources to foster a productive workforce and a strong economy.
The purpose of this brief is to provide decision-makers with information on areas in which the federal government can contribute to improving the health of Canadians and the health care system - an issue Canadians consistently rank as their top concern.
The CMA recommends that:
Recommendation # 1
The federal government endorse the Principles to Guide Health Care Transformation, developed by the CMA together with the Canadian Nurses Association and since endorsed by over 120 national organizations.
The federal government engage the provinces and territories in a consultative process to identify pan-Canadian metrics and measurement that link health expenditures to nationally comparable health outcomes. The purpose of which is to demonstrate accountability to Canadians.
Recommendation # 3
The federal government recognize the implications of the social determinants of health on the demands on the health care system.
Recommendation # 4
The federal government require that the federal cabinet's decision-making process include a Health Impact Assessment.
Recommendation # 5
The federal government, in consultation with provincial and territorial governments and other stakeholders, establish a program of comprehensive prescription drug coverage to be administered through provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drugs.
Recommendation # 6
The federal government, together with the provinces and territories, develop and implement a pan-Canadian strategy for continuing care, which would integrate home care and facility-based long-term, respite and palliative care services fully within health care systems.
Recommendation # 7
A targeted health infrastructure fund be established as part of the federal government's long-term plan for public infrastructure. The purpose of this fund would be to address infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times.
Recommendation # 8
The federal government expand the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates.
Recommendation # 9
The federal government establish programs to encourage Canadians to save for their long-term care needs by pre-funding long-term care through for example, private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance, such as an RESP-type savings vehicle.
Recommendation # 10
The federal government develop and implement a national dementia strategy. Such a strategy will contribute to addressing the alternative level of care crisis impacting the efficiency of the overall health care system.
Despite significant investments in health care and improvements in medical treatment and technologies, health outcomes in Canada are not improving. The incidence of chronic disease, such as diabetes and the corresponding risk factors, among them obesity, continues to rise. These negative outcomes can have a significant impact on the prosperity of the country as health is necessary for individuals to lead a prosperous and autonomous life. While the federal government's investment in the sector has continually increased, it is generally agreed that, in terms of its health care system, Canada is no longer a strong performer compared to similar nations.
As in other leading industrialized countries, the Government of Canada needs to play a stewardship role in the effective allocation of health-related resources, which in turn will foster a productive workforce and a strong economy. The federal government also has a role in addressing the social and economic factors that affect the health of Canadians. These factors are often referred to as the social determinants of health and were a central theme at the CMA's annual General Council meeting this year.
This brief provides tangible recommendations on how the federal government can contribute to the transformation of Canada's health care system and to improving the health of Canadians.
1. The Role of the Federal Government
Issue: The federal government has the levers to foster a healthy, productive workforce.
This section discusses opportunities for the federal government to address the challenges facing Canada's overall health care system.
Even though the fiscal arrangement for the future Canada Health Transfers has been established, the federal government has other significant responsibilities with respect to the health of Canadians and the overall health care system.
This view is shared by a majority of Canadians. Recent polling found that: 75 per cent of Canadians believe health care should be the federal government's top priority; 87 per cent believe that the federal government should pay more attention to health care, and 85 per cent believe the federal government should play a leading role in protecting and strengthening the health care system.
An important role to be fulfilled by the federal government is to ensure Canada's health care system is cost-effective, accountable and accessible across the country. Health expenditures account for an increasing proportion of provincial and territorial budgets, and many warn of increasing future demands on health care. In his Economic and Fiscal Outlook Report of May 17, 2012, the Parliamentary Budget Officer stated that "the provincial-territorial long-term fiscal situation has deteriorated." Measures that transfer costs from one level of government to another do not improve Canada's overall fiscal situation.
Despite the importance of the health care sector to Canada's economy and quality of life, it is generally agreed that in health care, Canada is no longer a strong performer relative to similar nations. For instance, OECD Health Data 2012 ranks Canada seventh highest of 34 member states in per capita health care spending,1 while Canada's health care system continues to rank below most of our comparator countries in terms of performance. In addition, recent projections indicate that the overall spending on health as a percentage of GDP will continue to increase.2
However, the health sector has an important role in sustaining Canada's economic recovery and enhancing economic growth. In fact, the health sector supports a healthy and productive workforce by providing over one million high-value jobs, representing about 10 per cent of Canada's labour force. The contribution of Canada's health care system to the international competitiveness of our economy has been repeatedly demonstrated in KPMG's Competitive Alternatives report.3
Taken together, these issues highlight significant potential for the health sector, through efficiency improvements gained by health care transformation, to support long-term economic recovery and growth in Canada.
Finally, while the provinces and territories have initiated positive steps to collaborate on the sharing of best practices in health care, federal leadership could contribute to these efforts by addressing the overall performance of the health care system in Canada.
The federal government should collaborate with the provinces and territories to introduce a pan-Canadian framework for reporting to Canadians on performance, outcomes and expenditures, including on whether national standards of quality and timeliness have been met.
The federal government would also fall under this framework, as it is responsible for the delivery of health care services to a large population. In fact, in health care delivery, it is the fifth-largest jurisdiction in Canada.
The CMA recommends that:
* The federal government engage the provinces and territories in a consultative process to identify pan-Canadian metrics and measurement that link health expenditures to nationally comparable health outcomes. The purpose of which is to demonstrate accountability to Canadians.
2. The need for a Health Impact Assessment (HIA)
Issue: All federal government decisions need to be viewed through the lens of their possible impact on health, health care and Canada's overall health objectives.
While a strong health care system is vital, improvements to it alone will not improve health outcomes or reduce the disparities that currently exist in disease burden and health risks. Research suggests that 50 per cent of population health is determined by our social and economic environment.4 What is needed is a process to address the social determinants that can be barriers or enablers to health and to ensure healthy public policy for all Canadians.
A Health Impact Assessment (HIA) is a systematic process for making evidence-based judgments on the health impacts of any given policy and to identify and recommend strategies to protect and promote health. The HIA is used in several countries, including Australia, New Zealand, Norway, the Netherlands and the United States.
The HIA can ensure that all government departments are able to consider the health impacts of their programs and policies by anticipating possible unintended health consequences or impacts on health care spending. The implementation of an evidence-based HIA is one way in which the federal government can play a leadership role in health care and strengthen accountability to Canadians.
The CMA recommends that:
* The federal government recognize the implications of the social determinants of health on the demands on the health care system; and that,
* The federal government require that the federal cabinet's decision-making process include a Health Impact Assessment to ensure that the health of Canadians is a key factor in every policy decision it makes and unintended consequences are avoided.
3. Contribute to Health Care Transformation (HCT)
Issue: A transformed health care system will be more effective and comprehensive and will strengthen Canada's competitive advantage.
In 2010, as part of its Health Care Transformation (HCT) initiative, the CMA broadly consulted Canadians across the country on their views on health care. Canadians said they do not believe they are getting good value from their health care system, a feeling borne out by studies comparing Canada's health care system to those in leading countries in Europe. Following this consultation, in partnership with the Canadian Nurses Association, the CMA developed Principles to Guide Health Care Transformation in Canada to guide the transformation of Canada's health care system. To date, over 120 national medical, health and organizations have endorsed these principles.
During the HCT consultation, we also heard that Canadians are concerned about inequities in access to care beyond the basic medicare basket, particularly in the area of prescription drugs. In fact, reports in 2002 by the Senate Standing Committee on Social Affairs, Science and Technology (Kirby) and the Commission on the Future of Health Care in Canada (Romanow) 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.
Under the National Pharmaceuticals Strategy (NPS), cost projections of catastrophic pharmaceutical coverage were explored and seemed to favour the use of a variable percentage threshold linked to income. However, there has been no public reporting on progress since 2006.5 Moreover, there is also an issue of expensive drugs that may be used for common diseases. Finally, as highlighted by recent experiences, Canada does not have a monitoring and early notification system for drug shortages nor a systematic mechanism to prevent interruptions in the provision of medically necessary medications.
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.6 In the CMA's view, this does not go far enough and what Canada must strive for is "comprehensive" coverage that covers the whole population and effectively pools risk across individuals, public and private plans, and jurisdictions.
There are several indicators that show health care services and coverage are not keeping up with Canadians' needs and vary depending on where one lives in Canada. Wide variation in access to pharmaceutical treatments remains the most glaring example of inequity in our
health care system - all Canadians should have a basic level of drug coverage. Further, long wait times for medical care can be found in smaller provinces and drug coverage and services for seniors are particularly poor in Atlantic Canada.
The fact remains that one in 10 Canadians cannot afford the medications they are prescribed.7 For this reason, ensuring access by all Canadians to needed prescription drugs is an essential element in the CMA's proposed framework for Health Care Transformation.
By working to establish comprehensive prescription coverage, the federal government would not only uphold its commitment to ensure the best health for Canadians, but also contribute to the transformation of our country's most cherished social program.
The CMA recommends that:
* The federal government endorse the Principles to Guide Health Care Transformation, developed by the CMA together with the Canadian Nurses Association and since endorsed by over 120 organizations.
* The federal government, in consultation with provincial, territorial and other stakeholders, establish a program of comprehensive prescription drug coverage to be administered through provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drugs.
4. Meeting the health and health care needs of Canadians
Issue: Measures should be taken to prepare for the looming demographic change and address the needs of Canada's aging population
Steps need to be taken to ensure that Canada is prepared to handle the growing long-term care needs of its citizens. These should include funding for much-needed infrastructure and additional support for both health care providers and informal caregivers.
In its most recent report, the Wait Time Alliance noted a link between the rise in diagnosis of dementia and the rise in alternate-levels-of-care (ALC) patient stays in hospitals. These are patients who are in hospital while they await an alternative level of care in a more appropriate setting, often a long-term facility. The shortage of long-term care facilities is a major impediment to achieving efficiency in the health care system and yet another issue for which the federal government is well positioned to collaborate and coordinate on a pan-Canadian strategy.
Under its next long-term infrastructure program, the federal government should include a targeted health sector infrastructure fund for long-term care facilities. This should be part of a pan-Canadian strategy to redirect care from hospitals to homes, communities and long-term care facilities, where patients can receive more appropriate care at a lower cost.
