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Authorizing Cannabis for Medical Purposes

https://policybase.cma.ca/en/permalink/policy11514
Last Reviewed
2020-02-29
Date
2015-02-28
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2015-02-28
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Authorizing Cannabis for Medical Purposes The legalization of cannabis for recreational purposes came into effect with the Cannabis Act in October 2018, and patients continue to have access to cannabis for therapeutic purposes. The Cannabis Regulations have replaced the Access to Cannabis for Medical Purposes Regulations. Patients can obtain cannabis for medical purposes when a physician or nurse practitioner provides a “medical document” , authorizing its use, and determining the daily dried cannabis dose in grams. With the authorization, patients have the choice whether to (a) buy directly from a federally licensed producer; (b) register with Health Canada to produce a limited amount for personal consumption; (c) designate someone to produce it for them; or (d) buy cannabis at provincial or territorial authorized retail outlets or online sales platforms, if above the legal age limit. While acknowledging the unique requirements of patients suffering from a terminal illness or chronic disease for which conventional therapies have not been effective and for whom cannabis may provide relief, physicians remain concerned about the serious lack of clinical research, guidance and regulatory oversight for cannabis as a medical treatment. There is insufficient clinical information on safety and efficacy for most therapeutic claims. There is little information around therapeutic and toxic dosages and knowledge on interactions with medications. Besides the need for appropriate research, health practitioners would benefit from unbiased, accredited educational modules and decision support tools based on the best available evidence. The Canadian Medical Association has consistently expressed concern with the role of gatekeeper that physicians have been asked to take as a result of court decisions. Physicians should not feel obligated to authorize cannabis for medical purposes. Physicians who choose to authorize cannabis for their patients must comply with their provincial or territorial regulatory College's relevant guideline or policy. They should also be familiar with regulations and guidance, particularly:
Health Canada’s Information for Health Care Practitioners – Medical Use of Cannabis (monograph, summary and daily dose fact sheet),
the Canadian Medical Protective Association’s guidance;
the College of Family Physicians of Canada’s preliminary guidance Authorizing Dried Cannabis for Chronic Pain or Anxiety; and
the Simplified guideline for prescribing medical cannabinoids in primary care, published in the Canadian Family Physician. The CMA recommends that physicians should:
Ensure that there is no conflict of interest, such as direct or indirect economic interest in a licensed cannabis producer or be involved in dispensing cannabis;
Treat the authorization as an insured service, similar to a prescription, and not charge patients or the licensed producer for this service;
Until such time as there is compelling evidence of its efficacy and safety for specific indications, consider authorizing cannabis only after conventional therapies are proven ineffective in treating patients’ conditions;
Have the necessary clinical knowledge to authorize cannabis for medical purposes;
Only authorize in the context of an established patient-physician relationship;
Assess the patient’s medical history, conduct a physical examination and assess for the risk of addiction and diversion, using available clinical support tools and tests;
Engage in a consent discussion with patients which includes information about the known benefits and adverse health effects of cannabis in its various forms (e.g., edibles), including the risk of impairment to activities such as driving and work;
Advise the patient regarding harm reduction strategies and the prevention of accidental exposure for children and other people;
Document all consent discussions in patients' medical records;
Reassess the patient on a regular basis for its effectiveness to address the medical condition for which cannabis was authorized, as well as for addiction and diversion, to support maintenance, adjustment or discontinuation of treatment; and
Record the authorization of cannabis for medical purposes similar to when prescribing a controlled medication. The Cannabis Regulations provide some consistency with many established provincial and territorial prescription monitoring programs for controlled substances. Licensed producers of cannabis for medical purposes are required to provide information to provincial and territorial medical licensing bodies upon request, including healthcare practitioner information, daily quantity of dried cannabis supported, period of use, date of document and basic patient information. The Minister of Health can also report physicians to their College should there be reasonable grounds that there has been a contravention of the Narcotic Control Regulations or the Cannabis Regulations. Approved by CMA Board February 2015 Latest update approved by CMA Board in February 2020
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Palliative care

https://policybase.cma.ca/en/permalink/policy11809
Last Reviewed
2020-02-29
Date
2015-10-03
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2015-10-03
Topics
Ethics and medical professionalism
Text
Palliative care is an approach that aims to relieve suffering and improve the quality of life of those facing life-limiting acute or chronic conditions by means of early identification, assessment, treatment of pain and other symptoms and support of all physical, emotional and spiritual needs. It may coexist with other goals of care, such as prevention, treatment and management of chronic conditions, or it may be the sole focus of care. General principles Goals 1. All Canadian residents should have access to comprehensive, quality palliative care services regardless of age, care setting, diagnosis, ethnicity, language and financial status.1 2. The Canadian Medical Association (CMA) declares that its members should adhere to the principles of palliative care whereby relief of suffering and quality of living are valued equally to other goals of medicine. 3. The CMA believes that all health care professionals should have access to referral for palliative care services and expertise.2 4. The CMA supports the integration of the palliative care approach into the management of life-limiting acute and chronic disease.3 5. The CMA advocates for the integration of accessible, quality palliative care services into acute, community and chronic care service delivery models4 that align with patient and family needs. 6. The CMA supports the implementation of a shared care model, emphasizing collaboration and open communication among physicians and other health care professionals.5 7. The CMA recognizes that the practice of assisted dying as defined by the Supreme Court of Canada is distinct from the practice of palliative care. Access to palliative care services 8. The CMA believes that every person nearing the end of life who wishes to receive palliative care services at home should have access to them. 9. Comprehensive, quality palliative care services must be made available to all Canadians and efforts to broaden the availability of palliative care in Canada should be intensified.6 10. The CMA calls upon the federal government, in cooperation with provincial and territorial governments, to improve access to pediatric palliative care through enhanced funding, training and awareness campaigns.7 11. The CMA will engage in physician human resource planning to develop an appropriate strategy to ensure the delivery of quality palliative care throughout Canada.8 Education 12. All physicians require basic competencies in palliative care and may require enhanced skills appropriate to their practice. 13. The CMA requests that all Canadian faculties of medicine create a training curriculum in palliative care suitable for physicians at all stages of their medical education and relevant to the settings in which they practise.9 Role of governments 14. The CMA calls on governments to work toward a common strategy for palliative care to ensure equitable access to and adequate standards for quality palliative care.10 15. The CMA recommends that all relevant legislation be amended to recognize that any person whose medical condition warrants it is entitled to receive palliative care.11 16. The CMA supports emergency funding for end-of-life care for uninsured people residing in Canada.12 BACKGROUND In Canada, the impact of end-of-life care on both individuals and the health care system is "staggering," and the demand for this care will continue to grow as the population ages.13 It is estimated that the number of Canadians dying each year will increase by 40% to 330,000 by 2026. The well-being of an average of five others will be affected by each of those deaths, or more than 1.6 million people.14 Against this backdrop, the availability of and access to palliative care is an urgent policy and practice imperative. There has been mounting support for, and mounting criticism of the lack of, a national strategy for palliative care.15 The delivery of palliative care varies greatly across Canada due to differences in regional demographics, societal needs, government involvement and funding structures. Similarly, funding and legislation supporting access to palliative care services vary significantly between jurisdictions. A recent survey of Canadian physicians who provide palliative medicine found that: (1) Canada needs an adequate palliative medicine workforce; (2) primary care providers need more support for palliative care education and training; (3) palliative medicine as a distinct discipline must be further developed to better meet the complex needs of patients; and (4) Canada must ensure minimum palliative medicine standards are met.16 In an effort to address the current challenges in palliative care and improve both the quality of care and access to care, the CMA developed recommendations for a national call to action: 1. All patients should have a primary care provider that can support them with their palliative care needs or else refer these patients earlier to a palliative care team to establish goals of care. 2. Physicians should provide leadership at local, regional, provincial/territorial and federal levels to promote the establishment of integrated models of palliative care. 3. All physicians should obtain essential palliative care skills and knowledge to provide basic palliative care services to their patients. 4. Physicians should advocate for adequate and appropriate home palliative care resources so their patients can stay in their homes as long as possible. 5. Physicians should advocate for an adequate number of palliative and/or hospice care beds to meet their communities' needs. 6. Continuing care facilities and long-term care homes should have in-house palliative care physician support on their palliative care teams. 7. Physicians should support the valuable work of hospice volunteers. 8. Medical students are encouraged to look at palliative care as a rewarding career. 9. Practising palliative care physicians are encouraged, if needed, to obtain additional certified training in palliative care from either the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada. 10. Physicians acknowledge the value of and support the participation of family and friends in caring for their loved ones at the end of life. Integrated palliative approach to care There are four main models of palliative care delivery in Canada: integrated palliative care programs, continuing care and long-term care facilities, residential hospices, and home-based palliative care. Palliative care was originally developed in cancer care to provide patients dying of cancer with care at the very end of life by a specialized palliative care team.17 This model has evolved significantly in response to the increasing occurrence of, and burden posed by, complex chronic disease18. Palliative care is now also provided to patients with multiple co-occurring morbidities who require multiple interventions. It is now recognized to benefit all those living with life-limiting acute or chronic conditions, including, or perhaps especially, when it is initiated earlier in the disease trajectory. Evidence shows that integrated and early provision of palliative care leads to: (1) better outcomes than those obtained with treatment alone (e.g., improvements in symptoms, quality of life and patient satisfaction; positive effects on emotional wellness; decreased suffering; and at times increased longevity) and (2) better use of resources (e.g., less burden on caregivers, more appropriate referrals to hospice palliative care, more effective use of palliative care experts, less use of emergency and intensive interventions and decreased cost of care).19-20-21-22 Taken together, these studies validate the benefits of integrating palliative care services with standard treatment and involving palliative care providers early, a collaborative approach that transcends the conventional view that palliative care is care delivered at the very end of life. At present, there is strong support for the development and implementation of an integrated palliative approach to care. Integration effectively occurs: * throughout the disease trajectory; * across care settings (primary care, acute care, long-term and complex continuing care, residential hospices, shelters, home); * across professions/disciplines and specialties; * between the health care system and communities; and * with changing needs from primary palliative care through to specialist palliative care teams. The integrated palliative approach to care focuses on meeting a person's and family's full range of physical, psychosocial and spiritual needs at all stages of frailty or chronic illness, not just at the end of life.23 It is provided in all health care settings. The palliative approach to care is not delayed until the end stages of an illness but is applied earlier to provide active comfort-focused care and a positive approach to reducing suffering. It also promotes understanding of loss and bereavement (Fig. 1). Figure 1 Specialized palliative units and hospices are essential for end-of-life care for some individuals but are not appropriate for all persons facing life-limiting chronic conditions. When a palliative approach is offered in multiple