We can expect that many more facilities will be required to meet the long-term care needs of Canadians. The most recent census data shows that over the last decade there has been a 38 per cent increase in the number of seniors living in special care facilities.8 Based on residency rates of the present population, Canada will need over 800,000 long-term care beds by 2047.
Considering the average size of existing long-term care facilities it is estimated that meeting this future demand will require construction of almost 6,000 additional long-term care facilities over the next 35 years, almost 170 a year.9
Another related issue that has the potential to affect productivity is the burden of providing care to family members. Without adequate long-term care resources and support for home care, Canada's labour force may experience a productivity drag as a result of increased leave and absenteeism to care for elderly relatives.
The 2011 federal budget took a first step at providing tax relief for informal caregivers with the introduction of the Family Caregiver Tax Credit. However, this credit of up to $300 a year by no means provides sufficient support for informal caregivers. A 2004 Canadian study estimated that the annual cost of a caregiver's time at market rates for moderately to severely disabled home care clients ranged from $5,221 to $13,374, depending on the community in which they reside.10 Expanding the Family Caregiver Tax Credit would help, but the CMA believes that additional support for informal caregivers will also be needed in the coming years.
Also, according to a 2012 World Health Organization (WHO) report on dementia,11 Canada is one of the few members of the G7 without a national strategy on dementia. There is a lack of awareness and understanding of dementia, which results in stigmatization and barriers to diagnosis and care, and has an impact on caregivers, families and societies - physically, psychologically and economically. Canada's aging population, and the projected rise in Alzheimer's disease and related dementias, pose an emerging health crisis that require federal leadership.
The CMA recommends that:
* The federal government, in partnership with the provinces and territories, develop and implement an integrated, pan-Canadian strategy for continuing care, which would integrate home care and facility-based long-term, respite and palliative care services fully within health care systems. Such a strategy would help prepare for the looming demographic change and the address the needs of Canada's aging population.
* A targeted health infrastructure fund be established as part of the federal government's next long-term plan for public infrastructure. The purpose of this fund would be to support communities across Canada in addressing infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times.
* The federal government expand the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates.
* The federal government establish programs to encourage Canadians to save for their long-term care needs by pre-funding long-term care through for example, private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance, such as an RESP-type savings vehicle.
* The federal government develop and implement a national dementia strategy. Such a strategy will contribute to addressing the alternative level of care crisis impacting the efficiency of the overall health care system.
1 OECD Health Data 2012 - http://www.oecd.org/health/healthgrowthinhealthspendinggrindstoahalt.htm
2 CD Howe Commentary Chronic healthcare spending disease: a macro diagnosis and prognosis and
Livio Di Matteo and ROSANNA DI MATTEO, The Fiscal Sustainability of Canadian Publicly Funded Healthcare Systems and the Policy Response to the Fiscal Gap CHSRF series of reports on financing models: Paper 5, January 2012. http://www.chsrf.ca/Libraries/Commissioned_Research_Reports/Dimatteo-Fiscal-E.sflb.ashx
3 KPMG. Competitive Alternatives: KPMG's Guide to International Business Location Costs. 2012 edition
4 The Standing Senate Committee on Social Affairs, Science and Technology Final Report of Senate Subcommittee on Population Health. June 2009.
5 Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceutical 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.
6 Xu K, Evans D, Carrin G, Aguillar-Riviera A. Designing health financing systems to reduce catastrophic health expenditure. Geneva: World Health Organization, 2005.
7 Law MR, Cheng L, Dhalla IA et al. The effect of cost on adherence to prescription medications in Canada. CMAJ February 21, 2012 vol. 184 no. 3
8 Statistics Canada. September 19, 2012. Living arrangements of seniors: Families, households and marital status Structural type of dwelling and collectives, 2011 Census of Population.
9 According to the Canadian Healthcare Association (New Directions for Facility-Based Long-Term care), in 2007 there were 2,577 long-term care facilities in Canada and 217,969 beds. We used the average number of beds per facility to calculate the number of facilities required to meet expected future demand.
10 Chappell, N.L., B.H. Dlitt, M.J. Hollander, J.A. Miller and C. McWilliam. 2004. "Comparative Costs of Home Care and Residential Care." The Gerontologist 44(3): 389-400
The Canadian Medical Association is pleased to take part in the second phase of the study of prescription pharmaceuticals by the Senate Standing Committee on Social Affairs, Science and Technology. During the first phase, we presented the CMA's policy position regarding clinical trials and the process for approving new drugs for use. In this phase we will discuss our position and recommendations on post-approval surveillance of prescription drugs.
The Canadian Medical Association represents 76,000 physicians in Canada. Its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care.
Prescription drugs are a very important part of high quality and cost-effective health care. They can prevent serious disease, reduce the need for hospital stays, replace surgical treatment and improve a patient's capacity to function productively in the community. Therefore, the CMA has developed a substantial body of policy on pharmaceutical issues, including on the post-approval surveillance of prescription drugs.
The essence of our position is contained in our first recommendation:
The CMA recommends that federal and provincial/territorial governments collaborate to develop and implement a national pharmaceutical strategy to ensure that every Canadian has timely access to an adequate supply of safe and effective prescription drugs.
This recommendation has two elements: "safe and effective" and "adequate supply," both of which we will discuss in this submission.
2) Ensuring Safety and Effectiveness
As we have previously told this Committee, the CMA supports a robust regulatory framework and system for researching and approving new pharmaceutical products. But however strong Canada's pre-approval system is, it will not identify all potential problems with a new drug. Pre-approval clinical trials tend to focus on small numbers of patients, and exclude vulnerable groups such as children and the elderly. They also tend to be of short duration, whereas in the real world, patients may take these drugs for years. As a consequence, problems with a drug are often identified only after widespread, long-term use in the general population. For this reason, it is essential that Canada have in place a robust regulatory framework that includes a timely system to monitor the performance of prescription drugs after they come on the market.
The Government of Canada has taken several recent steps to enhance its drug surveillance system. In 2009, it established the Drug Safety and Effectiveness Research Network. In 2008, it introduced Bill C-51, An Act to Amend the Food and Drugs Act, to improve drug safety and effectiveness monitoring by Health Canada. Unfortunately, the bill died with the 2008 election call and has not been re-introduced. That is why we are pleased that the Senate has chosen to re-open this issue.
What would a comprehensive post-approval surveillance regulatory framework and system look like? In order to effectively monitor the safety and effectiveness of the country's drug supply, the CMA believes it should include:
a) Comprehensive processes for gathering drug safety and effectiveness data
In gathering data about adverse drug reactions (ADRs) in Canada, Health Canada has traditionally relied on spontaneous reports from manufacturers and health professionals. The government could enhance its capacity to gather information by:
* making it easier for physicians and other health professionals to report ADRs voluntarily. This can be accomplished by making the reporting system user-friendly and easy to incorporate into a practitioner's busy schedule. Health Canada has improved the process by introducing online reporting, which may have contributed to the significant increase in the number of ADR reports over the past 10 years. The reporting process could be made even more efficient by incorporating it directly into the Electronic Medical Record (EMR) as this is developed.
* augmenting spontaneous reports with information gathered through other, more systematic means. These could include formal post-market studies of specific drugs, or recruitment of "sentinel" groups of health care providers who would contract to report ADRs in detail, and who, because of these contractual obligations, would be committed to assiduous reporting.
b) A capacity for rigorous and timely data analysis to identify significant threats to drug safety.
Information gathering does not in itself constitute post-market surveillance. In our opinion, the most important element of the process is the monitoring and analysis that occurs once an adverse drug reaction (ADR) report has been received.
Monitoring capacity requires rigorous data analysis that can sort "signal from noise" - in other words, sift through the reports, find the ones that indicate unusual events, investigate their cause, and isolate those that indicate a serious health risk. It also requires that the analysis be timely: we note that in 2011 the Auditor General was particularly critical of Health Canada's post-market surveillance timeliness, noting that it could take several years for reports to be reviewed internally.
Post-market monitoring should do more than identify safety risks. It should also provide information about a drug's efficacy and effectiveness. Does it achieve the health outcome for which it is being marketed? Does it perform better than other drugs or therapies for the same condition?
c) Communication of useful information to health care providers and the public.
When new information is uncovered about a prescription drug, it is important that physicians and other health professionals are made aware of it as quickly and efficiently as possible. Therefore, post-approval surveillance requires a system for communicating timely, reliable and objective information to physicians and other health professionals, which they can absorb quickly and incorporate into their everyday practice. Ideally, this communication would report not the safety problem alone but also its implications for their patients and practice: for example, whether some patients are particularly at risk, or whether therapeutic alternatives are available.
The CMA recommends that Health Canada continue to improve the capacity of its post-approval surveillance system to:
* Make it easier for health professionals to submit voluntary ADR reports;
* Analyze the data that has been gathered in a rigorous and timely manner; and
* Communicate essential information to health care providers and the public in a timely and user-friendly manner.
d) Increased regulatory authority for Health Canada
Drug safety is a serious issue; recent research has revealed that nearly a quarter of new drugs approved in Canada will eventually receive a serious safety warning1. Given the potential risks to patient safety we believe Health Canada should have the legal authority to take strong action when a safety problem is identified.
The CMA recommends that Health Canada should be given the authority to:
* require post-market studies of newly approved drugs if clinical trials identify possible safety risks;
* require manufacturers to disclose information if Health Canada thinks it germane to making a decision in the interest of patient safety; and
* take action if post-market research uncovers new safety concerns. This could mean ordering changes to product labels, or pulling a product off the market.
Granting Health Canada this regulatory authority is only the first step. Health Canada should not hesitate to use this authority if the situation warrants.
3) Ensuring an Adequate Drug Supply
In the past few years Canada's doctors have become deeply concerned about the persistent shortages of drugs that they and their patients are encountering. In a survey of physicians conducted by the CMA in September 2012, two-thirds of respondents said that the shortage of drugs was a significant issue in terms of its impact on patient care and outcomes. Of these physicians, 70 per cent indicated that their patient received a less effective medication, and 20 per cent had patients who had suffered clinical deterioration because an alternate drug was substituted. This in turn leads to a greater demand on the health care system, whether in physician visits or emergency room treatments. Twenty-three per cent reported that their patient suffered financially due to the cost of the substituted medication, since many of the drugs in short supply are older, low-cost generics.
The lack of information about shortages compounds the stress of dealing with them. When physicians prescribe a medication, unaware that it is in short supply, they later have to provide the patient with a new prescription, which often requires an additional patient visit. Physicians have expressed their frustration at the time it takes to find an appropriate substitute drug - time which could better be spent in patient care.
As a consequence, the CMA strongly supports the development of a comprehensive system for monitoring domestic shortages of medically necessary drugs. To be of greatest benefit to doctors, such a system should include:
* Information about the product in short supply;
* Expected duration of the shortage;
* Therapeutic alternatives;
* Regions affected;
* Notification of the end of the shortage.
Although pharmaceutical industry associations and drug manufacturers are now supporting a drug shortage reporting website (http://www.drugshortages.ca/drugshortages.asp), there is room for improvement. The reporting website does not yet capture all of the drug product shortages. It must become more user friendly for health practitioners and the public, with search and sort functions to easily find product listings. In addition, a mechanism to obtain information on possible therapeutic substitutions would be of value to practitioners.
The CMA recommends that Health Canada work with provincial and territorial governments, industry groups and health professionals to enhance the current system for reporting drug shortages and ensure its sustainability.
Finally, while a reporting system to provide information to health professionals and Canadians on drug shortages is valuable, it is essential that Canada address the root causes of drug shortages. A review of the supply processes, both domestic and international, is strongly recommended.
While the CMA acknowledges that provinces are responsible for purchasing drugs, we believe that solutions will be stronger if all provinces, and the federal government, work together on them. And since drug shortages are an international concern, it is the responsibility of the Government of Canada to work with other countries in seeking solutions.
The CMA supports an investigation into the underlying causes of prescription drug shortages in Canada.
4) Other Important Elements of a National Pharmaceutical Strategy
As Recommendation 1 states, the CMA believes that Canada's federal and provincial/territorial governments should implement a national pharmaceutical strategy, one of whose objectives would be to ensure an adequate supply of prescription drugs. The strategy should address other important objectives, as well, notably:
* ensuring comprehensive prescription drug coverage for all Canadians. According to a recent CMA survey, one in 10 Canadians has gone without a prescription drug because they couldn't afford it. Governments should work with private insurers and other stakeholders to develop a system to provide equitable, comprehensive prescription drug coverage to all Canadians.
* encouraging optimal prescribing by health professionals. To accomplish this, the CMA has recommended a strategy that includes education, user-friendly guidelines and practice tools, and the provision of impartial information to health professionals and the public.
Once again, we commend the Senate Social Affairs Committee for bringing this issue to your table. Canada's physicians are prepared to work with governments, health professionals and the public in strengthening Canada's post-approval surveillance system, to ensure that the prescription drugs Canadians receive are safe and effective and in adequate supply.
1 Lexchin J. New drugs and safety: what happened to new active substances approved in Canada between 1995 and 2010? Arch Intern Med. 2012;():1-2. doi:10.1001/archinternmed.2012.4444.
Question 1: Economic recovery and growth (What federal measures are required for sustained economic recovery and growth?)
The health sector has an important role in sustaining Canada's economic recovery and enhancing economic growth beginning with supporting a healthy and productive workforce and providing over one million high value jobs, representing about 10 per cent of the labour force.
Despite the importance of the sector, there is general agreement that Canada's health care system is no longer a strong performer when compared to similar nations. While the OECD's 2011 Health Data ranks Canada 7th highest of 34 member states in per capita health care spending, the performance of Canada's health care system continues to rank below most of our comparator countries.
Health spending accounts for an increasing proportion of provincial and territorial budgets, and many warn of increasing future demands on the overall system. In his Economic and Fiscal Outlook Report of May 17, 2012, the Parliamentary Budget Officer stated that "the provincial-territorial long-term fiscal situation has deteriorated." Taken together, these issues highlight significant potential for the health sector, through efficiency improved gained by health care transformation, to support long-term economic recovery and growth in Canada.
While the provinces and territories have initiated positive steps to collaborate on sharing best practices, there are key responsibilities under federal leadership that would contribute to these efforts by addressing the overall performance of the health care system in Canada. The CMA recommends that:
- The federal government recognize the relationship of the social determinants of health on the demands of the health care system and that it implement a requirement for all cabinet decision-making to include a Health Impact Assessment (see Question 5 for more detail).
- Further to the comments by the Health Minister following the new fiscal arrangement announcement, the federal government should prioritize federal-provincial-territorial engagement focused on accountability and undertake a consultative process with the aim of identifying pan-Canadian metrics and measurement that will link health expenditures and comparable health outcomes.
Question 2: Job creation (What federal actions should be taken to promote job creation in a context of enhanced internal and international trade?)
A high performing health care system across the country will help support labour mobility and job creation. An effective, comprehensive public health care system provides an important international competitive advantage. The contribution of Canada's health care system to the international competitiveness of our economy has been repeatedly demonstrated in KPMG's Competitive Alternatives report.
However, there are several signs that indicate health care services and coverage are not keeping up with Canadians' needs and vary depending on where one lives in Canada. For instance, long wait times for medical care can be found in smaller provinces, while drug coverage and services for seniors are particularly poor in Atlantic Canada. Wide variation in access to pharmaceutical treatments remains the most glaring example of inequity in our health care system-all Canadians should have a basic level of drug coverage. These variations are growing and will hinder job creation in some regions, serving as barriers to labour mobility for Canadians wishing to seek work elsewhere in the country. We believe that Canadians would be better served if federal health care transfers came with specific guidelines ensuring that the system provides care of comparable access and quality to Canadians across the country, regardless of their circumstances.
Recognizing the contribution of the health care system to Canada's international competitive advantage, improvements in Canada's health care system would further support job creation. The federal government should focus its efforts towards supporting the transformation of our health care system to better meet the objectives of better care, better health and better value. The CMA recommends that:
- The federal government, in consultation with provincial, territorial and other stakeholders, 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 drugs.
- The federal government, together with the provinces and territories, develop and implement a pan-Canadian strategy for continuing care which would integrate home care and facility- based long-term, respite and palliative care services fully within health care systems.
Question 3: Demographic change (What federal measures should be implemented to help address the aging population and skills shortages?)
The CMA remains concerned about the status of Canada's retirement income system and the ability of Canada's seniors to adequately fund their long-term and supportive care needs. Steps need to be taken to ensure that Canada is prepared to handle the long-term care needs of its citizens, including the funding of necessary infrastructure and additional support for both health care providers and informal caregivers.
The availability of long-term care facilities has an important role in the efficiency of the overall health care system. For example, in its most recent report, the Wait Time Alliance noted that dementia is a key diagnosis related to the rise in alternate-levels-of-care (ALC) patient stays in hospitals. This is yet another issue facing all provinces and territories for which the federal government is well positioned to coordinate a pan-Canadian strategy. In addition, as part of the next long-term infrastructure program, the federal government should include a targeted health sector infrastructure fund for long-term care facilities as part of a pan-Canadian strategy to redirect care from the hospitals to homes, communities and long-term care facilities, where better care is provided at a lower cost.
The CMA recommends that:
- The federal government establish programs to encourage Canadians to save for their long- term care needs by pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance, such as an RESP- type savings vehicle.
- That a targeted health infrastructure fund be established as part of the government's long- term plan for public infrastructure. The purpose of this fund would be to address infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times.
The CMA has supported the federal government's efforts to expand retirement savings options by establishing the Pooled Retirement Pension Plans. However, as highlighted by federal, provincial and territorial finance ministers, this is only one component of a larger pension reform framework to address the retirement income adequacy needs of Canadians. The CMA encourages the federal government to continue working with the provinces, territories and stakeholders to implement all elements of this framework.
Question 4: Productivity (What federal initiatives are needed to increase productivity in light of labour market challenges such as the aging of Canada's population?)
An effective and comprehensive health care system supports the productivity of the Canadian workforce. Failure of our health care system to respond to workers' health needs, on the other hand, leads to loss of productivity and high costs both in terms of lost income for Canadian families as well as foregone tax revenues for governments. Numerous studies have pointed out the enormous cost of waiting (in the billions of dollars per year) affecting both individuals and the economy.
Another related issue that has the potential to increasingly affect productivity is the burden of providing care to family members. Without adequate provision of long-term care resources and support for home care, Canada's labour force may experience a productivity drag through increased leaves and absenteeism to care for elderly relatives.
The 2011 federal budget took a first step at providing tax relief for informal caregivers through the Family Caregiver Tax Credit. However, this credit of a maximum of $300 per year by no means provides sufficient support for informal caregivers.
A 2004 Canadian study estimated that the annual cost of a caregiver's time at market rates for moderately to severely disabled home care clients ranged from $5,221 to $13,374 depending on the community in which they reside. An increase to the Family Caregiver Tax Credit is positive for the development of one aspect of the necessary support informal caregivers require but the CMA believes other enhancements will also be needed in the coming years.
In order to meet the needs of our country's aging population, the CMA recommends that:
- The federal government expand the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates.
- That a targeted health infrastructure fund be established as part of the government's long-term plan for public infrastructure. The purpose of this fund would be to address infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times.
Question 5: Other challenges (Who is facing most challenges, what are they and what federal action is required?)
Despite significant investments in health and improvements in medical treatment and technologies, health outcomes in Canada have not been moving in the right direction. Chronic diseases such as diabetes and the corresponding risk factors, among them obesity, continue to rise. These negative outcomes can have a significant impact on the prosperity of the country as health is necessary for individuals to lead a prosperous and autonomous life. Research suggests that 50 per cent of population health is determined by our social and economic environment. While a strong health care system is vital, changes to medicare alone will not improve health outcomes or reduce the disparities that currently exist in disease burden and health risks.
What is needed is a process to address the social determinants of health that can be barriers or enablers to health, a process to ensure healthy public policy for all Canadians. A Health Impact Assessment (HIA) is a systematic process for making evidence-based judgments on the health impacts of a policy and to identify and recommend strategies to protect and promote health. HIA is used in several countries, including Australia, New Zealand, Norway, the Netherlands and the United States. HIA is also used in Canada, most extensively for policy appraisals in Quebec.