settings, people and their families can receive better care through the many transitions of chronic conditions like dementia, lung, kidney and heart diseases, and cancer. This requires that all physicians be competent in initiating a primary palliative approach: they must be able to engage in advance care planning discussions, ask about physical and emotional symptoms and make appropriate, timely referrals to other providers and resources. Primary care physicians may need to develop more expertise in palliative care. A cadre of expert palliative care physicians will be required to provide care in complex cases, engage in education and research, and provide support for health professional colleagues providing palliative care in multiple settings. All health professionals must be able to practise competently in an integrated palliative approach to care. At the heart of an integrated palliative approach to care are a patient and family surrounded by a team of multidisciplinary professionals and community providers (Fig. 2). While team members vary depending on the needs of the patients and families, the principles of whole-person care and family care do not change. This allows patients and families to have their symptoms managed, receive care in the setting of their choice, engage in ongoing discussions about their preferences for care and experience a sense of autonomy in living their lives well. Figure 2 A report on The Way Forward, a project of the Quality End-of-Life Coalition of Canada and the Canadian Hospice Palliative Care Association, summarizes the situation as follows: "Only a small proportion of Canadians will need the kind of complex, intensive or tertiary hospice palliative care provided by expert palliative care teams in institutional settings, such as residential hospices and acute care hospitals. However, everyone who is becoming frail or is faced with a chronic illness could benefit from certain key palliative care services. As our population ages, we must ensure that all Canadians have access to palliative services integrated with their other care that will help them manage symptoms, enhance their lives, give them a greater sense of control, and enable them to make informed decisions about the care they want. More equitable access to palliative care integrated with their other care will enable more Canadians to live well with their illness up to the end of life. It will also enable more people to receive care in the setting of their choice and reduce the demand on acute care resources." 24 Access to palliative care services There are currently no reliable data on the number of specialized or semi-specialized palliative care physicians in Canada. It is difficult to count these physicians because palliative care has not historically existed as a specialty. Physicians practising palliative care have a wide variety of backgrounds and training, and many provide palliative care on a part-time basis. The Canadian Society of Palliative Care Physicians is currently working with partner organizations including the CMA, the Royal College of Physicians and Surgeons and the College of Family Physicians of Canada to better define the different types of palliative care physicians to conduct a meaningful count. On the question of access, studies have found that palliative care services are not aligned with patient preferences. For example, while 70% of hospitalized elderly patients reported wanting comfort measures rather than life-prolonging treatment, more than two-thirds were admitted to intensive care units.25 Most patients and caregivers report wanting to die at home26 and in-home palliative team care is a cost-effective intervention,27 but the value of this form of care is not reflected in many provincial policies. Instead, Canadian families frequently shoulder 25% of the total cost of palliative care because they must pay for home-based services,28 such as nursing and personal care services, that are not provided by governments. With the goal of improving the congruence between patient treatment preferences for end-of-life care and the services provided, Health Quality Ontario developed an evidentiary platform to inform public policy on strategies to optimize quality end-of-life care in in-patient and outpatient (community) settings. It identified four domains in which access to end-of-life care should be optimized to align with patient preferences: (1) location (determinants of place of death); (2) communication (patient care planning discussions and end-of-life educational interventions); (3) team-based models of care; and (4) services (cardiopulmonary resuscitation [CPR] and supportive interventions for informal caregivers).29 Education It is well recognized that education in palliative care is lacking in medical school and residency training. In response, the Association of Faculties of Medicine of Canada, in partnership with the Canadian Hospice Palliative Care Association and the Canadian Society of Palliative Care Physicians, conducted the Educating Future Physicians in Palliative and End-of-Life Care Project30 to develop consensus-based competencies for undergraduate medical trainees and a core curriculum that was implemented in all 17 Canadian medical schools. Despite these efforts, a survey conducted by the Canadian Society of Palliative Care Physicians found that the competencies are not being consistently taught in medical schools, as evidenced by the fact that 10 medical schools offered less than 10 hours of teaching on palliative care and two offered none.31 Moreover, evidence suggests that Canadian physicians are not consistently or adequately trained in palliative care. There is a general lack of providers trained in palliative care for service provision, teaching, consultative support to other physicians and research. To fill the observed gap in education, the Royal College of Physicians and Surgeons of Canada is developing Palliative Medicine as a subspecialty, and the College of Family Physicians of Canada is developing a Certificate of Added Competence in Palliative Care. What is more, different levels of palliative care competencies are required for different physicians: * All physicians require basic skills in palliative care. * Palliative consultants and physicians who frequently care for patients with chronic illnesses and/or frail seniors require enhanced skills. * Palliative medicine specialists and palliative medicine educators require expert skills. More broadly, the undergraduate curricula of all health care disciplines should include instruction in the principles and practices of palliative care, including how to access specialized palliative care consultation and services. Role of governments Access to palliative care must be treated with the same consideration as access to all other medical care. Provincial/territorial and federal legislation, however, is vague in this regard and does not recognize access to palliative care as an entitlement. Government funding of community-based hospice palliative care has not increased proportionately to the number of institutionally based palliative care beds that have been cut, leaving a significant gap in the health care system.32 To address this issue, efforts to broaden the availability of and access to palliative care in Canada need to be intensified. It is imperative that governments develop a common palliative care strategy to ensure equitable access to and adequate standards for quality palliative care, including emergency funding for those who are uninsured. Glossary Integrated palliative approach to care: An approach that focuses on quality of life and reduction of suffering as a goal of care. This approach may coexist with other goals of care - prevention, cure, management of chronic illness - or be the sole focus of care. The palliative approach integrates palliative care services throughout the treatment of a person with serious life-limiting illness, not just at the very end of life. Palliative care services: Generally consists of palliative care provided by a multidisciplinary team. The team may include a primary care physician, a palliative care physician, nurses, allied health professionals (as needed), social workers, providers of pastoral care and counselling, bereavement specialists and volunteers. The team members work together in a shared care model. Shared care model: An approach to care that uses the skills and knowledge of a range of health professionals who share joint responsibility for an individual's care. This model involves monitoring and exchanging patient data and sharing skills and knowledge among disciplines.33 References 1 Policy Resolution GC99-87 - Access to end-of-life and palliative care services. Ottawa: Canadian Medical Association; 1999. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 2Policy Resolution GC14-20 - Palliative care services and expertise. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 3Policy Resolution GC13-67 - Palliative Care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 4Policy Resolution GC13-66 - Palliative Care Services. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 5 Policy Resolution GC13-80 - Collaborative palliative care model. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 6Policy Document PD15-02 - Euthanasia And Assisted Death (Update 2014). Ottawa: Canadian Medical Association; 2015. Available: https://www.cma.ca/Assets/assetslibrary/document/en/advocacy/EOL/CMA_Policy_Euthanasia_Assisted%20Death_PD15-02-e.pdf#search=Euthanasia%20and (accessed 2015 Nov 26). 7 Policy Resolution GC06-12 - Access to pediatric palliative care. Ottawa: Canadian Medical Association; 2006. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 8Policy Resolution GC14-23 - Delivery of quality palliative end-of-life care throughout Canada. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 9Policy Resolution GC13-71 - Training in palliative care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 10Policy Document PD10-02 - Funding the continuum of care.Ottawa: Canadian Medical Association; 2010. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 11Policy Resolution GC13-70 - Palliative Care. Ottawa: Canadian Medical Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 12Policy Resolution GC14-26 - Emergency funding for end-of-life care for uninsured people residing in Canada. Ottawa: Canadian Medical Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2015 Nov 26). 13 OHTAC End-of-Life Collaborative. Health care for people approaching the end of life: an evidentiary framework. Toronto: Health Quality Ontario; 2014. Available: http://www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/eol-evidentiary-framework. 14 Quality End-of-Life Care Coalition of Canada. Blueprint for action 2010 to 2012. Ottawa: Quality End-of-Life Care Coalition of Canada; 2010. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf. 15 Fowler R, Hammer M. End-of-life care in Canada. Clin Invest Med. 2013;36(3):E127-E32. 16 Canadian Society of Palliative Care Physicians. Highlights from the National Palliative Medicine Survey. Surrey (BC): Canadian Society of Palliative Care Physicians, Human Resources Committee; May 2015. 17 Bacon J. The palliative approach: improving care for Canadians with life-limiting illnesses. Ottawa: Canadian Hospice Palliative Care Association; 2012. Available: http://www.hpcintegration.ca/media/38753/TWF-palliative-approach-report-English-final2.pdf. 18 Ontario Health Technology Advisory Committee OCDM Collaborative. Optimizing chronic disease management in the community (outpatient) setting (OCDM): an evidentiary framework. Toronto: Health Quality Ontario; 2013. Available: www.hqontario.ca/Portals/0/Documents/eds/ohtas/compendium-ocdm-130912-en.pdf. 19 Zimmermann C, Swami N, Krzyzanowska M, Hannon B, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930):1721-1730. 20 Klinger CA, Howell D, Marshall D, Zakus D, et al. Resource utilization and cost analyses of home-based palliative care service provision: the Niagara West end-of-life shared-care project. Palliat Med. 2013;27(2):115-122. 21 Temel JS, Greer JA, Muzikansky MA, Gallagher ER, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. NEJM. 2010;363:733-742. 22 Bakitas M, Lyons KD, Hegel MT, Balan S, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. 2009;302:741-749. 23 Quality End-of-Life Care Coalition of Canada, Canadian Hospice Palliative Care Association. The Way Forward National Framework: a roadmap for an integrated palliative approach to care. Ottawa: Quality End-of-Life Care Coalition of Canada; 2014. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf 24 Quality End-of-Life Coalition of Canada, Canadian Hospice Palliative Care Association. The Way Forward National Framework: a roadmap for the integrated palliative approach to care. Quality End-of-Life Coaltion of Canada; 2014. Available: http://www.hpcintegration.ca/media/60044/TWF-framework-doc-Eng-2015-final-April1.pdf. 25 Cook D, Rocker G. End of life care in Canada: a report from the Canadian Academy of Health Sciences Forum. Clin Invest Med. 2013;36(3):E112-E113. 26 Brazil, K, Howell D, Bedard M, Krueger P, et al. Preferences for place of care and place of death among informal caregivers of the terminally ill. Palliat Med. 2005;19(6):492-499. 27 Pham B, Krahn M. End-of-life care interventions: an economic analysis. Ontario Health Quality Technology Assessment Series. 2014;14(18):1-70. Available: http://www.qelccc.ca/media/3743/blueprint_for_action_2010_to_2020_april_2010.pdf. 28 Dumont S, Jacobs P, Fassbender K, Anderson D, et al. Costs associated with resource utilization during the palliative phase of care: a Canadian perspective. Palliat Med. 2009;23(8)708-717. 29 OHTAC End-of-Life Collaborative. Health care for people approaching the end of life: an evidentiary framework. Toronto: Health Quality Ontario; 2014. Available: www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/eol-evidentiary-framework 30 Association of Faculties of Medicine of Canada. Educating future physicians in palliative and end-of-life care. Ottawa: Association of Faculties of Medicine of Canada; 2004. Available: http://70.38.66.73/social-educating-physicians-e.php. 31 Daneault S. Undergraduate training in palliative care in Canada in 2011. Montreal: Soins palliatifs, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal; 2012. 32 Canadian Hospice Palliative Care Association. Fact sheet 2012: hospice palliative care in Canada. Available: http://www.chpca.net/media/330558/Fact_Sheet_HPC_in_Canada%20Spring%202014%20Final.pdf. 33 Moorehead, R. Sharing care between allied health professional and general practitioners. Aust Fam Physician. 1995;24(11).