HIA is necessary for ensuring that all government departments are able to consider the health impacts of their work. Such a tool would have been very beneficial in assessing cuts to program spending to ensure the impact on health would not be counterproductive (i.e., lead to higher overall costs to society once the health impact is taken into account). The adoption of an evidence-based HIA is one way in which the federal government can play a leadership role in health care. The CMA recommends that:
- The federal government include a Health Impact Assessment as part of its policy development process to ensure that the health of Canadians is a key factor in every policy decision it makes.
- The federal government recognize the relationship of the social determinants of health on the demands of the health care system.
Thank you for this opportunity to appear before this committee on behalf of the CMA and its 76,000 members. Canadians believe that transforming our health care system to meet the needs of 21st century Canada must be among the highest priorities for all levels of government, including the federal government.
I would like to begin by commenting on the health transfer framework announced by the Minister of Finance in December. This announcement provided some predictability for the years ahead.
However, with the federal government reducing its involvement in several areas affecting health or health care, added costs will end up in the laps of the provinces and territories.
So while this budget may enhance the federal government's fiscal prospects, it will do so to the detriment of the provinces and territories.
But there's more to this debate than funding. We believe that Canadians would be better served if federal health care transfers came with specific guidelines ensuring that the system provides care of comparable access and quality to Canadians across the country, regardless of their circumstances.
We are encouraged that the Minister of Health has indicated she wants to collaborate with the provinces and territories on developing accountability measures to ensure value for money and better patient care. We look forward to the
minister's plan for accountability.
This budget is notable for other missed opportunities. For many years, groups across the political spectrum have called for a pharmaceutical strategy to reduce national disparities. In fact, such a strategy was committed to by governments under the 2004 Health Accord.
Minister Kenney referred to this issue indirectly when he said the recent cancellation of supplemental health benefits for refugee claimants is justified because refugees should not have access to drug coverage that Canadians do not have.
Rather than cutting off those desperately vulnerable people, Canada's physicians urge the federal government to work with the provinces and territories to develop a plan that ensures all Canadians have a basic level of drug coverage.
Indeed, we now appear to be in a race to the bottom in the way we treat vulnerable groups - by, for example, deferring Old Age Security for two years; and changing service delivery to veterans, mental health programs for our military and the Employment Insurance program.
Significant policy changes have been announced since the budget, with little opportunity for debate and little evidence provided. We note, as well, the lack of open consultation with Canadians on matters of great import to their lives. Successful policy requires buy-in, which is best achieved when those interested are able to participate in the policy-making process.
This brings me to a wider concern shared by our members - that policy-makers are not paying adequate attention to the social determinants of health, factors such as income and housing that have a major impact on health outcomes. We remind the government that every action that has a negative effect on health will lead to more costs to society down the road.
The federal government is the key to change that benefits all Canadians. While there are costs and jurisdictions to consider, the CMA believes the best way to address this is to make the impact on health a key consideration in every policy decision that's made. The federal government has used this approach in the past, in considering rural Canadians, for example.
We therefore call for a new requirement for a health impact assessment to be carried out prior to any decision made by cabinet. This would require that, based on evidence, all cabinet decisions take into account possible impacts on health and health care, and whether they contribute to our country's overall health objectives. A similar model is in use in New Zealand and some European countries.
For instance, what health impact will cuts in funding to the tobacco strategy have?
Such an assessment would in particular have a dramatic impact with regard to poverty. Poverty hinders both human potential and our country's economic growth - and needlessly so as there are many ways to address it effectively.
The National Council on Welfare - which will disappear as a result of this budget - reported last fall that the amount it would have taken in 2007 for every Canadian to have an income over the poverty line was $12.6 billion, whereas the consequences of poverty that year added up to almost double that figure.
Close to 10 per cent of Canadians were living in poverty in 2009, many of them children, as UNICEF underlined yesterday. This is a huge challenge for our country.
In closing, as this budget cycle ends and as you begin to prepare for the next, please bear in mind that as prosperous as our country is, if we do nothing for the most vulnerable in our society - children, the elderly, the mentally ill, Aboriginal peoples - we will have failed.
Bill C-38 covers a lot of ground and we welcome the occasion to discuss it.
Right at the outset, let me remind you that the Canadian Medical Association has a long tradition of staunch non-partisanship. Our mandate is to be the national advocate for the highest standards in health and health care.
In a bill as wide-ranging as this one, there is a great deal I could talk about. In the time allotted, however, I am going to frame my brief remarks around three themes... namely:
First, what is very clearly in the bill;
Second, what is lacking in the bill, and
Third, what I would characterize as a general lack of clarity and consultation on certain aspects of the federal government's actions on health care.
First, I will comment on one of the key measures contained in the budget bill.
We are greatly concerned about the move to raise the age of eligibility for Old Age Security.
Many seniors have low incomes and delaying this relatively modest payment by two years is certain to have a negative impact.
For many older Canadians, who tend to have more complex health problems, medication is a life line. We know that, already, many cannot afford their meds.
Gnawing away at Canada's social safety net will no doubt force hard choices on some of tomorrow's seniors... the choice between whether to buy groceries or to buy their medicine.
I think it is safe to say it would not hold up to a cost-benefit analysis.
People who skip their meds, or lack a nutritious diet or enough heat in their homes, will be sicker.
In the end, this will put a greater burden on our health care system.
Let me now turn to a couple of things we were hoping to see in the budget but that are not there.
As we all know, the Finance Minister announced the government's plans for the Canada Health Transfer in December.
The CMA was encouraged when the Minister of Health subsequently spoke about collaborating with the provinces and territories on developing accountability measures for this funding.
We look forward to this accountability plan for the minimum of $446 billion that will flow to the provinces and territories in federal transfers for health over the next twelve years.
In both 2008 and 2009, the Euro-Canada Health Consumer Index ranked Canada last out of 30 countries in terms of value for money spent on health care.
We believe that federal government should lever its spending on health care to bring change to the system.
It could introduce incentives, measurable goals, pan-Canadian metrics and measurement that would link health care spending to comparable health outcomes.
This would recognize, too, that the federal government is itself the fifth-largest jurisdiction in health care delivery.
We believe the federal government has a role to play in leading this change and that transferring billions of federal dollars in the absence of this leadership shortchanges Canadians.
This budget thus represents an opportunity lost to find ways to transform the health care system and help Canadians get better value and better patient care for the money they spend on health care.
The other major piece missing from this budget is any move to establish a national pharmaceutical strategy.
A pharmaceutical strategy that would ensure consistent coverage and secure supply across the country remains unfinished business from eight years ago.
Access to pharmaceutical treatments remains the most glaring example of inequity of our health care system.
I should point out that the Senate Social Affairs Committee in its recent report on the 2004 Health Accord also recommended the implementation of a national pharmaceutical strategy.
Now I come to the third part of my remarks, which is about a general lack of clarity in regard to certain aspects of the federal government's responsibilities vis-a- vis health care.
Since the budget was tabled, the federal government has announced $100 million in cuts to the Interim Federal Health Program and eliminated the National Aboriginal Health Organization.
As far as we know, no one was consulted on these changes, and since they are not in the budget bill, there is no opportunity for debate on the potential implications on the health of Canadians.
We are also uncertain about the impact of changes in service delivery at Veterans Affairs Canada, changes in the mental health programs at the Department of National Defence, and plans to consolidate some of the functions of the Health Canada and the Canadian Public Health Agency.
There are many unknowns and these are serious matters that warrant serious consideration.
The government committed that it would not balance the books on the backs of the provinces, yet there appears to be a trend toward the downloading of health care costs to federal client groups or the provinces and territories or individuals.
As we have seen in the past, cost downloading is not the same as cost saving.
In fact, when health is impacted, the costs will be inevitably higher, both in dollars and in human suffering.
A Doctor for Every Canadian - Better Planning for Canada's Health Human Resources: The Canadian Medical Association's brief to the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities - Addressing Existing Labour Shortages in High-Demand Occupations
The Canadian Medical Association (CMA) is pleased to present this brief for consideration by the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities as part of its current study, Fixing the Skills Gap: Addressing Existing Labour Shortages in High Demand Occupations.
The health sector provides essential services and high value jobs supporting communities across Canada. Statistics Canada reports that employment in the health sector accounts for 10 per cent of the Canadian labour force.i Beyond the renewed commitment for the long-term fiscal arrangement for health care, Canada requires a pan-Canadian approach to health human resources planning to achieve self-sufficiency in health human resources. This submission focuses on physicians and proposes action at the federal level to begin to address specific shortages and ensure a needs-based specialty mix distribution and self-sufficiency for our country.
Health Care Transformation
In 2010, the CMA initiated a cross-country consultation with Canadians on the future of the health care system. Based on that input, the CMA, together with the Canadian Nurses Association, developed six principles to guide health care transformation. These principles have since been endorsed by over 100 medical, health and patient organizations.
One of the principles is sustainability. Sustainable health care requires universal access to quality health services that are adequately resourced and delivered along the full continuum in a timely and cost-effective manner. Addressing health human resource shortages is critical to ensuring a sustainable, accessible and patient-centred health care system.
The principles outline a vision to ensure adequate health human resources: health care will be delivered within collaborative practice models; pan-Canadian eligibility for licensure will support inter-provincial portability of all health care providers; and health human resource planning will align with communities in the short, medium and long term. In fulfillment of this vision, this submission will focus on:
* Ensuring a needs-based specialty mix;
* Targeting health infrastructure investment to optimize the supply of health human resources; and
* Foreign credential recognition.
Canada's experience with physician shortages dates back to the mid-1990s following significant cuts to first-year medical school enrolment. While there have been substantial increases since then, it took a decade to rebound. In 2010, first-year enrolment stood at 2,830 - 80 per cent higher than the mid-1990s.ii
Despite these significant gains, Canada's supply of physicians relative to our population is well below the Organization for Economic Co-operation and Development (OECD) average.iii Indeed, with the seventh-lowest supply of physicians per capita among OECD nations, Canada ranks below the European Union nations and the United States.
Currently, between four million and five million Canadians do not have a family physician. Over one-third of all Canadian physicians are over the age of 55. Many will either retire soon or reduce their practice workload. Many physician practices are at capacity and unable to take on new patients.
Findings from the CMA's 2012 survey of provincial-territorial medical associations (PTMAs) with respect to physician resources underscore the pressing need for a pan-Canadian approach to health human resources planning.iv While all jurisdictions in Canada are experiencing challenges, shortages by type of practice vary by jurisdiction.