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Direct-to-consumer advertising (DTCA)

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

https://policybase.cma.ca/en/permalink/policy1967
Last Reviewed
2020-02-29
Date
2002-06-06
Topics
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-06-06
Topics
Health systems, system funding and performance
Text
Medicare emerged from the 1990s bent, but not broken — in large measure due to the tireless efforts of health professionals whose commitment has always been, first and foremost, to their patients. However, this level of effort cannot continue. Canadian health providers and the facilities they work in are stretched to the limit. Over the past decade there have been countless studies on what is wrong with Canada’s health care system. However, very little action has been taken to solve the problems identified in the reports because very few of these reports provided a roadmap with concrete recommendations on how to achieve change. Furthermore, many decisions regarding the health care system have been made by governments without meaningful input from health professionals. As we indicated in our first submission, there is clearly a need for a collaborative approach to “change management” that is based on early, ongoing and meaningful involvement of all key stakeholders. However, before consideration is given to how to solve the woes of the health care system, it is essential to establish a shared vision of Canada’s health care system. Several attempts have been made to this end; however, few have included health care providers or the public in the process. The CMA has established its own vision for a sustainable health care system, upon which the recommendations we have presented in this submission are based. To ensure that our health care system in Canada is sustainable in the future, longer-term structural and procedural reforms are required. The CMA proposes 5 recommendations involving the implementation of three integrated “pillars of sustainability” that together will improve accountability and transparency in the system. These pillars would also serve as the basis for addressing the many short- to medium-term issues facing Medicare today and into the future. To this end, we put forward 25 recommendations suggesting specific “hows” for solving these critical problems. The three “pillars” are: a Canadian Health Charter, a Canadian Health Commission, and a renewal of the federal legislative framework. A Canadian Health Charter would underline governments’ shared commitment to ensuring that Canadians will have access to quality health care within an acceptable time frame. It would also clearly articulate a national health policy that sets out our collective understanding of Medicare and the rights and mutual obligations of individual Canadians, health care providers, and governments. The existence of such a Charter would ensure that a rational, evidence-based, and collaborative approach to managing and modernizing Canada’s health system is being followed. In conjunction with the Canadian Health Charter, a permanent, independent Canadian Health Commission would be created to promote accountability and transparency within the system. It would have a mandate to monitor compliance with and measure progress towards Charter provisions, report to Canadians on the performance of the health care system, and provide ongoing advice and guidance to the Conference on Federal-Provincial-Territorial ministers on key national health care issues. Recognizing the shared federal and provincial/territorial obligations to the health care system, one of the main purposes of the Canadian Health Charter is to reinforce the national character of the health system. The federal government would be expected to make significant commitments in a number of areas, including a review of the Canada Health Act, changes to the federal transfers to provinces and territories, and a review of federal tax legislation. While these three “pillars” will address the broader structural and procedural problems facing Canada’s health care system, there are many other changes required to meet specific needs within the system in the short to medium term. The CMA has provided specific recommendations in the following key areas: * Meaningful stakeholder input and accountability * Defining the public health system (e.g. core services, a “safety valve”, Public Health, Aboriginal health) * Investing in the health care system (e.g. human resources, capital infrastructure, surge capacity, information technology, and research and innovation) * Health system financing * Organization and delivery of services (e.g. consideration of the full continuum of care, physician compensation, rural health, the private sector, the voluntary sector and informal caregivers) The following is a summary of the key recommendations set out in A Prescription for Sustainability. While we have put an emphasis on having the recommendations as self-contained as possible, readers are encouraged to consult the corresponding section of this paper as appropriate for further details. The first five recommendations refer specifically to the three pillars. The remaining recommendations address the more specific and immediate needs of the health care system. Recommendation 1 That the governments of Canada adopt a Canadian Health Charter that * reaffirms the social contract that is Medicare * acknowledges the ongoing roles of governments in terms of overall coordination and health planning * sets out the accessibility and portability rights and responsibilities of residents of Canada * sets out the rights and responsibilities of the governments, providers and patients in Canada * provides for a “Canadian Health Commission.” Recommendation 2 That a permanent Canadian Health Commission be established and operate at arm’s length from governments. The Commission’s mandate would include * monitoring compliance with the Canadian Health Charter * reporting annually to Canadians on the performance of the health care system and the health status of the population * advising the Conference of Federal-Provincial-Territorial Ministers of Health on critical issues. Recommendation 3 That the federal government undertake a review of the Canada Health Act with the view to amending it * to embody the Canadian Health Charter within it * to provide for the Canadian Health Commission and * to allow for a broader definition of core services and for certain service charges under certain terms and conditions. Recommendation 4 (a) That the federal government’s contribution to the publicly funded health care system * be harmonized with the five-year review of the federal equalization program * be locked-in for a period of five years, with an escalator tied to a three-year moving average of per capita GDP * rise to a target of 50% of provincial/territorial per capita health spending for core services * provide for notional earmarking of funds for health. (b) That the federal government create special purpose, one-time funds totalling $2.5 billion over five years (or build on existing funds) to address pressing issues in the following areas * health human resources planning * capital infrastructure * information technology * accessibility fund. Recommendation 5 That a blue ribbon panel of Parliament be established to work with the Canadian Health Commission to review the current provisions of federal tax legislation with a view to identifying ways of enhancing support for health policy objectives through tax policy. Recommendation 6 That governments and regional health authorities initiate or enhance significant efforts to secure the participation of and input from practicing physicians at all levels of health care decision-making. Recommendation 7 That all Canadians be provided coverage for a basket of core services under uniform terms and conditions. Recommendation 8 (a) That the scope of the basket of core services be determined and be updated regularly to reflect and accommodate the realities of health care delivery and the needs of Canadians. (b) That the scope of core services should not be limited by its current application to hospital and physician services, provided that access to medically necessary hospital and physician services is not compromised. Recommendation 9 (a) That the scope of the basket of core services be determined and regularly updated by a federal-provincial-territorial process that has legitimacy in the eyes of Canadians – patients, taxpayers and health care professionals. (b) That the values of transparency, accountability, evidence-based, inclusivity and procedural fairness should characterize the process used to determine the basket of core services to include under Medicare. Recommendation 10 (a) That governments develop a new framework to govern the funding of a basket of core services with a view to ensuring that * Canadians have reasonable access to core services on uniform terms and conditions in all provinces and territories * governments, providers and patients are accountable for the use of health care resources * no Canadian is denied essential care because of her or his personal financial situation. (b) That legislation be amended to permit at least some core services to be cost-shared under uniform terms and conditions in all provinces and territories. (c) That once the basket of core services is defined, minimum levels of public funding for these services be uniformly applied across provinces and territories, with flexibility for individual governments to increase the share of public funding beyond these levels. Recommendation 11 (a) That Canada’s health system develop and apply agreed upon standards for timely access to care, as well as provide for alternative care choices – a “safety valve” – in Canada or elsewhere, if the publicly funded system fails to meet these standards. (b) That the following approach be implemented to ensure that governments are held accountable for providing timely access to quality care. * First, governments must establish clear guidelines and standards around quality and waiting times that are evidence-based and that patients, providers and governments consider reasonable. An independent third-party mechanism must be put in place to measure and report on waiting times and other dimensions of health care quality. * Second, governments must develop a clear policy which states that if the publicly funded health care system fails to meet the specified agreed-upon standards for timely access to core services, then patients must have other options available to them that will allow them to obtain this required care through other means. Public funding at the home province rate would follow the patient in this circumstance, and patients would have the opportunity to purchase insurance on a prospective basis to cover any difference in cost. Recommendation 12 (a) That governments demonstrate healthy public policy by making health impact the first consideration in the development of all legislation, policy and directives. (b) That the federal government provide core funding to assist provincial and territorial authorities in improving the coordination of prevention and detection efforts and the response to public health issues among public health officials, educators, community service providers, occupational health providers, and emergency services. (c) That governments invest in the human, infrastructure and training resources needed to develop an adequate and effective public health system capable of preventing, detecting and responding to public health issues. (d) That governments undertake an immediate review of Canada’s self-sufficiency in preventing, detecting and responding to emerging public health problems and furthermore, facilitate an ongoing, inclusive process to establish national public health priorities. Recommendation 13 That the federal government adopt a comprehensive strategy for improving the health of Aboriginal peoples which involves a partnership among governments, nongovernmental organizations, universities and the Aboriginal communities. Recommendation 14 (a) That the federal government establish a $1 billion, five-year Health Resources Education and Training Fund to (1) further increase enrolment in undergraduate and postgraduate medical education (including re-entry positions), (2) expand the infrastructure (both human and physical resources) of Canada’s 16 medical schools in order to accommodate the increased enrolment and (3) enhance continuing medical education programs. (b) That the federal government increase funding targeted to institutions of postsecondary education to alleviate some of the pressures driving tuition fee increases. (c) That the federal government enhance financial support systems for medical students that are (1) non-coercive, (2) developed concomitantly or in advance of any tuition increase, (3) in direct proportion to any tuition fee increase and (4) provided at levels that meet the needs of the students. (d) That incentives be incorporated into medical education programs to ensure adequate numbers of students choose medical fields for which there is greatest need. Recommendation 15 (a) That governments and communities make every effort to retain Canadian physicians in Canada through non-coercive measures and optimize the use of existing health human resources to meet the health needs of Canadian communities. (b) That the federal government work with other countries to equitably regulate and coordinate international mobility of health human resources. (c) That governments adopt a policy statement that acknowledges the value of the health care workforce in the provision of quality care, as well as the need to provide good working conditions, competitive compensation and opportunities for professional development. Recommendation 16 (a) That a national multistakeholder body be established with representatives from the health professions and all levels of government to develop integrated health human resource strategies, provide planning tools for use at the local level and monitor supply, mix and distribution on an ongoing basis. (b) That scopes of practice should be determined in a manner that serves the interests of patients and the public, safely, efficiently, and competently. Recommendation 17 (a) That hospitals and other health care facilities conduct a coordinated inventory of capital infrastructure to provide governments with an accurate assessment of machinery and equipment. (b) That the federal government establish a one-time catch-up fund to restore capital infrastructure to an acceptable level. (see Recommendation 4(b).) (c) That governments commit to providing adequate, ongoing funding for capital infrastructure. (d) That public-private partnerships (P3s) be explored as a viable alternative source of funding for capital infrastructure investment. Recommendation 18 That the federal government cooperate with provincial and territorial governments and with governments of other countries to ensure that a strong, adequately funded emergency response system is put in place to improve surge capacity. Recommendation 19 That federal government make an additional, substantial, ongoing national investments in information technology and information systems, with the objective of improving the health of Canadians as well as improving the efficiency and effectiveness of the health care system. Recommendation 20 That governments adopt national standards that facilitate the collection, use and exchange of electronic health information in a manner which ensures that the protection of patient privacy and confidentiality are paramount. Recommendation 21 That the federal government’s investment in health research be increased to at least 1% of national health expenditures. Recommendation 22 (a) That the provincial and territorial governments’ commitment to funding core services be locked-in for an initial five-year period with an escalator tied to provincial population demographics and inflation. (b) That governments establish a health-specific contingency fund to mitigate the effects of fluctuations in the business cycle and to promote greater stability in health care financing. Recommendation 23 That any effort to change the organization or delivery of medical care take into account the impact on the whole continuum of care. Recommendation 24 (a) That governments work with the provincial and territorial medical associations and other stakeholders to draw on the successes of evaluated primary care projects to develop a variety of templates of primary care models that would * suit the full range of geographical contexts and * incorporate criteria for moving from pilot projects to wider implementation, such as cost-effectiveness, quality of care and patient and provider satisfaction. (b) That family physicians remain as the central provider and coordinator of timely access to publicly funded medical services, to ensure comprehensive and integrated care, and that there are sufficient resources available to permit this. Recommendation 25 (a) That governments develop a national plan to coordinate the most efficient access to highly specialized treatment and diagnostic services. * This plan should include the creation of defined regional centres of excellence to optimize the availability of scarce specialist services. * Any realignment of services must accommodate and compensate for the relocation of providers. * That the federal government create an accessibility fund that would support interprovincial centres of excellence for highly specialized services. Recommendation 26 That governments respect the principles contained in the CMA’s policy on physician compensation and the terms of duly negotiated agreements. Recommendation 27 That governments work with universities, colleges, professional associations and communities to develop a national rural and remote health strategy for Canada. Recommendation 28 That Canada’s health care system make optimal use of the private sector in the delivery of publicly financed health care provided that it meets the same standards of quality as the public system. Recommendation 29 That governments examine ways to recognize and support the role of the voluntary sector in the funding and delivery of health care, including enhanced tax credits. Recommendation 30 That governments support the contributions of informal caregivers through the tax system. 1. Introduction Medicare emerged from the 1990s bent, but not broken — in large measure, due to the tireless efforts of professionals whose commitment has always been, first and foremost, to their patients. But this level of effort cannot continue. Canadian health care providers and the facilities they work in are stretched to the limit. Our system is truly at a crossroads. The Commission on the Future of Health Care in Canada has a unique opportunity to sculpt a health care system that will meet the needs and expectations of Canadians for the 21st century. Fundamentals and principles of change management must be satisfied for change to be of lasting value. Decision-making processes must become more accessible, accountable and transparent to those most affected. Canadians are tired of the “blame game,” and physicians and other health providers are tired of being marginalized. Why is it that those who have the most at stake and those who have the most invested in the health system — namely patients, physicians and other providers — have the least say in system change? All parties need to be at the table. Health professionals have not been involved in an early, ongoing or meaningful way in discussions about the future of their health and health care systems. This must change. Another prerequisite for effective change is to reaffirm that there is more to health than health care. Although Canada has led the world in thinking about the overall determinants of health, the same cannot always be said when it comes to action. Canada needs broad consensus around a multi-year, national health action plan — one that is developed in collaboration with all the key players in the system and one that has clear goals, objectives and milestones. At the same time, sustainability must be seen as ensuring that Canadians have access to required services at the time and to the extent of their need. Canadians have lost confidence that the system will be there for them and for their children. Sustainability is about the legacy of Medicare. These are some of the key issues and challenges that the CMA stressed in earlier submissions to the Commission. In our first report, entitled Getting the Diagnosis Right (November 2001; see Appendix A), we described the signs and symptoms of a system in distress. Earlier this year, in our interim submission, entitled Getting It Right (Appendix B), we outlined some of the broad choices that we have to make as a society to help stabilize the Medicare “patient” and transport it into a sustainable future. As part of this future, the interim report proposed a Canadian Health Charter, which has received considerable attention. In this, our final submission to the Commission, we have built on the earlier work and ask the Commission to consider our Prescription for Sustainability. It is important to note that the recommendations we present to the Commission are integrated; and therefore we ask that they not be “cherry-picked”. This document also refers to a number of appendices that will be available as a separate volume. A great deal of policy research has been done on what changes are needed to make progress. The weak link has been in dealing with the “how.” The CMA believes that if we get the structures and processes right in terms of accountabilities, positive health outcomes will follow for our patients and for the future sustainability of the system. 2. Vision Several attempts have been made over the years to articulate a national vision for Medicare, but they have all proven inadequate. However laudable these attempts may be, they all suffer the fatal flaw of isolationism: they were all developed by governments — federal, provincial or territorial — in isolation from health care providers and the public. Goodwill, collaboration and partnership cannot be legislated or dictated from on high. In planning for the future, we have consistently argued for a values-based approach centred on a shared vision. The CMA has established a vision for Medicare that forms the basis of our recommendations for improving the design and functioning of the health care system. CMA’s Vision for a Sustainable Health System The goal of Canada’s health system is to preserve, protect and improve the health and well-being of each Canadian. This will be achieved through timely access to services that not only keep people well or restore health, but also enhance their quality of life and add longevity. Health care is an investment in both economic and social terms, providing benefits of value to both individuals and society. The objective of publicly funded health care is timely access to quality care through a defined set of core services that — as the principal building blocks of Canada’s overall health care system — must be provided on a sustainable basis. These core services must be determined and regularly reviewed in an inclusive and transparent manner. This will result in clear choices as to which services will be fully publicly funded, partly publicly funded and fully privately funded. The special nature of care related to illness — the original focus of Medicare — must continue to be recognized. Core services must reflect the immediacy with which such care is required, the potential to place a financial burden on individuals and families, and the unpredictability as to when such care will be required by an individual. Canadians should be able to choose who will provide their care, what the treatment(s) will be and where it will be provided. Every Canadian should have access to a physician of their choice and, in particular, should be encouraged to select a primary care physician who provides continuity of care. Physicians play key roles as agents and advocates for their own patients and for the public at large; they seek a health care system that respects the integrity and primacy of the patient–physician relationship. Payment and delivery mechanisms should be structured to foster and support these roles and to protect clinical and professional autonomy. Evidence-based care with explicit standards and benchmarks (e.g., maximum, acceptable waiting times) is a prerequisite to achieving high-quality health care — a primary objective of the public system. Individuals should have the opportunity to purchase health services where they are not publicly funded and where the public system does not meet agreed-upon standards. 3. Three Pillars of Sustainability The CMA believes that the current health policy decision-making system is fundamentally flawed and that three steps must be taken to help put the health of Canadians first. The three inextricably linked “pillars of sustainability” presented here are long-term structural and procedural reforms needed to improve accountability and transparency and, thus, enhance the overall sustainability of the system. In Getting the Diagnosis Right, we contended that Canadians had lost confidence that the system would be there for them and their families at the time and to the extent of their need. In our interim report, we also indicated that Canadian health care providers have never felt more demoralized or disenfranchised. The shortages of providers, poor access, resource constraints and passive privatization that occurred through most of the 1990s have combined to create uncertainties around the scope of coverage and the standard of care Canadians can expect from their health care system. The CMA believes that these uncertainties that accompany unplanned changes have also had a deleterious effect on the Canadian economy and a demoralizing effect on the health care community. On both counts, a clarification of the social contract for health is required at the highest level. 3.1 Canadian Health Charter The need to renew the social contract underlying Medicare raises a number of fundamental questions. What will this new social contract look like? Where will it be vested? Who will oversee its development and implementation? And what difference will it make for Canadians? The answers to these questions are set out below in the CMA’s proposal for a Canadian Health Charter. 3.1.1 What is it? The concept of a Canadian Health Charter is not new. The 1964 report of the Royal Commission on Health Services chaired by Justice Emmett Hall recommended a charter that set out a vision for a universally accessible system of prepaid health care, including the roles and responsibilities for individual Canadians, providers and governments. Currently, neither the Canada Health Act nor the Charter of Rights and Freedoms offers Canadians an explicit right of access to quality health care delivered within an acceptable time-frame.1 Moreover, Canadians do not have the benefit of a clearly articulated national health policy that sets out our shared understanding of Medicare and the rights and mutual obligations of individual Canadians, health care providers and governments. Without such a national policy statement to set the broad parameters around which Canada’s health system can be managed and modernized, the Medicare debate will continue to be characterized by rhetoric, hidden agendas and fruitless finger-pointing. To be certain, the notion of a Canadian Health Charter raises many issues in a decentralized federation such as Canada, where the constitutional responsibility for health care delivery lies with provinces and territories. Having examined the relevant legal, political and health policy considerations, the CMA is proposing the development and formal approval of a Canadian Health Charter based on a renewed partnership between levels of government and with the agreement of patients and providers.2 3.1.2 What would it look like? The CMA envisions a charter with three main parts: a vision statement, a section on national planning and coordination and a section on roles, rights and responsibilities. The CMA has developed an illustrative example of a charter in a separately released paper, Charter at a Glance. Vision Although there is no shortage of vision statements for Medicare, there is no single shared vision. The federal government, provinces and territories and individual stakeholders have all developed their own visions for various purposes and at various times. In some cases, such as the September 2000 Health Accord, governments have gone as far as issuing jointly approved vision statements. What is needed is for all parties to come together and achieve consensus on a shared vision that will lay out a modern view of Canada’s health system. The CMA has articulated its own vision in section 2, above. National planning and coordination The Canadian Health Charter would set out the requirement for national planning and coordination based on such principles as collaboration, evidence-based decision-making, stable and predictable funding, regional and local flexibility, and accountability. It could also specify areas where national planning and coordination are required, particularly with respect to the determination and regular review of core health care services; the development of national benchmarks for timeliness, accessibility and quality of health care; health system resources including health human resources and information technology; and the development of national goals and targets to improve the health of Canadians. The charter would also provide for the creation of a Canadian Health Commission to monitor compliance with and measure progress towards charter provisions, report to Canadians on the performance of the health care system, and provide ongoing advice and guidance to the Conference of Federal–Provincial–Territorial Ministers on key national issues. Roles, rights and responsibilities One of the key aims of the charter would be to develop a common understanding of the roles, rights and responsibilities of the key players in the renewal of Medicare. Key aspects of understanding would include * Acknowledgement of the ongoing role of governments in terms of overall coordination and health planning * Reinforcement of the accessibility and portability rights of the residents of Canada by a clear and unequivocal statement that governments must do everything in their power to provide reasonably comparable access to timely, high-quality health care3 * Establishment of the rights and responsibilities of patients, providers and governments in Canada. 3.1.3 Development and implementation of a charter Key features of our proposed Canadian Health Charter are as follows. * National mandate: It will be an inclusive document — one that is truly national as opposed to federal or interprovincial or interterritorial. * Values-based: It will be consistent with publicly accepted values and principles. * Enforceable: It will achieve compliance to its provisions through administrative mechanisms rather than through the courts. * Non-derogational: It will respect federal, provincial and territorial jurisdictional boundaries. The Canadian Health Charter will only be as good as the process put in place to develop it and to oversee its implementation. Although it may be too early to speculate on how this would be orchestrated, we make the following observations. * The development of the Canadian Health Charter will require a broad consultative process. Although this process could be led by governments, it should be developed in an inclusive manner with all stakeholders, including organizations representing health care providers and consumers. * Once consensus is reached on a proposed Canadian Health Charter, it will be important for the federal, provincial and territorial governments to give it formal approval. This could be accomplished in a number of ways, including approval at a first ministers meeting, through the elected assemblies or by way of a royal proclamation.4 Recommendation 1 That the governments of Canada adopt a Canadian Health Charter that * reaffirms the social contract that is Medicare * acknowledges the ongoing roles of governments in terms of overall coordination and health planning * sets out the accessibility and portability rights and responsibilities of residents of Canada * sets out the rights and responsibilities of the governments, providers and patients in Canada * provides for a “Canadian Health Commission.” 3.2 Canadian Health Commission What is clear from the past decade — through numerous provincial Commissions, a three-year National Health Forum, a Senate study and now the Commission on the Future of Health Care in Canada — is that strategic health planning is a never-ending challenge. This is why we need a permanent, depoliticized forum at the national level for ongoing dialogue and debate — a Canadian Health Commission. 3.2.1 Structure, composition and mandate Our thinking on the development of a Canadian Health Commission has been guided by a number of precedents and models that have been used in the Canadian context, beginning with the Dominion Council of Health, which was provided for in the Act constituting the Department of Health in 1919. It was formed to facilitate coordination with the provinces and territories and various private organizations on health matters and was the principal advisory agency to the Minister of National Health and Welfare. Membership comprised the federal deputy minister (chair), provincial deputy ministers and external members representing women’s organizations, labour, agriculture and medical science. We also examined more recent models of national advisory and oversight bodies. More details on the structures and basic mandates of these bodies are provided in Appendix C. Our assessment of these Commissions, roundtables and councils leads us to a number of conclusions about the structure and composition of the Canadian Health Commission: * Independence: The Commission should be at arm’s length from governments and have the freedom to conduct research and advise governments on a broad range of health and health care issues. However, it should have close links with government agencies such as the Canadian Institute for Health Information and the Canadian Institutes for Health Research to facilitate its work. * Transparency: The Commission should be open and transparent. We do not want to recreate the black box of executive federalism. Government representatives would be welcome as observers, and the Commission’s deliberations would be made public. * Credibility: The composition of the Commission should reflect a broad range of perspectives and expertise necessary fulfill its mandate. Appointments should not be constituency-based, to ensure that constituency politics do not interfere with the Commission’s deliberations. * Legitimacy: Although the Commission would be established by the federal government, its structure, composition and mandate will have to be legitimate in the eyes of provincial and territorial governments. * Permanence: The Commission should be permanent and it should be afforded adequate resources to do its job, subject to a regular review of its mandate and effectiveness. * Stakeholder engagement: The Commission should include representation from the general public and should seek to engage Canadians at large through research, consultation and public education activities. * Authoritative leadership: The Commission should be chaired by a Canadian Health Commissioner, who would be an officer of Parliament (similar to the Auditor General) appointed for a five-year term by consensus among the federal, provincial and territorial governments. The Health Commissioner would not be a substitute for the federal minister of health. The minister of health would continue to be responsible to Parliament for federal health policies and programs, as well as for promoting intergovernmental collaboration on a range of health and health care issues. The Commissioner would be afforded the powers necessary to conduct the affairs of the Commission, such as the power to call witnesses before hearings of the Commission. The Commission’s mandate would include the following responsibilities: * Monitor compliance with the Canadian Health Charter * Report annually to Canadians on the performance of the health care system and the health status of the population * Advise the Conference of Federal–Provincial–Territorial Ministers of Health on critical questions such as: - defining the basket of core services that would be publicly financed - establishing national benchmarks for timeliness, accessibility and quality of health care - planning and coordinating health system resources at the national level, including health human resources, information technology, and capital infrastructure - developing national goals and targets to improve the health of Canadians. Recommendation 2 That a permanent Canadian Health Commission be established and operate at arm’s length from governments. The Commission’s mandate would include * monitoring compliance with the Canadian Health Charter * reporting annually to Canadians on the performance of the health care system and the health status of the population * advising the Conference of Federal-Provincial-Territorial Ministers of Health on critical issues. 