Issue 1: Needs-based Specialty Mix
A sustainable health care system requires health human resource planning to ensure an appropriate specialty mix. At present, there is no pan-Canadian system to monitor or manage the specialty mix. The findings from the 2012 CMA survey of PTMAs revealed that only three jurisdictions have a long-term physician resource plan in place, while only one jurisdiction employs a supply and needs-based projection model.
To illustrate the consequences of the lack of monitoring and management of the physician specialty mix, from 1988 to 2010, the numbers of post-graduate trainee positions in geriatric medicine were essentially constant at only 18 positions, while the number of trainees in pediatric medicine increased by 58 per cent.v
It has been almost four decades since the federal government has completed a needs-based projection of physician requirements in Canada. The last federally commissioned study, the Report of the Requirements Committee on Physician Manpower to the National Committee on Physician Manpower, was published by the Minister of National Health and Welfare in 1975.
The CMA recommends that the federal government, in collaboration with medical organizations, lead a benchmark study on the current specialty mix in Canada, as well as a supply and needs-based projection to support health human resources planning.
Issue 2: Targeted Health Infrastructure
Adequate health infrastructure is an important element in optimizing the capacity of health human resources. Health infrastructure shortages have been reported as a limiting factor on physician resources.
For example, the recruitment of specialists and sub-specialists is being affected not by a lack of demand for their services, but, rather, by the limitations of existing hospital infrastructure, such as operating rooms. This too has been revealed by the CMA's 2012 survey of PTMAs.
Ensuring there is sufficient health infrastructure to optimize the current capacity of health human resources would no doubt help address Canada's persistent problems with wait times.
The CMA recommends that a targeted health infrastructure fund be established to address infrastructure shortages that prevent the optimization of health human resources and exacerbate wait times.
Issue 3: Foreign Credential Recognition
The CMA recognizes the federal government's commitment to address foreign credential recognition and that physicians are among the target group for 2012. The medical profession is well positioned to support the federal government's objective. Under the auspices of the National Assessment Collaboration, a group of federal, provincial and other stakeholders, the medical profession is currently working to streamline the evaluation process for international medical graduates (IMGs) licensure in Canada.
Related to this effort, the pan-Canadian portable eligibility for licensure is an important issue in health human resources, especially for physicians. The CMA and the medical professional have been active in this important issue for many years.
In 1992, the Federation of Medical Licensing Authorities of Canadavi adopted a national standard for portable eligibility for licensure. In 2009, the Federation of Medical Regulatory Authorities adopted an agreement on national standards for medical registration in Canada that reflects the revised labour mobility chapter of the Agreement on Internal Trade. FMRAC and the Medical Council of Canada are working on a one-stop process for IMGs to apply for licensure in Canada (with support from Human Resources and Skills Development Canada).
The CMA fully supports bringing into practice qualified IMGs already in Canada. Canada has historically benefited from a steady flow of IMGs to our country. In fact, close to one-quarter of all physicians in Canada are IMGs.
While IMGs may be seen as a key strategy to addressing shortages in Canada, actively recruiting from developing countries is not an acceptable solution to our physician shortage. Canada must strive for greater self-sufficiency in the education and training of physicians. In fact, self-sufficiency is a key principle of the Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources' Framework for Collaborative Pan-Canadian Health Human Resources Planning.vii
The CMA recommends that the federal government continue to support the efforts of medical organizations to promote the pan-Canadian portable eligibility of licensure.
The CMA recommends that the federal government continue to support efforts of medical organizations to streamline the process of credential verification and assessment of eligibility of licensure for IMGs.
Despite progress in addressing the shortage of physicians in Canada, serious challenges in health human resources persist. At present, few jurisdictions engage in health human resources planning. Further, despite changing shifting demographics, it has been almost four decades since the federal government has completed a study of physician requirements. Canada requires a pan-Canadian approach to ensure adequate health human resources in support of a sustainable health care system.
Summary of Recommendations
CMA recommends that the federal government, in collaboration with medical organizations, lead a benchmark study on the current specialty mix in Canada, as well as a supply and needs-based projection to support health human resources planning.
The CMA recommends that a targeted health infrastructure fund be established to address infrastructure shortages that prevent the optimization of health human resources and exacerbate wait times.
The CMA recommends that the federal government continue to support the efforts of medical organizations to promote the pan-Canadian portable eligibility of licensure.
The CMA recommends that the federal government continue to support efforts of medical organizations to streamline the process of credential verification and assessment of eligibility of licensure for IMGs.
i 2006 Census data
ii Association of Faculties of Medicine of Canada. 2010. First Time Enrolment in Canadian Faculties of Medicine by Faculty of Medicine, 1994/95-2010/11.
iii OECD. OECD Health Data 2011. Available at: http://www.oecd.org/document/60/0,3746,en_2649_33929_2085200_1_1_1_1,00.html
iv CMA. Results of PTMA Physician Resource Interviews.
vi Since renamed the Federation of Medical Regulatory Authorities of Canada.
vii Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources. 2009. How Many Are Enough? Redefining Self-Sufficiency for the Health Workforce A Discussion Paper.
Good afternoon. My name is Dr. Maura Ricketts and I am the Director of Public Health for the Canadian Medical Association. The CMA appreciates the opportunity to appear before this Committee today as part of your study of clinical trials and drug approvals.
The CMA represents more than 76,000 physicians in Canada. Its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with all Canadians, for the highest standards of health and health care.
Because prescription drugs are an essential component of health care, the CMA has developed a considerable body of policy on pharmaceutical issues. This work can be distilled into one fundamental principle: The CMA believes that our country requires a National Pharmaceutical Strategy to ensure every individual has timely access to safe, effective and affordable prescription drugs. Despite the commitment in the 2004 Health Accord to the creation of such a strategy, Canadians continue to wait for government leadership on this issue. Drugs replace more costly and invasive medical interventions. They are an essential tool in the physician's tool box.
To ensure safety and effectiveness, the CMA also believes in the need for a strong, unbiased, evidence-based system for research and approval. This is at the heart of our commitment to patient-centred care.
In evaluating whether to prescribe a new drug to a patient, a physician will weigh several factors: Does this product offer any benefits over what I am prescribing now? Will it be more effective? Will this new drug be safer? Will it solve any tricky clinical problems, such as drug interactions, or reduce side effects that prevent a medication from being used properly? The physician may also ask: What is the evidence that this new drug is an improvement? Can I trust the evidence? Where can I get access to accurate, reliable information and data on this drug?
Pre-approval drug research must provide answers to these fundamental questions.
I will now focus on two particular issues of concern to practising physicians with regard to clinical trials:
* First, what is being compared to what? Clinical trials may be sufficient for Health Canada's regulatory purposes, but may provide only part of the information a physician needs. For example, is a new cholesterol drug effective on all patients, or only on some of them? Would other patients derive equal benefit from an already existing drug, or from a lifestyle change such as diet or exercise? The CMA recommends that researchers compare a new product to other drugs on the market - and to other interventions, as well.
* Second, is timely, reliable and objective information available on all clinical trial results, not just the positive ones? Canadians need to be informed when a drug has performed disappointingly in trials if they are to make informed decisions about their health care. The CMA, therefore, recommends the results of all clinical trials, not just those with positive results, be made available to health professionals and the public.
I would like to add that the current documentation is not very user-friendly. We recommend that Health Canada prepare summaries of the most essential data, not only for physicians, but for all Canadians to be able to access this information.
The Drug Approval Process
Turning now to the drug approval process, the CMA believes the following principles should apply:
* The primary criteria for approval should be whether the drug improves health outcomes and offers an improvement over products currently on the market.
* The review process should be as timely as is consistent with ensuring optimal health outcomes and the safety of the drug supply.
* The review process should be impartial and founded on the best available scientific evidence.
* The review process should be open and transparent.
* Finally, approval of a drug is not an endpoint, but rather one step in that drug's life cycle. It is not uncommon to identify serious safety hazards after a drug has been approved, because that's when it first goes into wide use. It is important that the approval process be complemented by a rigorous and vigilant post-market surveillance process. We look forward to presenting our recommendations on this subject to your Committee at a future session.
Before closing, I would like to briefly address two other matters:
First, the issue of drugs for rare disorders. We are aware that the current clinical trial and approval processes, which place a high value on studies with large population samples, may be unable to adequately capture the value of drugs that are prescribed to only a handful of people. Some patient groups active in the area of rare disorders, such as the Canadian MPS Society and Alpha-1 Canada, have shared their concerns about this with us. These groups, along with the Canadian Organization for Rare Disorders, have been advocating for years for a fair process for evaluating drugs for rare diseases. Because Canada doesn't have a rare disorders strategy, Canadian patients have access to fewer therapies than patients in other developed countries. The issue of how to approve drugs for rare disorders merits closer consideration. The CMA recommends that the federal government develop a policy on drugs for rare disorders that encourages their development, call for ongoing evaluation of their effectiveness, and ensures fairness so that all patients who might benefit have reasonable access to them.
The second matter is that Health Canada's review process provides little guidance on another question which physicians are increasingly asking: Can my patient afford this drug? It is not sufficient that the Common Drug Review conducts reviews of the cost effectiveness of drugs and that provincial/territorial formularies undertake similar studies, as the fact remains that cost is one of the factors physicians need to consider when deciding whether to prescribe a new drug. This is especially true in the case of new biologics, which are very expensive. Canadian doctors believe that the difficulty of making effective prescribing decisions without information about cost needs to be overcome. This only underscores the necessity of a National Pharmaceutical Strategy.
Thank you. We would be happy to answer your questions.
The Canadian Medical Association (CMA) is pleased to provide this submission to the House of Commons Health Committee for consideration as part of its study on drug supply in Canada. The severe impact of the disruption in production at one pharmaceutical company's manufacturing facility has demonstrated the significant shortcomings in how drug shortages are managed in Canada. This submission focuses on what is needed to ensure Canada's health care system delivers patient-centred care.
In order to deliver the best possible care to patients, physicians require timely, comprehensive and accurate information about current and anticipated drug supply shocks and constraints. With this objective in mind, we have provided input to the government and to the pharmaceutical industries. Further, Canada requires an uninterrupted supply of medically necessary medication for patients.