3.3 Renewing the Federal Legislative Framework Flowing from the Canadian Health Charter will be a number of moral and political obligations directed at the federal, provincial, and territorial governments, providers and patients. Recognizing the shared federal, provincial and territorial obligations to the health care system, one of the main purposes of the Charter is to reinforce the national character of Canada’s health system. The federal government would be expected to make significant commitments in a number of areas. 3.3.1 The Canada Health Act The Canada Health Act (CHA) was adopted by Parliament in 1984 as the successor to federal legislation governing cost-sharing agreements for hospital and medical insurance. Its principles have become the cornerstone of Medicare. The CHA articulates the underlying vision and values of Medicare and sets out the five conditions with which provincial and territorial health insurance plans must comply — universality, accessibility, comprehensiveness, portability and public administration — to receive the full federal financial contribution that they are entitled to under the Canada Health and Social Transfer (CHST). Thus, the Canada Health Act is the linchpin that holds together 13 separate provincial and territorial health systems. Although the CHA has been a lightning rod for several federal–provincial–territorial disputes over the years, the reasons for these disagreements have had more to do with politics than with the substance of the act. In fact, if there is one public policy issue in Canada over which there is near unanimity across provinces and territories and across political parties, it is that the principles of the CHA are sound. Recently, federal, provincial and territorial governments agreed to establish a formal dispute avoidance and resolution mechanism to deal more openly and transparently with issues arising from the interpretation of the Canada Health Act. The CMA applauds this development. In section 5.1.3 of this report, the CMA calls for the establishment of a process at the national level to determine and review regularly the basket of core services in an open, transparent and evidence-based manner. The CHA should be amended to provide for such a process. Finally, and perhaps most importantly, the CHA should be amended to reflect the Canadian Health Charter. This would include changing the preamble to ensure that it reflects a modern vision and values of Medicare, provides for a Canadian Health Commission, recognizes the federal role and reflects the accessibility and portability rights of Canadians. Recommendation 3 That the federal government undertake a review of the Canada Health Act with the view to amending it * to embody the Canadian Health Charter within it * to provide for the Canadian Health Commission and * to allow for a broader definition of core services and for certain service charges under certain terms and conditions. 3.3.2 Transfers to provinces and territories The nature of Canada’s publicly funded health care system creates unique challenges and opportunities regarding accountability and sustainability. Provinces and territories have the constitutional responsibility for health care and provide most of the funding; the federal government’s role includes funding and is based on the desire of Canadians to have the semblance of a national health care program. The CMA has been a strong advocate of stable, predictable and adequate federal funding for health care. The federal government has responded by introducing a cash floor for the CHST and by restoring some of the cuts made during the 1990s. However, the federal government still has a long way to go. Cash transfers must be increased if the federal government is to be considered a credible partner in Medicare. A larger and continuing federal role in health care financing is required, and the allocation of funds must be done more transparently and in support of a longer planning horizon. Transparency in federal funding for health care means that the federal government can no longer claim to be spending its CHST contribution three ways. Canadians have a right to know how much of their federal tax dollars is being transferred to provinces and territories to support Medicare. The same should hold for transfers related to postsecondary education and social services. Although this may be at odds with the prevailing doctrine in the ministries of finance and intergovernmental affairs, it is the least that Canadians can expect from their governments in terms of accountability. It also serves to underscore the fact that the underlying purpose of fiscal federalism is to support Medicare and other important social programs, not the reverse. In addition to the transfer of block funds to provinces and territories, the sheer magnitude and pressing nature of many issues facing Medicare warrant the use of one-time only, targeted, special-purpose transfers. Precedents for these types of transfers include the National Health Grants Program created in 1948 to develop hospital infrastructure across the country, as well as the more recent funds created to support early child development, medical equipment, the health infoway and primary care renewal. This type of approach, coupled with more stringent accountability provisions to ensure that the funds are spent as intended, should be used to address serious system shortcomings in the areas of health human resources, capital infrastructure and information technology. Recommendation 4 (a) That the federal government’s contribution to the publicly funded health care system * be harmonized with the five-year review of the federal equalization program * be locked-in for a period of five years, with an escalator tied to a three-year moving average of per capita GDP * rise to a target of 50% of provincial/territorial per capita health spending for core services * provide for notional earmarking of funds for health. (b) That the federal government create special purpose, one-time funds totalling $2.5 billion over five years (or build on existing funds) to address pressing issues in the following areas * health human resources planning * capital infrastructure * information technology * accessibility fund. 3.3.3 Tax policy in support of health In the past, the Government of Canada has relied heavily on its spending power and legislation to influence the development of Medicare across Canada. However, increasing concern associated with Canada’s health care system has obliged the federal government to maximize all its available policy levers, including taking another look at how the tax system can be used to support renewal of the health sector. Although taxes are widely used as a public policy tool, to date the role of taxation in the area of health has been relatively small. In total, personal income tax assistance (i.e., foregone government revenue) for health was estimated at $3.8 billion in 2001, equal to only a little more than 3.7% of total health expenditures for that year. The tax system interfaces with the health sector at three levels — health care financing, health care inputs and lifestyle choices. Key questions of reform that could be addressed through a review of the tax system at these levels include the following. Health care financing * Could tax incentives be used to improve access to private supplemental insurance? * How could increased tax relief be provided to people with high out-of-pocket medical expenses? * Should the tax system be used to encourage personal savings for long-term care? Health care inputs * How could tax incentives be used to address health human resource issues (e.g., attracting physicians and nurses to rural and remote areas, off-setting high costs of medical education, promoting continuing education)? * How can the federal government proceed with changes to the tax system to ensure equitable treatment of all health providers (e.g., GST)? * Could enhanced tax credits be developed to support informal caregivers? * Could tax incentives be used to promote research and innovation in health care beyond the pharmaceutical sector? Lifestyle choices * How could the tax system be used to encourage healthy lifestyles (e.g., incentives to eat well and exercise; disincentives for unhealthy choices)? The level of support provided by the tax system for people facing high out-of-pocket expenses is a particularly pressing question. Currently, the medical expenses tax credit provides limited relief to those whose expenses exceed $1,637 or 3% of net income. The 3% threshold was established before Medicare was introduced. Does it still make sense in 2002? Are there ways to enhance this provision to reduce financial disincentives facing many Canadians when they have to pay for health services that may not be medically necessary, but are beneficial and worthy of government support? The CMA encourages the federal government to undertake a comprehensive review of these and other tax questions pertaining to health. Clearly, we do not believe tax policy will, by itself, solve all of the challenges facing Canada’s health care system. Nevertheless, the CMA believes that the tax system can play a key role in helping the system adapt to changing circumstances, thereby complementing the other two components of our renewal strategy. Recommendation 5 That a blue ribbon panel of Parliament be established to work with the Canadian Health Commission to review the current provisions of federal tax legislation with a view to identifying ways of enhancing support for health policy objectives through tax policy. 4. Meaningful Stakeholder Input and Accountability In the Commission’s interim report, the question was posed: why are those who have the most to contribute, who are the most committed — Canada’s health professionals — not at the table when the future of health and health care is being discussed by this country’s leaders? Physicians individually and collectively feel disempowered and disengaged. They feel frustrated, marginalized and left out at all levels of decision-making. Nowhere is this more evident than at the national level, where physicians and other health care providers have tried in vain to gain access to the “black box” of executive federalism. Physicians and other providers have been systematically excluded from participating in decisions about the future of health and health care. During the past decade, with the exception of successful joint management ventures at the provincial, territorial or regional levels, physicians have been increasingly marginalized in terms of policy decisions. At the federal–provincial–territorial level, physicians have been frozen out since the late 1980s. At the federal level, organized medicine had no opportunity for formal input to the National Forum on Health. Physicians were specifically excluded from many regional boards when they were established in the early 1990s. Finally, the consolidation of many local governance structures (e.g., hospital boards) into regional boards has reduced opportunities for local decision-making. A basic principle of justice states that those who are affected directly by decisions ought to be present when such decisions are made. Physicians, nurses and others bring much to the table. The grounds for exclusion are often not clear, but tend to be a result of the misguided notion that self-interest might prevail over the collective interest. In today’s environment, with the rapid turnover of senior health officials, we believe the pendulum must swing toward building a table where enlightened self-interest is promoted. Whereas elected officials are in the health business for only a short time, physicians and other providers have their careers on the line. We have the most invested, the most to give and, next to our patients, the most to lose. Why is it that we have the least say in decisions about the future of health and health care? Why is it that we learn about decisions after the fact and are then expected to support them? Canada has paid an enormous price for this policy of exclusion. Ill-informed policy decisions in human health resources planning have had catastrophic results. Recently, the shell game around investments in medical technology has typified how federal, provincial and territorial governments working behind closed doors tend to promote solutions that minimize friction between the two levels of government, but are of little or no concrete benefit to the health care system. We need a more transparent and accountable process. Recommendation 6 That governments and regional health authorities initiate or enhance significant efforts to secure the participation of and input from practicing physicians at all levels of health care decision-making. 5. Defining the Public Health Care System Sustainability and accountability are overarching themes of this submission, and our ultimate goal is timely access to quality care for all Canadians. The time has come to stop making excuses for rationing the publicly funded health care system. Our patients deserve health care that is available to them in a timely fashion in their own country. Canada’s physicians support publicly funded health care, but not if it means patients are denied timely access to quality care and not if it means rationing and denial of necessary care. We strongly believe that all Canadians, regardless of where they live, should have access to high-quality health care. 5.1 Core Services One of the pathways identified in our initial submission was the need to strike a better balance among everything and everyone. No country in the world has been able to provide first-dollar5 coverage for timely access to all services. In light of the rapidly transforming delivery system with its shift from institutional to community-based care, a re-examination of the Medicare “basket” is overdue. 5.1.1 Uniform coverage for all Canadians All Canadians should have coverage for basic health care services under uniform terms and conditions, regardless of where they live. A clearly defined basket of core services is an essential requirement for a national program in a decentralized system of health care such as Canada’s. This basket would ensure that a minimum level of coverage is applied uniformly across all provinces and territories. However, it is important to acknowledge that variation will occur in health care priorities across provinces and territories; as a result, provinces and territories may choose to add to this basket. Recommendation 7 That all Canadians be provided coverage for a basket of core services under uniform terms and conditions. 5.1.2 Redefining core services Since the inception of Medicare in Canada, core services have generally been understood to be those subject to the five program criteria set out in the Canada Health Act. These include medically necessary hospital services, physician services and surgical dental services provided to insured persons. However, as health care delivery has evolved, more and more services have migrated out of the hospital setting, effectively reducing the relative size of the basket of core services. For example, while hospital and physician expenditures accounted for 56% of total health spending in 1984, by 2000 this had declined to 45%. Many services previously provided in hospitals are now delivered through a combination of community-based services and drug therapy. Services that continue to be provided in hospitals are increasingly being provided on a “day surgery” basis (requiring no admission) or during a much shorter stay. If Medicare is to continue to meet the needs of Canadians, then the notion of core services must be changed to cover an array of services consistent with the realities of health care in the 21st century. Specifically, the definition of core services should be reviewed to determine the extent to which it should go beyond hospital and physician services. Recommendation 8 (a) That the scope of the basket of core services be determined and be updated regularly to reflect and accommodate the realities of health care delivery and the needs of Canadians. (b) That the scope of core services should not be limited by its current application to hospital and physician services, provided that access to medically necessary hospital and physician services is not compromised. 5.1.3 A process for clarifying what is in and what is out There is no simple way to decide what the basket of core services should include or exclude. It involves making difficult value judgements and trade-offs and achieving consensus among a broad cross-section of perspectives and interests. For several years, the CMA has advocated a balanced approach to the determination of core services that addresses the issues of ethics, quality (evidence) and economics (Appendix D). The risks of not making these difficult decisions have become all too clear: a health system that is locked into antiquated notions of health care and is increasingly out of touch with the needs of Canadians. The process used to determine core services should be inclusive and transparent. Decisions should be evidence-based and not biased in favour of any single provider or setting in which care is provided. The special nature of care related to illness should be recognized ? emergent vs. non-emergent conditions, the potential financial burden on individuals and families, and the inability to predict when such care will be required. Most important, whoever is assigned the task of defining and updating the basket of core services must have legitimacy in the eyes of the public. The CMA believes that the values listed below should characterize the process used to determine the basket of core services covered under Medicare. Values for Determining Core Services Transparency: The process and principles or rules on which decisions are based should be open to scrutiny and made public. Accountability: Decision makers should have proper authority to make these decisions and provisions should be in place for them to be held accountable for the decisions they make. Evidence-based: The decision-making process should incorporate relevant empirical evidence as available and appropriate. Inclusivity: Parties having an important stake in the decisions, should be identified, consulted and included in decision-making. Recommendation 9 (a) That the scope of the basket of core services be determined and regularly updated by a federal-provincial-territorial process that has legitimacy in the eyes of Canadians – patients, taxpayers and health care professionals. (b) That the values of transparency, accountability, evidence-based, inclusivity and procedural fairness should characterize the process used to determine the basket of core services to include under Medicare. 5.1.4 Funding core services - finding a new Canadian compromise Under the Canada Health Act, provinces and territories must ensure that medically necessary physician and hospital services are provided on a first-dollar basis. Beyond these core services, provinces and territories provide varying degrees of coverage for other services, which are funded through a mix of government funding and patient cost-sharing. Some services are completely funded from private sources. Beyond hospital and physician services, there is no uniformity across provinces and territories in the terms and conditions under which services may be partly covered under the public funding umbrella. If the basket of core services is to be expanded beyond its focus on physician and hospital care, then certain realities must be addressed. First, although first-dollar coverage may be required to maintain access to services for the most vulnerable in society, its universal application creates the illusion that health care services are free when they clearly are not. Second, given limited fiscal resources and political priorities, governments will likely not be able to afford first-dollar coverage for an expanded set of core services. Without additional funding, resources will have to be reallocated from hospital and physician services to finance other services added to the basket. This argues for a different approach to the funding of core services — one that is more pragmatic and less ideologically driven. Under this approach, health services would be divided into three categories: those that are exclusively publicly funded, those that are partly publicly funded, and those that are exclusively privately funded. The services in the first two categories would be defined as core services. As discussed earlier, the basket of core services would be determined and regularly updated by a legitimate, multistakeholder group using an evidence-based process; it should no longer be defined on the basis of whether the services are 100% publicly financed. If core services are redefined to include services that are currently financed through a mix of private and public funding, then Canadians must be prepared to review the use of first-dollar coverage to ensure that it is applied where it is most needed to maintain access to core services. Uniform terms and conditions for core services with mixed private–public funding must also be developed, i.e., by defining the minimum level of public funding from all provinces and territories. The development of uniform terms and conditions around those services that receive a mix of public and private funds has never been addressed in Canada. Even though the criteria of the Canada Health Act ? universality, accessibility, comprehensiveness, portability and public administration ? should be relatively easy to apply in a world of first-dollar coverage, Canada’s health system has not been able to satisfy all of them consistently. It is essential that these criteria be more diligently applied to core services that are funded on the basis of first-dollar coverage. In addition, they must be adapted to provide an effective framework of terms and conditions to govern access to services with mixed private–public funding. There is a need for a more rational discussion of the role of patient cost-sharing in the Canadian health care system. Many types of mechanisms for cost-sharing are in place today, including premiums, deductibles, co-payments, charges at point of service and taxation of health benefits. Here again, governments should adopt approaches that promote transparency and accountability, while ensuring that no one is denied care because they cannot afford to pay. Service charges are an acceptable part of the provision of many important health-related products and services such as pharmaceuticals and dental care. Furthermore, the Canada Health Act makes an explicit provision for chronic care co-payments. However, other services such as physician and hospital services are currently considered off-limits. Certain services that possess an “amenity” component, such as some pharmaceuticals, prostheses and certain elements of home care could continue to include a service charge to cover a portion of the service. However service charges are applied, it should be done in a fair and equitable manner that takes into consideration those at a financial disadvantage so that it does not impede access to necessary care, but encourages appropriate use of the health care system. In addition, patient cost-sharing arrangements for core services must be consistent across provinces and territories. Minimum thresholds for the public share of financing could be established for different categories of core services; however, any jurisdiction would be free to increase its share to a level above the minimum. Recommendation 10 (a) That governments develop a new framework to govern the funding of a basket of core services with a view to ensuring that * Canadians have reasonable access to core services on uniform terms and conditions in all provinces and territories * governments, providers and patients are accountable for the use of health care resources * no Canadian is denied essential care because of her or his personal financial situation. (b) That legislation be amended to permit at least some core services to be cost-shared under uniform terms and conditions in all provinces and territories. (c) That once the basket of core services is defined, minimum levels of public funding for these services be uniformly applied across provinces and territories, with flexibility for individual governments to increase the share of public funding beyond these levels. 5.2 Care Guarantee and “Safety Valve” A common frustration in recent years among many physicians and patients has been the lack of any recourse or alternative care in Canada when the publicly funded health system fails to provide timely access to health care. For Canadians, the only alternative since the inception of Medicare has been to turn to the United States or other countries for medical care. This may have been acceptable in the early days of Medicare when public funding was plentiful and the need to seek care outside of Canada was more theoretical than real; however, in 1998, the National Population Health survey estimated that some 17,000 Canadians traveled to the United States to seek medical care. Clearly, this is not an option for most Canadians. Recent court cases have held provincial governments accountable for providing timely care. An increasing number of Canadians are seeking private care in Canada, such as at private magnetic resonance imaging (MRI) clinics, even though this service is potentially in conflict with the principles of the Canada Health Act. The public has, in effect, built its own safety valve. This is a concrete example of what happens when the publicly funded system fails to respond to a legitimate demand. This gap in Canadian health policy must be addressed in a way that compels the system to provide timely care while preserving the right of Canadians to seek alternate care if the public system fails to deliver. The first step in addressing these issues is to define core services. The second step is to establish guidelines and standards around quality and waiting times that are evidence-based and that patients, providers and governments consider reasonable. To date, the best example of such benchmarking in Canada has been by the Cardiac Care Network in Ontario. The CMA has reviewed progress toward the development of benchmarks in A Canadian Health Charter: A Background Discussion Paper, which examines Canadian and international experience with health charters. We have also written a policy on operational principles for the measurement and management of waiting lists (Appendix E). If the publicly funded health care system fails to meet the specified agreed-upon standards for timely access to core services, then patients must have other options to allow them to obtain this required care through other means. Step three involves setting up a “safety valve” to address situations where the established time guarantees cannot be met. This safety valve provision would allow patients and their physicians to seek required care wherever it is available. Attempts would be made to find care geographically close to the patient — first within the province or territory, then in another province or territory or even out of country. The public funds that would have been used to pay for the patient’s care if the time guarantee had been met would be used to pay for the service wherever it is provided. In some cases, the cost of this service will be more than what would have been charged had the service been available in a timely manner from the public system in the patient’s home province or territory. Patients would be able to purchase supplementary private insurance on a prospective basis to cover this difference in cost. Ideally, Canadians would never have to use this “safety valve.” However, its inclusion in Canadian health policy will provide assurances and help restore public confidence in the health system. It will also remind governments about the repercussions of not living up to mutually agreed-upon commitments to provide timely access to care. Recommendation 11 (a) That Canada’s health system develop and apply agreed upon standards for timely access to care, as well as provide for alternative care choices – a “safety valve” – in Canada or elsewhere, if the publicly funded system fails to meet these standards. (b) That the following approach be implemented to ensure that governments are held accountable for providing timely access to quality care. * First, governments must establish clear guidelines and standards around quality and waiting times that are evidence-based and that patients, providers and governments consider reasonable. An independent third-party mechanism must be put in place to measure and report on waiting times and other dimensions of health care quality. * Second, governments must develop a clear policy which states that if the publicly funded health care system fails to meet the specified agreed-upon standards for timely access to core services, then patients must have other options available to them that will allow them to obtain this required care through other means. Public funding at the home province rate would follow the patient in this circumstance, and patients would have the opportunity to purchase insurance on a prospective basis to cover any difference in cost. 5.3 Public Health Canada has been a leader in recognizing that there is more to health than health care. The Hon. Marc Lalonde’s 1974 New Perspective on the Health of Canadians, which has since become world renowned, introduced the health field concept that emphasized the role of environmental and lifestyle determinants of health. Public health is often associated with measures to prevent illness, such as safe drinking water, sanitation, waste disposal, immunization programs, well-baby clinics or programs promoting healthy lifestyles. It is the organized response of society to protect and promote health and to prevent illness, injury and disability. Public health carries out its mission through organized, interdisciplinary efforts that address the physical, mental and environmental health concerns of the population at risk of disease and injury. These efforts require coordination and cooperation among individuals, governments (federal, provincial, territorial and municipal), community organizations and the private sector. Putting patients first means, among other things, making sure that the health system is capable of stretching to capacity to meet unforeseen circumstances. The need for this “surge capacity” is discussed in more detail in section 6.3. Canadian physicians have long recognized the value of health promotion and disease prevention and have incorporated these elements into their practices. The CMA and its divisions and affiliates have also been active in the field of public health. For its part, the CMA * Worked with the CBC on the first series of public health broadcasts * Was the first organization to call for a ban of smoking on airplanes * Developed a tool to help physicians determine medical fitness to drive * Launched a campaign to reduce traffic injuries (seatbelts, breathalyzers, etc) * Carried out a national Bicycle Helmet Safety Program * Supported warning labels on tobacco products. Public health is complex, and the current status of the public health system in Canada requires a full and open review. In 1999, the auditor general found Health Canada unprepared to fulfill its responsibilities in the area of public health: communication among multiple agencies was poor and weaknesses in the key surveillance system impeded the effective monitoring of communicable and noncommunicable diseases and injuries. It is imperative that various departments and sectors coordinate and communicate effectively to synergize efforts and to avoid duplication. The capacity of the public health care sector to deliver disease prevention and health promotion programs is inadequate, and its ability to respond varies across the country. This situation is due to a lack of trained professionals and a lack of operational funds. Greater commitment is needed from governments at all levels to ensure that adequate human resources and infrastructure are available to respond to public health issues when they arise. This includes the expansion of the public health training programs. Once a public health issue has been identified, it is the responsibility of professionals within the system to use effective means of control. The public health system must be supported by a strong and viable infrastructure to allow them to meet such challenges. Major public health issues facing Canadians include, but are not limited to, high rates of obesity, tobacco and other substance use, mental health challenges, ensuring a clean and safe environment and prevention of injury and violence. The ability of the public health system to respond to these issues directly affects the well-being of Canadians, in a manner as important as the ability of the acute care system to respond to medical emergencies. However, investment in public health initiatives must not be made at the expense of acute and long-term care. Since the 1970s, the World Health Organization and national governments around the world have paid increasing attention and put greater effort into establishing goals for improving public health and into monitoring achievement. Numerous examples can be cited in the United States, England and Australia. In Canada, although the federal government has not attempted to establish goals, several provinces have undertaken such an exercise. Public health priorities or goals are considered to be an asset to a health care system in that they * Provide a baseline assessment of a population’s health and a tracking system for monitoring change * Encourage an increase in the breadth and intensity of health improvement activities and improve the efficiency and effectiveness of existing activities * Facilitate evaluation of the impact of health improvement activities * Foster unity of purpose, organization, participation and spirit of cooperation through consensus * Build awareness of and support for health programs among policymakers and the public * Guide decision-making and funding allocations. At their meeting in September 2000, the first ministers made several commitments to improve public health * Promote the public services, programs and policies that extend beyond care and treatment and that make a critical contribution to the health and wellness of Canadians * Develop strategies and policies that recognize the determinants of health, enhance disease prevention and improve public health * Further address key priorities for health care renewal and support innovations to meet the current and emerging needs of Canadians * Report regularly to Canadians on health status, health outcomes and the performance of publicly funded health services, and the actions taken to improve these services. Unfortunately, there has been little progress to date. Canada must develop a strategic approach to sustain and strengthen the capacity of the public health system to prevent, detect and respond to public health issues. Recommendation 12 (a) That governments demonstrate healthy public policy by making health impact the first consideration in the development of all legislation, policy and directives. (b) That the federal government provide core funding to assist provincial and territorial authorities in improving the coordination of prevention and detection efforts and the response to public health issues among public health officials, educators, community service providers, occupational health providers, and emergency services. (c) That governments invest in the human, infrastructure and training resources needed to develop an adequate and effective public health system capable of preventing, detecting and responding to public health issues. (d) That governments undertake an immediate review of Canada’s self-sufficiency in preventing, detecting and responding to emerging public health problems and furthermore, facilitate an ongoing, inclusive process to establish national public health priorities. 