Impacts on Patients and the Health Care System
Canada's doctors are deeply concerned about the persistent shortages of drugs that they and their patients are encountering. Prescription drugs can prevent serious disease, reduce hospital stays, replace surgical treatment and improve a patient's capacity to function productively in the community. Pharmaceuticals benefit the health care system by reducing costs in other areas such as hospital stays and disability payments. Disruptions in the supply of pharmaceuticals can impact patient care, patient health and the efficiency of the overall health care system.
At the CMA, patient organizations are telling us about the anxiety, pain and harm that drug shortages are inflicting on patients. Below are excerpts of these experiences:
* According to the Brain Injury Association of Canada: "Any drug medication shortage endangers Canadian patients. In the brain injury community, anti-depressants are prescribed to some, as is pain medication, so if there is a shortage some members in the community will be endangered even if the medication is altered."
* The interim-president of the Canadian Arthritis Patient Alliance, Louise Bergeron, wrote CMA to say: "Actually, I have had this happen to me on three occasions and it is quite scary when you know you will not have access to certain drugs for an extended period of time, since you know your health will be on the line."
* Sharon Baxter, Executive Director, of the Canadian Hospice Palliative Care Association, says: "All are encouraging the government to find a solution very quickly as pain medication at the end of life is essential and urgent. I don't think we are at the stage where people are dying without access, but getting to that end is totally unacceptable in a country like Canada."
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 when alternate therapies are used; and
* increased non-compliance when patients, particularly those on long-term therapy, find it harder to comply with a new medication regime.
Any one of these situations can impact patient health, particularly in patients with complex problems. In many instances, this in turn leads to a greater demand on the health care system, whether in physician visits or emergency room treatments.
In a survey of physicians conducted by the CMA in 2011, two-thirds of respondents said that the shortage of generic drugs had had negative consequences for their patients or practice.
Of these physicians, 22 per cent indicated that the consequences were that their patient suffered clinical deterioration because an alternate drug was substituted. Similarly, in a survey of pharmacists by the Canadian Pharmacists Association in 2011, 69 per cent of respondents indicated that they believed that patients' health outcomes had been adversely affected by drug shortages.
Notably, of the physicians who indicated the shortage of generics resulted in consequences to their patients or practice, 28 per cent reported that their patient did not fill the substitution prescription due to the cost of the medication. Numerous respondents raised concerns about the financial impact of substitute medications on patients.
Survey responses also shed light on the increased demand on the health care system created by the lack of information on drug shortages provided to physicians. When physicians are not made aware of a drug shortage, and prescribe that medication, they later have to provide the patient with a new prescription, which often requires an additional patient visit. Better informing physicians about drug shortages can reduce demand on the health care system by eliminating the inefficiencies associated with drug shortages.
Scope of Drug Shortages
In an attempt to outline the scope of the problem, the Canadian Agency for Drugs and Technologies in Health (CADTH) stated that:
"It is difficult to quantify and determine the extent of drug shortages in Canada because manufacturers are not required to report disruptions in drug supply to Health Canada and because there is no single accountable Canadian organization that provides system-wide drug distribution oversight."i
Surveys by the CMA and the Canadian Pharmacists Association (CPA) shed light on the lack of drug shortages management in Canada. Taken together, the results of these surveys paint an alarming picture of drug shortages management in Canada and underscore the need to improve our system.
In terms of notification, the majority of physicians and pharmacists indicated they never (51 per cent and 29 per cent) or infrequently (32 per cent and 33 per cent) receive advance notice of shortages. Ironically, given the high proportion of pharmacists reporting they never or infrequently receive notice, 65 per cent of physicians indicated that they receive notification from pharmacists. Meanwhile, 30 per cent of physicians also indicated that they were notified of drug shortages by their patients.
Alarmingly, 81 per cent of the pharmacists surveyed indicated they had trouble locating medications to fill a prescription during their last shift prior to completing the survey and 93 per cent had difficulty over the week prior.
This is not a new problem, but since we surveyed CMA members in the fall of 2011, the situation has worsened. Currently about 250 medications are listed on Canadian drug shortage websites. Before the dire impact of the loss of production at Sandoz, Canadian hospitals were already dealing with shortages in the supply of sterile injectables - critical in specialties like surgery, oncology and anesthesia.
What Canada's Doctors Require to Provide Care
Physicians have expressed their frustration at the time it takes to find an appropriate drug for substitution - time taken from the physician, the pharmacy and the patient. Time better spent with patients is being used by physicians to work with pharmacists to identify alternative drugs and therapies.
Of greatest concern are those drugs that are single sourced. When single source medications are in short supply, there are no clear substitutes. The impact of this is being felt now in hospitals across the country as they grapple with the loss of numerous Sandoz products and are forced to ration the remaining stock.
The majority of physicians surveyed by the CMA indicated that greater knowledge of drug supply issues would allow them to deliver better patient care.
To this end, the CMA strongly supports the development of a comprehensive system for monitoring and responding to domestic shortages of medically necessary drugs. Canada needs a sustainable, adequately resourced system to: identify shortages, rapidly and proactively inform health care professionals, and respond quickly to allocate supply as needed to resolve shortages.
The CMA has provided input to both industry and government on the key information needs of doctors. These are:
* Information about the product in short supply;
* Expected duration of the shortage;
* Therapeutic alternatives;
* Regions affected;
* Notification of the end of the shortage.
While the recent establishment of the online inventories by the pharmaceutical industry associations marks an improvement in Canada's management of drug shortages, significant issues remain to be addressed. These include the need for: complete and more consistent information; automatic notifications to alert physicians, pharmacists and other health care providers; a mechanism to prevent potential disruptions; and a mechanism to seek new or interim sources of supply during a shortage.
The CMA recognizes that other countries are also grappling with drug shortages. Canada must also work with its partners abroad to find an international solution to this phenomenon.
Drug shortages management in Canada has significant shortcomings that impact patients, doctors and the health care system. With the current shortage of injectable drugs teetering on the verge of a crisis, quick action and cooperation are required to address the supply shock.
The CMA calls on Members of Parliament to exercise leadership to ensure that Canada's health care providers have access to the information necessary for them to care for their patients, and that Canadians have access to medically necessary drugs.
i Canadian Agency for Drugs and Technologies in Health. (2011) "Environmental Scan: Drug Supply Disruptions." Ottawa: CADTH, accessed online at: http://www.cadth.ca/media/pdf/Drug_Supply_Disruptions_es-18_e.pdf, 1.
The Canadian Medical Association (CMA) supports the Government of Canada's efforts to improve Canada's retirement income system, specifically by establishing a legislative framework to permit pooled registered pension plans (PRPPs) as proposed in Bill C-25, the PRPP Act.
The CMA has long supported the Government of Canada's efforts to expand access to pensions, including by permitting PRPPs. However, the CMA is concerned that as currently proposed, Bill C-25 limits the potential for PRPPs to expand the access to, and investment in, pensions of self-employed individuals.
The CMA has participated in, and made recommendations to, Finance Canada over the course of the department's multi-year consultative process, including responding to the 2010 consultative paper Ensuring the Ongoing Strength of Canada's Retirement Income System. The CMA has also made recommendations to Finance Canada as a member of the Retirement Income Improvement Coalition (RIIC), which consists of 11 national professional associations representing over 1 million self-employed professionals. The following discussion and recommendations align with those previously made by the CMA and the RIIC.
The pension framework is a critical issue to CMA's membership of over 76,000 physicians. In addressing the pension framework, including permitting PRPPs, two principles are central to the CMA's membership: to ensure that self-employed Canadians can retire with an appropriate level of retirement income (e.g., a target of 70% of pre-retirement income); and, to expand the retirement savings options that are available to self-employed Canadians.
The CMA's comments herein, and recommendations to the Finance Committee to amend Bill C-25, are in support of these two principles. As elaborated below, the CMA encourages the Finance Committee to:
1. Amend Bill C-25 to raise the combined limit for RRSPs and PRPPs in order to increase the retirement savings capacity of self-employed individuals.
2. Amend Section 12(1) of Bill C-25 to expand the PRPP framework so it includes defined benefit and targeted benefit pension plans, which provide more secure savings vehicles than defined contributions plans.
3. Ensure the eligibility clauses of Bill C-25 (Sections 14-26) would allow well-governed professional organizations that represent a particular membership to be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members.
1. Increase the combined contribution limit
It is our understanding that the core benefit of the proposed PRPP framework is in providing smaller businesses access to low-cost pension plans, thereby providing a vehicle to encourage employers to establish, and contribute to, pensions for their employees. However, as explained by the Explanatory Notes accompanying the proposed Income Tax Act amendments, "an employer's contributions to an individual's PRPP account [and...] an individual's PRPP contributions in a taxation year will immediately reduce the individual's ability to make deductible RRSP contributions in that same year." While the CMA recognizes the value of, and supports, this objective, this proposal in effect maintains the status quo for self-employed individuals.
Like the Canadian population at large, physicians represent an aging demographic - 38% of Canada's physicians are 55 or older - for whom retirement planning is an important concern. In addition, the vast majority of CMA members are self-employed physicians and, as such, they are unable to participate in workplace registered pension plans (RPPs). At present, physicians are more reliant on registered retirement savings plans (RRSPs) relative to other retirement savings vehicles.
While individuals with employer contributions stand to benefit from increased retirement savings via employer contributions, self-employed individuals are merely provided with access to an alternate retirement savings vehicle. As explained in the Summary Report on Retirement Income Adequacy Researchi, "[h]igher income groups tend to exhibit a greater tendency to substitute one form of saving for another since they tend to be bound by limits...[I]f newly introduced plans are included in limitations imposed on the degree to which contributions may be deductible for tax purposes, saving may not increase for individuals who are constrained (i.e. saving up to their limit), since they would more likely substitute one type of saving for another (e.g., RRSP for a private pension plan)."
Therefore, the CMA encourages the Finance Committee to consider amending Bill C-25 to increase the retirement savings capacity of self-employed individuals by raising the combined limit for RRSPs and PRPPs.
2. Include Defined Benefit and Targeted Benefit Pension Plans
As currently proposed, Section 12(1) of Bill C-25 limits PRPPs to defined contribution pension plans by specifically excluding from eligibility of registration: (a) a pension plan as defined by 2(1) of the Pension Benefits Standards Act; (b) an employees' or a deferred profit-sharing plan; (c) an RRSP or a retirement compensation arrangement defined by 248(1) of the Income Tax Act; and, (d) any other prescribed plan or arrangement.