5.4 Aboriginal health Despite improvements in many areas, First Nations, Métis and Inuit people continue to have a poorer health status than the general Canadian population. The current health status of Canada’s Aboriginal peoples is a result of a broad range of factors. It is generally acknowledged that improving it will take a lot more than simply increasing the quantity of health services. The underlying roots of the problem must be addressed; for example, poverty, low levels of education, unemployment and underemployment, exposure to environmental contaminants, inferior housing, substandard infrastructure and maintenance, low self-esteem and loss of cultural identity. A problem of this magnitude and complexity must be addressed in a comprehensive way, with all components of health, government and other sectors working in full partnership with the Aboriginal community. In recognition of this need, in February 2002 the CMA signed a letter of intent with the National Aboriginal Health Organization (NAHO) (Appendix F) to collaborate on activities in four areas of mutual interest: 1. Workforce initiatives: To increase recruitment and retention of physicians and other health professionals, particularly of Aboriginal descent, who serve Aboriginal communities. 2. Research and practice enhancement initiatives: To promote research into Aboriginal health issues and the translation of research into effective clinical practice through means such as dissemination of best-practice information and the development of user-friendly practice tools. 3. Public and community health programs: To address and develop initiatives to promote healthy living for Aboriginal communities. 4. Leadership programs: To develop and implement leadership development initiatives including mentoring programs for Aboriginal physicians. The exploration of these and other areas is essential to improve Aboriginal health status so that it is on par with the rest of the Canadian population. Recommendation 13 That the federal government adopt a comprehensive strategy for improving the health of Aboriginal peoples which involves a partnership among governments, nongovernmental organizations, universities and the Aboriginal communities. 6. Investing in the Health Care System 6.1 Health Human Resources Governments must demonstrate their commitment to the principle of self-sufficiency in the production of physicians to meet the medical needs of the Canadian population. Coverage means nothing without access, and access means nothing without availability of health care professionals. Unfortunately, there are shortages of human resources in various health care disciplines, and these shortages will be exacerbated by the demographics of the Canadian population and of each provider group and by changing public expectations. The population in general is becoming older. Older age groups experience an increased incidence of illness and disability, and thus place higher demands on the health care system. At the same time, significant numbers of health care providers are approaching retirement; in many cases, there are not enough young people entering the professions to replace those who will soon be leaving. Over the past two decades, one of the most striking changes in the medical workforce in Canada has been the increased proportion of female medical graduates: in 1980, women represented 32% of medical graduates; by 1996, this proportion reached 50%. Women now represent 30% of the practising profession in Canada and this will approach 40% by the end of the decade. Although more research is needed, it is clear that male and female physicians have different practice patterns. The changing gender distribution must be taken into consideration when examining the problem of physician supply. A more highly educated population and the widespread use of information sources such as the Internet are contributing to a heightened sense of patient empowerment, higher expectations and consumerism. These factors will increase pressure for high-quality health services. Although we encourage patients to be informed, we must be prepared for the added demands on the health system that this enhanced knowledge will create, especially in terms of the supply of health human resources. The human resources crisis is one of the most important issues facing health care today. Solutions must be found to address the many specific problems that are plaguing all health provider groups. The nursing field is suffering from many of the same challenges as physicians, including attrition and the “brain drain.” The accessibility crisis is compounded by shortages of laboratory technologists and others in the health care field, who directly support the work of physicians. Although these problems must all be addressed to make our health care system sustainable for the future, this document focuses on the professionals about whom the CMA has the greatest knowledge and expertise: physicians. 6.1.1 Supply, training and continuing education All areas of the health care continuum are experiencing a shortage of physicians. The key factors underlying this shortage include physician demographics (e.g., age and gender distribution), changing lifestyle choices and productivity levels (expectations of younger physicians and women differ from those of older generations) and the insufficient numbers entering certain medical fields. According to 2001 data from the Organisation for Economic Co-operation and Development (OECD), Canada ranked 21st out of 26 countries in terms of the ratio of practising physicians to the population. In addition to the factors affecting physician supply mentioned above, other drivers of change, such as technological innovation and information technology, are adding further pressure to an already overworked medical profession. The OECD report further states that empirical evidence shows that lower doctor numbers are closely linked with higher mortality, after taking other health determinants into consideration. Yet, in terms of female and male life expectancy at birth, Canada ranks 7th and 6th, respectively.6 This is a powerful testament to the efforts of Canadian health professionals in putting patients first. Increasing numbers of Canadians feel the impact of the widespread physician shortages when they are unable to find a family physician or they experience delays in seeing specialists. Physicians themselves are finding that they must reduce the time they can spend doing research, teaching and pursuing continuing medical education in order to focus on direct patient care. In November 1999, the Canadian Medical Forum7 (CMF) and the Society of Rural Physicians of Canada met with the federal, provincial and territorial governments to present a detailed report on physician supply containing five specific recommendations. The CMA and the other CMF organizations were encouraged to see that many jurisdictions across Canada agreed with the need to increase enrolment in undergraduate medical education programs, although we are still far from the 2,000 medical students by year 2000 that was recommended. The necessary increases in undergraduate enrolment in medicine require funding not only for the positions themselves, but also for the infrastructure (human and physical resources) needed to ensure high-quality training that meets North American accreditation standards. The concomitant increases in postgraduate positions that will be required three to four years later must also be resourced appropriately. This is in addition to the extra positions recommended in the November 1999 CMF report, which are needed to increase flexibility in the postgraduate training system; the capacity to provide training to international medical graduates; and opportunities for re-entry for physicians who have been in practice. The CMA remains very concerned about high and rapidly escalating increases in medical school tuition fees across Canada. According to data from the Association of Canadian Medical Colleges (ACMC), in just five years (1996 to 2001), average first-year medical school tuition fees increased by 100%. In Ontario, they went up by 223% over the same period. Student financial support through loans and scholarships has not kept pace with this rapid escalation in tuition fees. The CMA is particularly concerned about the impact this will have on the physician workforce and the Canadian health care system. High tuition fees will have a number of consequences. They create barriers to application to medical school and threaten the socioeconomic diversity of future physicians serving the public. They also exacerbate the “brain drain” of physicians to the United States where newly graduated physicians can pay down their large student debts much more quickly. Medical education does not end with earning the title MD; in fact, this is just the beginning of a physician’s learning. The continuously evolving nature of medicine requires that physicians remain up-to-date on emerging medical technologies, new treatment modalities and numerous other developments. In the early 1990s, the conventional wisdom was that medical knowledge was doubling every five years. Now, a time of less than two years is more commonly cited. Clearly, there is an increasing role for continuing medical education (CME), underscored by explicit requirements for self-directed activities to promote maintenance of certification for both family practitioners and specialists. Historically, this is an area where physicians have largely had to fend for themselves. For its part, the CMA has sponsored the Physician Manager Institute, which provides training for physicians moving into leadership positions. Although many provincial and territorial medical associations have negotiated CME benefits with their governments, it is essential that academic health science centres be supported to expand capacity in the area of CME. In the early days of Medicare, the federal government played a leadership role in building the infrastructure for health education through the Health Resources Fund, which distributed $500 million during 1966–1980. The purpose of this fund was to help provinces bear the capital costs of constructing, renovating and acquiring health training facilities and research institutions. More recently, the federal government supported a rebuilding of the university research infrastructure generally through the $800-million Canada Foundation for Innovation fund, which was announced in the 1997 budget, and the $900-million Canada Research Chairs program, which was announced in the 2000 budget to support the establishment of 2,000 research chairs by 2000. The health field will be a significant beneficiary of these funds. However, considering the shortage of health professionals that we face today and that will soon worsen, as well as the prospect of diminished access to professional education as a result of higher tuition, there is an urgent need for targeted federal funds to address this situation immediately. Recommendation 14 (a) That the federal government establish a $1 billion, five-year Health Resources Education and Training Fund to (1) further increase enrolment in undergraduate and postgraduate medical education (including re-entry positions), (2) expand the infrastructure (both human and physical resources) of Canada’s 16 medical schools in order to accommodate the increased enrolment and (3) enhance continuing medical education programs. (b) That the federal government increase funding targeted to institutions of postsecondary education to alleviate some of the pressures driving tuition fee increases. (c) That the federal government enhance financial support systems for medical students that are (1) non-coercive, (2) developed concomitantly or in advance of any tuition increase, (3) in direct proportion to any tuition fee increase and (4) provided at levels that meet the needs of the students. (d) That incentives be incorporated into medical education programs to ensure adequate numbers of students choose medical fields for which there is greatest need. 6.1.2 Physician retention and recruitment As important as investments in medical education may be, they will only begin to pay off in terms of increased supply of physicians in the medium- to long-term. In the short-term, shortages of family physicians and specialists will persist and possibly worsen. There is no quick fix for this problem; we must manage the best we can. This means making sure that we retain the physicians who are now practising in communities across the country. Physician turnover is a chronic problem in both rural and urban areas. The loss of a physician in a community has a very real impact in terms of continuity of care. There are unmeasured costs to patients, such distress and turmoil, as well as to the remaining physician(s) and communities that must cope with the repeated loss of valued physicians. Canada is both an exporter and an importer of physicians. The two-way flow, mainly between Canada and the United States, is tracked by the Canadian Institute for Health Information. Since tracking began in the 1960s, Canada has been a net exporter of physicians to the United States. During the mid-1990s, the net loss exceeded 400 ? roughly equal to 4 graduating medical classes. Since then, it has abated to 164 in 2000, but this is still the equivalent of 1.5 medical classes. Conversely, Canada is a net importer of physicians from the rest of the world. Although the figure is more difficult to quantify, it is estimated that Canada is a net importer of 200–400 international medical graduates, who are most typically recruited to work in rural and remote communities. Short-term responses to the physician shortage include repatriating Canadian physicians working abroad and integrating qualified international medical graduates and other providers. Canada must recognize that there is a global shortage of physicians ? and a global marketplace for our services; a widespread, organized recruitment of physicians from other countries, especially from those that are also experiencing physician shortages, is not the way to solve Canada’s health human resources problems.8 Recommendation 15 (a) That governments and communities make every effort to retain Canadian physicians in Canada through non-coercive measures and optimize the use of existing health human resources to meet the health needs of Canadian communities. (b) That the federal government work with other countries to equitably regulate and coordinate international mobility of health human resources. (c) That governments adopt a policy statement that acknowledges the value of the health care workforce in the provision of quality care, as well as the need to provide good working conditions, competitive compensation and opportunities for professional development. 6.1.3 The need for integrated health human resources planning Health human resource planning is complex. The CMA seeks to build consensus within the medical profession on major program and policy initiatives concerning the supply, mix and distribution of physicians and to work with major stakeholders in identifying and assessing issues of mutual importance. Planning for the provision of services by a broad array of providers to meet changing health care needs should focus on having the right providers in the right places doing the right things. This first requires the determination of the needed supply, mix and distribution of physicians, which will assist in the development of a similar assessment for all other providers. Resource planning must be based on the health care needs of Canadians rather than driven by cost. The CMA has developed principles and criteria for the determination of scopes of practice. The primary purpose is to meet health care needs and to serve the interests of patients and the public safely, efficiently and competently. These principles and criteria (listed below) have been endorsed by the Canadian Nurses Association and the Canadian Pharmacists Association. See Appendix G for more details. Principles and Criteria for the Determination of Scopes of Practice Principles: * Focus * Flexibility * Collaboration and cooperation * Coordination * Patient choice Criteria: * Accountability * Education * Competencies and practice standards * Quality assurance and improvement * Risk assessment * Evidence-based practices * Setting and culture * Legal liability and insurance * Regulation The CMA remains sensitive to Canada’s provincial and territorial realities with respect to the fact that health human resource planning requires assessment and implementation at the local or regional level. However, there is a need for a national body to develop and coordinate health human resources planning initiatives. Recommendation 16 (a) That a national multistakeholder body be established with representatives from the health professions and all levels of government to develop integrated health human resource strategies, provide planning tools for use at the local level and monitor supply, mix and distribution on an ongoing basis. (b) That scopes of practice should be determined in a manner that serves the interests of patients and the public, safely, efficiently, and competently. 