As highlighted in the Summary Report on Retirement Income Adequacy Research, "defined benefit pension funds and annuities enable investors to share longevity risks as well as pool risky investments to diversify risk." By pooling risk, defined benefit and targeted benefit pension plans provide more secure savings vehicles than defined contribution plans. The CMA encourages the Finance Committee to amend Bill C-25 to expand the PRPP framework to include defined benefit and targeted benefit pension plans.
3. Clarify the eligibility criteria of "PRPP administrators" to include professional associations
Further clarification is required on the type of organization that may qualify as a PRPP administrator under Bill C-25. While Sections 14-26 of Bill C-25 can be interpreted to extend administrator eligibility to organizations that are able to fulfill the criteria it establishes, Finance Canada's Framework for Pooled Registered Retirement Plans states that eligibility of administrators would be limited to "regulated financial institutions that are capable of taking on a fiduciary role."
The CMA encourages the Finance Committee to ensure that the eligibility clauses of Bill C-25 would allow well-governed professional organizations that represent a particular membership to be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members.
While the CMA supports the proposed PRPP framework in principle, the limitations currently proposed by Bill C-25 should be addressed to ensure that PRPPs also provide value to self-employed Canadians, including physicians. The CMA appreciates the opportunity to comment to the Finance Committee as part of its study of Bill C-25.
Summary of Recommendations
Amend Bill C-25 to raise the combined limit for RRSPs and PRPPs in order to increase the retirement savings capacity of self-employed individuals.
Amend Section 12(1) of Bill C-25 to expand the PRPP framework so it includes defined benefit and targeted benefit pension plans, which provide more secure savings vehicles than defined contributions plans.
Ensure the eligibility clauses of Bill C-25 (Sections 14-26) would allow well-governed professional organizations that represent a particular membership to be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members.
i Prepared for the Research Working Group on Retirement Income Adequacy of Federal-Provincial-Territorial Ministers of Finance.
As previously indicated in the Retirement Income Improvement Coalition's (RIIC) letter to the Minister of Finance on August 10, 2011, the CMA supports the federal government's proposal to expand access to pensions, specifically by establishing a legislative and regulatory framework to permit pooled registered retirement plans (PRPPs).
The CMA is concerned that as currently proposed, the PRPP framework, including Bill C-25 and the proposed legislative amendments to the Income Tax Act, would limit the potential for PRPPs to contribute to expanding access to, and investment in, pensions for self-employed individuals.
With respect to the pension framework, a critical issue, two principles are central to the CMA's membership of over 76,000 physicians. These are, to encourage the federal government to: 1) ensure that self-employed Canadians can retire with an appropriate level of retirement income (e.g., a 70% of pre-retirement income target); and, 2) expand the retirement savings options that are available to self-employed Canadians. The CMA's comments herein on the proposed amendments to the Income Tax Act are in support of these two principles.
As elaborated below, the CMA encourages the federal government to:
1. Increase the retirement savings capacity of self-employed individuals by raising the combined limit for RRSPs;
2. Expand the PRPP framework to include defined benefit and targeted benefit pension plans; and,
3. Clarify the eligibility criteria of "PRPP administrators" to include professional associations.
1. Increase the combined contribution limit for PRPPs and RRSPs
As proposed, it is our understanding that the core benefit of the PRPP framework is in providing smaller businesses access to low-cost pension plans, thereby providing a vehicle to encourage employers to establish, and contribute to, pensions for their employees. While the CMA recognizes the value of, and supports, this objective, this proposal in effect maintains the status quo for self-employed individuals.
Under Clause 10 of the proposed amendments to the Income Tax Act, the contribution limit to PRPPs would be calculated as an additional component of the current registered retirement savings plan (RRSP) contribution limit. As outlined in the Explanatory Notes, "an employer's contributions to an individual's PRPP account [and...] an individual's PRPP contributions in a taxation year will immediately reduce the individual's ability to make deductible RRSP contributions in that same year."
While individuals with employer contributions stand to benefit from increased retirement savings via employer contributions, self-employed individuals are merely provided with access to an alternate retirement savings vehicle. As explained in the Summary Report on Retirement Income Adequacy Researchi, "[h]igher income groups tend to exhibit a greater tendency to substitute one form of saving for another since they tend to be bound by limits...[I]f newly introduced plans are included in limitations imposed on the degree to which contributions may be deductible for tax purposes, saving may not increase for individuals who are constrained (i.e. saving up to their limit), since they would more likely substitute one type of saving for another (e.g., RRSP for a private pension plan)."
Therefore, the CMA encourages the federal government to consider increasing the retirement savings capacity of self-employed individuals by raising the combined limit for RRSPs and PRPPs.
2. Include defined benefit and targeted benefit pension plans
As noted under Clause 12, the registration criteria for PRPPs will be established by the PRPP Act, Bill C-25. Of concern, Bill C-25 limits PRPPs to defined contribution pension plans by specifically excluding from eligibility of registration: (a) a pension plan as defined by 2(1) of the Pension Benefits Standards Act; (b) an employees' or a deferred profit sharing plan; (c) an RRSP or a retirement compensation arrangement defined by 248(1) of the Income Tax Act; and, (d) any other prescribed plan or arrangement.
As highlighted by the Summary Report on Retirement Income Adequacy Research, "defined benefit pension funds and annuities enable investors to share longevity risks as well as pool risky investments to diversify risk." By pooling risk, defined benefit and targeted benefit pension plans provide more secure savings vehicles than defined contributions plans. The CMA encourages the federal government to expand the PRPP framework to include defined benefit and targeted benefit pension plans. While the CMA will advance this recommendation to the House of Commons Finance Committee during its consultation on Bill C-25, we include it as part of this submission as modifications to the proposed amendments to the Income Tax Act would be required.
3. Clarify the eligibility criteria of "PRPP administrators" to include professional associations
Further clarification is required on the type of organization that may qualify as a PRPP administrator. As noted under Clause 12, an administrator of a PRPP is authorized under the PRPP Act. As Bill C-25, the PRPP Act, is still in the legislative process, the CMA will elaborate on this issue during the formal Parliamentary consultation.
However, as it stands, further clarification is required on the eligibility criteria proposed by Bill C-25. While Bill C-25 can be interpreted to extend administrator eligibility to organizations that are able to fulfill the criteria established by the PRPP Act, Finance Canada's Framework for PRPPs states that eligibility of administrators would be limited to "regulated financial institutions that are capable of taking on a fiduciary role". Well-governed professional organizations that represent a particular membership should be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members.
While the CMA supports the proposed PRPP framework in principle, the proposed limitations to PRPPs should be addressed to ensure that they also provide value to self-employed Canadians, including physicians. The CMA appreciates the opportunity to comment on the proposed amendments to the Income Tax Act and to once again advance recommendations to Finance Canada on the PRPP framework.
i Prepared for the Research Working Group on Retirement Income Adequacy of Federal-Provincial-Territorial Ministers of Finance.
The Canadian Medical Association (CMA) appreciates the opportunity to provide additional comments and recommendations as part of Finance Canada's 2012 pre-budget consultations.
The health sector provides essential services and high value jobs supporting communities across Canada. Statistics Canada reports that employment in the health sector accounts for 10% of the Canadian labour force.i In considering possible additional economic stimulus measures that build on the success of Canada's Economic Action Plan, the CMA encourages the federal government to consider investments that target efficiency improvements in the health sector. Efficiency improvements in the health sector yield benefits to all orders of government and Canadians.
The following recommendations are advanced for Finance Canada's consideration:
* In order to improve the delivery of better care, better health, and better value, the CMA recommends that the federal government work with the provinces, territories and health sector stakeholders to develop a model for accountability and patient-centred care. The CMA encourages the federal government to adopt the Principles to Guide Health Care Transformation, developed by the CMA together with the Canadian Nurses Association and since endorsed by over 60 organizations, as the basis of a pan-Canadian model for accountability and patient-centred care.
* Recognizing the significance of nationally comparable metrics on health outcomes and the health care system together with the effectiveness of national public reporting in demonstrating accountability, the CMA recommends that the federal government undertake efforts towards identifying pan-Canadian metrics and measurement that will link health care expenditures to comparable health outcomes.
* As the federal government prepares to engage with the provinces and territories to further map out improvements to Canada's health system, the CMA strongly encourages consideration be given to the federal role in coordinating the development of pan-Canadian clinical practice guidelines (CPGs).
* While, as previously indicated, the CMA supports the federal government's proposal to expand access to pensions, specifically by developing pooled registered retirement plans (PRPPs), the limitations to PRPPs should be addressed to ensure that they provide value to self-employed Canadians, including physicians. Specifically, addressing the limitations would include: (1) expanding the PRPP framework to include defined benefit and targeted benefit pension plans; (2) increasing the retirement savings capacity of self-employed individuals by either raising the RRSP limit or providing a distinct limit for PRPPs; and, (3) ensuring the PRPP framework expands the eligibility of administrators beyond financial institutions.
The Canadian Medical Association (CMA) appreciates the opportunity to provide additional recommendations to the Government of Canada as part of its 2012 Pre-Budget consultation. Building upon the CMA's recommendations to the House of Commons' Finance Committee, this submission focuses on three issues: (1) improving accountability and patient-centred care in the delivery of new federal health care funding; (2) coordinating the development of pan-Canadian clinical practice guidelines; and (3) addressing limitations in the federal framework for pension reform.
1. Accountability and patient-centred care
"Raising sufficient money for health is imperative, but just having the money will not ensure universal coverage. Nor will removing financial barriers to access through prepayment and pooling. The final requirement is to ensure resources are used efficiently." World Health Organization (2010)
As the federal government finalizes the Strategic and Operating Review and considers other measures to eliminate the deficit, including scaling down the Economic Action Plan, it must be recognized that improved health systems and the resultant improved productivity pay economic dividends for the country; and, further, that "health" by today's standards is not just the assessment and treatment of illness, but also the prevention of illness, and the creation and support of social factors that contribute to health should also be considered.
With the recent announcement by Minister Flaherty with respect to the Canada Health Transfer (CHT) and Canada Social Transfer (CST), the financial parameters for future health care funding have been established.
Consistent with previous public opinion research, recent polling by Ekos Research Associates shows that 76% of Canadians identify improving health care as the leading priority for the federal government, ahead of reducing the national debt and deficit.ii However, as we have learned with the 2004 Health Accord, funding alone is not sufficient to ensure Canadian taxpayers benefit from improvements in health care, health outcomes, and value for money.
Despite laying out laudable objectives, progress to improve our health care system has been slow following the 2003 and 2004 agreements. There is a general agreement that Canada's health care system is no longer a strong performer when compared to similar nations. The OECD's Health Data, 2011 ranks Canada eighth highest of 34 member states in per capita health care spending, the second highest in hospital spending per discharge, and the seventh lowest in the number of physicians per capita. While Canada outperforms the U.S. on most measures, we fall below the median performance of the OECD on common health quality and system measures. With the new health care funding commitment to 2024, it is now time to plan how to transform the health care system.
Principles-based approach is required
The CMA is advocating built-in accountability mechanisms to ensure Canada's health care system is focused on delivering improved patient outcomes. Developing a system that is accountable and patient-centred depends on continuously striving to achieve the Institute for Healthcare Improvement's (IHI) Triple Aim objectives of better care, better health and better value. Launched in 2007, the IHI Triple Aim initiative was designed to direct the improvement of the patients' experience of care (including quality, access, and reliability) while lowering the per capita cost of care.
It was with the Triple Aim objectives in mind that the CMA jointly developed Principles to Guide Health Care Transformation in Canada with the Canadian Nurses Association (CNA). It is our strong belief that discussions about the future of health care in Canada must be guided by these principles.
The CMA-CNA principles are summarized as follows:
* Patient-centred: Patients must be at the centre of health care, with seamless access to the continuum of care based on their needs.
* Quality: Canadians deserve quality services that are appropriate for patient needs, respect individual choice and are delivered in a manner that is timely, safe, effective and according to the most currently available scientific knowledge.
* Health promotion and illness prevention: The health system must support Canadians in the prevention of illness and the enhancement of their well-being, with attention paid to broader social determinants of health.
* Equitable: The health care system has a duty to Canadians to provide and advocate for equitable access to quality care and commonly adopted policies to address the social determinants of health.
* Sustainable: Sustainable health care requires universal access to quality health services that are adequately resourced and delivered across the board in a timely and cost-effective manner.
* Accountable: The public, patients, families, providers and funders all have a responsibility for ensuring the system is effective and accountable.
In order to ensure that future federal funding delivers on the Triple Aim objectives of better care, better health and better value, a model for accountability and patient-centred care is required. Such a model would expand upon the CMA-CNA Principles through the development of a set of measurable indicators related to each principle that can be used for setting national standards, monitoring progress and demonstrating accountability to Canadians.
The CMA therefore urges the federal government to facilitate discussions with the provinces and territories to identify how resources will be used to improve patient care and health outcomes across the country. To this end, the CMA has urged the Minister of Health to move quickly to engage the provincial and territorial health ministers on transforming the health care system.
The CMA recommends that the federal government work with provinces and territories, in consultation with national health sector stakeholders, to develop a model for accountability and patient-centred care. The CMA encourages the federal government to adopt the CMA-CNA Principles to Guide Health Care Transformation as the basis of a pan-Canadian model for accountability and patient-centred care.
Improving public reporting: The cornerstone of accountability
The federal government has a significant stake in national public reporting on the health of Canadians and on the performance of the health care system. As required by the Canada Health Act, the Minister of Health must publicly report administration, operation and adherence to the Act each year. Further, as the largest contributor to the single-payer system, the federal government has a unique role in demonstrating value for money and reporting on strategies to improve the quality, effectiveness and sustainability of the health care system. To facilitate public reporting, in addition to Statistics Canada, the federal government is supported by the Health Council of Canada and the Canadian Institute for Health Information, both established as government-funded non-profits, however, with distinct mandates.
Despite pan-Canadian efforts such as provincial health quality councils and federal and non-governmental reporting, there remains significant room for improvement in the area of monitoring and reporting, both on health outcomes and system performance. As noted in the Commonwealth Fund's report on international health care systems, "reporting on health system performance [in Canada] varies widely across the provinces and territories...there is so far little connection between financial rewards and public reporting of performance." Not surprising, this issue was also identified by the Health Council of Canada in its Progress Report 2011. It highlights the challenges in reporting progress and explains the difficulties inherent to the current patchwork, "[w]here provinces and territories had set and publicized targets, it was easier for us to track progress. Where we could not find targets, assessing progress was more difficult."
The CMA has long supported improved pan-Canadian public reporting on health and health care. Most recently, the CMA hosted a symposium with health reporting stakeholders to discuss the current status of national reporting and the need for the development of a pan-Canadian reporting framework. As recognized by the symposium's participants, there is a great deal of excellent data collection work occurring across the country. However, these efforts are largely uncoordinated and do not tell the full story of the health of Canadians or adequately assess the performance of the health care system. Indeed, despite an abundance of metrics and measurement, in many cases, data is not necessarily usable by the public or decision-makers and, unfortunately, is not necessarily comparable between jurisdictions.
The CMA recommends that the federal government recognize the significance of nationally comparable metrics on health and the health care system and national public reporting in demonstrating accountability (i.e. better health, better care, and better value). In achieving these objectives, the CMA recommends that the federal government mandate an appropriate national organization, such as the Health Council of Canada, to undertake a consultative process with the aim of identifying pan-Canadian metrics and measurement that will link health expenditures and comparable health outcomes.
2. Coordinate the development of pan-Canadian Clinical Practice Guidelines
As the federal government prepares to engage with the provinces and territories to further map out improvements to Canada's health system, the CMA strongly encourages consideration be given to the federal role in coordinating the development of pan-Canadian clinical practice guidelines (CPGs). Such a role would build upon the commitment made by the provinces and territories under the auspices of the Council of the Federation to collaborate on the development of three to five CPGs over the coming year.
CPGs are systematically developed, evidence- or consensus-based statements to assist health care providers in making decisions about the most appropriate health care to be provided in specific clinical circumstances. There is compelling evidence in the literature, supported by the experience of other countries, that well-designed and disseminated CPGs can enhance the clinical behaviour of providers and provide a positive impact on patient outcomes.
The principle argument in support of CPGs is their ability to enhance quality of care and patient outcomes. In addition, CPGs have been found to:
* Provide publicly accessible descriptions of appropriate care by which to gauge health care performance;
* Help to reduce inappropriate variations in care across diverse geographical and clinical settings;
* Offer the potential of empowering patients as to appropriate care expectations; and,
* Contribute to public policy goals, such as cost containment, through encouraging more appropriate provider use of resources.
However, in the absence of a pan-Canadian approach, CPGs across Canada are of uneven quality and even excellent guidelines may not be effectively disseminated or implemented. In contrast to Canada, peer-nations such as the United Kingdom, the United States and Australia have committed at a national level to support the development and dissemination of CPGs.
In November 2011, the CMA, together with leading national medical and health sector stakeholders, convened a Canadian Clinical Practice Guidelines Summit, attended by representatives of the federal and most provincial and territorial governments, to explore key components of a pan-Canadian strategy on CPGs. Emerging from this summit was a clear consensus that it was the federal role to provide the infrastructure support necessary to facilitate the development and dissemination of high-quality CPGs, customizable to the needs of all jurisdictions in Canada.
Guideline development and implementation is a complex, lengthy and resource-intensive process. In the absence of federal coordination in Canada, guidelines are produced by disparate, disease-specific groups, often funded by the pharmaceutical industry. This creates an obvious potential for conflict of interest where the guideline development process is far from transparent. Many guidelines are published without disclosure on conflict of interest or methodology applied. Concern over the quality of guidelines presents one the most persistent barriers to adoption by physicians of the recommended practice. The resulting underutilization of CPGs in Canada is widely documented. Clearly, the development and dissemination of pan-Canadian CGPs present a unique and significant opportunity for improvement in Canada's health care system.
The CMA recommends that as part of further discussions with the provinces and territories, the federal government commit to working with the provinces, territories and health sector stakeholders towards the development of a pan-Canadian clinical practice guideline initiative. In particular, the CMA recommends that the federal government commit support for the infrastructure necessary for the development, maintenance, and active dissemination of relevant, high-quality clinical practice guidelines.
3. Address the limitations proposed under the pension reform framework
As previously indicated in the August 2011 submission to Finance Canada by the Retirement Income Improvement Coalition (RIIC), the CMA supports the federal government's proposal to expand access to pensions, specifically by developing pooled registered retirement plans (PRPPs).
While we are currently assessing the package of proposed Income Tax Act amendments and will provide more detailed comments as part of the legislative process, the CMA is concerned that the framework, as proposed, limits the potential for PRPPs to expand physician access to, and investment in, pensions.
Based on preliminary analysis, it is our understanding that the core benefit of the PRPP framework is in providing small businesses access to low-cost pension plans, thereby providing a vehicle to encourage employers to establish, and contribute to, pensions for their employees. Given that a significant proportion of physicians are self-employed, they would not benefit from employer contributions to a PRPP. Further, as proposed, the contribution limit to PRPPs would be calculated as an element of the current RRSP and pension contribution limit. Finally, further clarification is required on the type of organization that may qualify as a PRPP administrator. Well-governed organizations that represent a particular membership should be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members.
While the CMA supports the proposed PRPP framework in principle, the limitations to PRPPs should be addressed to ensure that they provide value to self-employed Canadians, including physicians.
The CMA recommends that Finance Canada consider amendments to the proposed Income Tax Act amendments to address limitations to PRPPs, specifically: (1) expanding the PRPP framework to include defined benefit and targeted benefit pension plans; (2) increasing the retirement savings capacity of self-employed individuals by either raising the RRSP limit or providing a distinct limit for PRPPs; and, (3) ensuring the PRPP framework expands the eligibility of administrators beyond financial institutions.
The comments and recommendations provided herein represent the CMA's priority recommendations for targeted federal funding towards the achievement of efficiency improvements in Canada's health sector.
It is the CMA's position that these measures will contribute to a healthy, more productive and innovative economy by contributing to better care, better health and better value in the health care system.
Once again, the CMA appreciates the opportunity to provide these additional comments and recommendations.
i 2006 Census data