6.2 Capital Infrastructure The crisis in health human resources is exacerbated by an underdeveloped capital infrastructure ? bricks, mortar and tools. This is seriously jeopardizing timely access to quality care within the health care system. In our 2001 discussion paper, Specialty Care in Canada, the CMA indicated there has been inadequate investment in buildings, machinery and equipment and in scientific, professional and medical devices. Provincial and territorial government spending on construction, machinery and equipment for hospitals, clinics, first-aid stations and residential care facilities has remained, on average, 16.5% below its peak in 1989. Specifically, real capital expenditures on new building construction decreased 5.3% annually between 1982 and 1998. Investment in new hospital machinery and equipment declined by 1.8% annually between 1989 and 1998. In 1998, hospital expenditures on scientific, professional and medical devices were nearly 17% below 1994 levels. While these cutbacks were occurring, significant innovations in medical technology were being introduced worldwide. Although hospitals are still providing most acute care services, whether patients are treated as inpatients or outpatients, the equipment required is not keeping pace with the growth of new technologies, the health needs of the patients and the increase and aging of the population. Equipment and machinery in the hospital sector are overaged due to a lack of replacement capital. In the absence of timely access to current and emerging health technologies, Canadians face the prospect of unrestrained progression of disease, increased stress and anxiety over their health status and, possibly, premature death. Meanwhile, society bears the direct and indirect costs associated with delayed access. On September 11, 2000, the federal government announced a new $1 billion transfer to provinces and territories for the purpose of purchasing new medical equipment. A recent analysis by the CMA found that just over half of this fund can be accounted for as being spent as intended (Appendix H). The question remains as to what has happened to the remainder of the fund. Governments have been placing a lower priority on capital investment when allocating financial resources for health care. It will not be enough simply to bring Canada’s health infrastructure up to par; a commitment to ongoing funding to maintain the equipment must also be made. This, in turn, requires continuous inventory maintenance for regular replacement. Therefore, it may be necessary for hospitals to develop innovative approaches to financing capital infrastructure. The CMA agrees with other organizations such as the Canadian Healthcare Association on the need to explore the concept of entering into public–private partnerships (P3s) to address capital infrastructure needs as an alternative to relying on government funding. Joint ventures and hospital bonds are but two examples of P3 financing. Recommendation 17 (a) That hospitals and other health care facilities conduct a coordinated inventory of capital infrastructure to provide governments with an accurate assessment of machinery and equipment. (b) That the federal government establish a one-time catch-up fund to restore capital infrastructure to an acceptable level. (see Recommendation 4(b).) (c) That governments commit to providing adequate, ongoing funding for capital infrastructure. (d) That public-private partnerships (P3s) be explored as a viable alternative source of funding for capital infrastructure investment. 6.3 Surge Capacity Putting patients first means, among other things, making sure that the health care system is capable of stretching its capacity to meet unforeseen circumstances, that the system is monitored for quality, that compensation is available when unintended harm occurs and that patient privacy and confidentiality are respected. The tragic events of September 11, 2001, followed closely by the distribution of anthrax through the United States postal service, provided a grim reminder of the necessity of having a strong public health infrastructure in place at all times. As was demonstrated quite vividly, we do not have the luxury of time to prepare for these events. Although it is not possible to plan for every contingency, certain scenarios can be sketched out and anticipated. To succeed, all communities must maintain a certain consistent level of public health infrastructure to ensure that all Canadian residents are protected from threats to their health. In addition to external threats, the Canadian public health system must also cope with domestic issues such as diseases created by environmental problems (e.g., asthma), sexually transmitted diseases and influenza, among many others. Even before the spectre of bioterrorism, this country’s public health experts were concerned about the infrastructure’s ability to deal with multiple crises. Like our hydro system, “surge capacity” must be built into the system nationally to enable hospitals to open beds, purchase more supplies and bring in the health care professionals they require to meet the need. The CMA’s 2001 pre-budget submission lays out comprehensive recommendations to address this issue (Appendix I). Recommendation 18 That the federal government cooperate with provincial and territorial governments and with governments of other countries to ensure that a strong, adequately funded emergency response system is put in place to improve surge capacity. 6.4 Information Technology Much of the recent debate about the future of the health care system has focused on the need to improve its adaptability and overall integration. One critical ingredient in revitalizing the system is establishing the information technology (IT) and information systems (IS) that physicians and other health care professionals must have at their disposal. Effective and efficient networks will facilitate integrated and coordinated care, as well as better management of clinical information. Although health care is information-intensive, health care systems in Canada and abroad have generally been slow to adopt IT. Other sectors of the economy have invested heavily in IT/IS over the past two decades and have reaped enormous benefits in efficiency and service to clients. IT should be viewed as a “social investment” in the acquisition of knowledge. Patients will benefit through potential reductions in rates of mortality and morbidity due to misdiagnosis and improper treatment, as well as reductions in medication errors that come with access to online drug reference databases and the virtual elimination of handwritten prescriptions. IT will permit better access to diagnostic services and online databases, such as clinical practice guidelines, that are widely available but underused. Health promotion and disease prevention will be enhanced through superior monitoring and patient education (e.g., e-libraries), and decision-making by providers and patients will be improved. These represent only a subset of the potential benefits to Canadians. A great deal of effort is currently being devoted to the development of a secure electronic health record (EHR) that provides details of all health services provided to a patient. An EHR will not generate new information on patients; it will simply make existing information more readily accessible to the physician or appropriate health care provider. We are still at the infant stage of EHRs. Implementation will require a process of continual expansion, beginning with the most basic of patient information and evolving into a comprehensive record of all of the patient’s encounters with the health care system ? as well legislation protecting personal privacy and unwarranted access. It is widely accepted in industry that 4 – 5% of financial budgets is a reasonable target for information technology spending. It is equally widely accepted that in Canada the health care sector falls well short of this target. As part of the September 2000 Health Accord, the federal government invested $500 million to create the Canada Health Infoway with a mandate to accelerate the development and adoption of modern systems of IT, such as electronic patient records. The CMA applauds this investment, but notes that the $500-million down-payment is only a fraction of the $4.1 billion that the CMA estimates it would cost to fully connect the Canadian health care system. A number of provincial and territorial governments are also moving ahead with the development of IT in health care, but further financial support is required. The CMA is prepared to play a pivotal partnership role in achieving the buy-in and cooperation of physicians and other health care providers through a multistakeholder process. Toward this end, the CMA has developed principles for the advancement of EHRs (Appendix J). The CMA’s involvement would be a critical success factor in helping the federal government make an electronic health care system a realizable goal in the years to come. Recommendation 19 That federal government make an additional, substantial, ongoing national investments in information technology and information systems, with the objective of improving the health of Canadians as well as improving the efficiency and effectiveness of the health care system. Recommendation 20 That governments adopt national standards that facilitate the collection, use and exchange of electronic health information in a manner which ensures that the protection of patient privacy and confidentiality are paramount. 6.5 Research and Innovation Research and innovation in the health sector are producing an expanding array of treatments and therapies that improve quality of life and longevity, e.g., pharmaceuticals, surgery, human genome, etc. Health research provides substantial economic, social and health care benefits to society. It * Creates high-quality, knowledge-based jobs that drive economic growth * Supports academic institutions across the country and helps train new health professionals in the latest health care technologies and techniques * Supports health care delivery and is key to maintaining centres of excellence for highly specialized care * Leads directly to better ways to treat patients and promote a healthier population. In Canada, health research is carried out by a mix of public, voluntary and private-sector organizations with the federal government being the main player in publicly funded health research. Several provinces have their own health research funding agencies. Canada’s health charities play an important role in funding research on a range of diseases and conditions. The pharmaceutical industry, especially the name-brand companies, invests heavily to develop new drugs. Recent federal investments have begun to revitalize Canada’s health research capacity. With the creation of the Canadian Institutes for Health Research (CIHR), Canada now has a modern funding agency that integrates biomedical, clinical, health services and population health research. New programs have been introduced to attract world-class scientists, modernize research infrastructure and equipment and support research in genomics. As significant as these investments have been, Canada still ranks second-to-last among G7 countries in terms of support for health research. The United States’ National Institutes of Health has a budget that is 50 times that of the CIHR for a population only 10 times bigger than Canada’s. Other countries are increasing their investment in health research to keep pace. If Canada is to improve it position vis-à-vis our key competitors, the federal government must map out a plan to increase its investment in health research to internationally competitive levels. The federal government’s investment in health research currently stands at about 0.5% of total health expenditures. There is a broad consensus in the health community that this should be increased to at least 1% of total health expenditures. Recommendation 21 That the federal government’s investment in health research be increased to at least 1% of national health expenditures. 7. Health System Financing Governments’ contributions to funding Canada’s health system should support the long-term sustainability of the system and the provision of high-quality health care for all Canadians. Governments’ contribution to Medicare should promote greater public accountability, transparency and a linkage of sources with their uses. Changes in health system financing have played a central role in the crisis facing Medicare. Significant and unpredictable funding cuts at both federal and provincial–territorial levels have wreaked havoc in the planning and delivery of a very complex array of services. Health care costs that were previously covered by provincial and territorial health insurance plans have been gradually shifted to individuals (“passive privatization”) leaving those without private insurance coverage increasingly vulnerable. Mounting evidence of unacceptably long waits for treatment and poor access to services has underlined the risks attached to having a single-payer system, with insufficient accountability for timeliness and accessibility of care. Growing problems of access and declining provider morale, combined with constant bickering about funding between federal and provincial–territorial governments have led to deterioration of public confidence in the system. The message from the front lines is clear: restoring the health care system to a sustainable footing cannot be accomplished by simply managing our way out of this crisis. As Medicare is renewed, it is essential that its underlying financing framework is modernized, taking into account the multiple policy objectives served by health financing mechanisms. 10 Policy Objectives for Health Financing Mechanisms 1. Stable and sustainable funding 2. Risk-pooling 3. Equity (between population subgroups, across regions) 4. Responsible use 5. Administrative simplicity 6. Transparency and accountability 7. Choice 8. Efficiency 9. Meet current needs 10. Fairness between generations (intergenerational equity) Our recommended changes to the legislation governing federal transfers to provinces and territories are set out in section 3.3.2. To restore the federal–provincial–territorial partnership in health, we recommend that the federal contribution to the public health care system be locked in for a 5-year period, with a built-in escalator tied to increases in GDP, rising to a target of 50% of spending for core services. We also recommend that the federal government establish special purpose, one-time funds to address a number of pressing issues. Given their constitutional responsibility in the area of health care, provinces and territories will continue to play the lead role in regulating the flow of public funding for health care. Once the basket of core services is determined according to the process outlined in section 5.1, provinces and territories will have to commit sufficient funding to ensure that these services are available and accessible in a timely way. The funding commitment of provinces and territories will, therefore, drive the federal government’s 50% contribution. In addition to providing half of public funding for core services, provinces and territories will also have the option of funding additional health services beyond the national minimum core basket, much as they do now. Although adequate and stable funding for health care is imperative at the federal level, it is equally important at the provincial and territorial level. Provincial and territorial commitment to funding core services must also be locked-in for a five-year period with an escalator tied to provincial demographics and inflation. To ensure stability, a buffer will also be needed to protect provincial and territorial health care budgets from the ebbs and flows of the business cycle. Currently, the federal Fiscal Stabilization Program compensates provinces if their revenues fall substantially from one year to the next due to changes in economic circumstances. However, this program is not health-specific and only takes effect when provincial revenues drop by over 5%. It is also funded from general revenues, which makes it more vulnerable to economic and political factors. A more robust approach to guaranteeing stability of public funding for health care would be to create a stand-alone contingency fund to which all governments would contribute. Excess revenues would be collected into this fund during periods of high economic growth, and could be used during less prosperous periods when governments experience fiscal capacity shortfalls. Recommendation 22 (a) That the provincial and territorial governments’ commitment to funding core services be locked-in for an initial five-year period with an escalator tied to provincial population demographics and inflation. (b) That governments establish a health-specific contingency fund to mitigate the effects of fluctuations in the business cycle and to promote greater stability in health care financing. 8. Organization and Delivery of Services 8.1 The Medical Care Continuum There is a tendency to separate medical care into two areas; primary care and specialty care. However, we must recognize that medical and health care encompass a broad spectrum of services ranging from primary prevention to highly specialized care. Primary and specialty care are so closely interrelated that the renewal of either should not be attempted without considering the impact on the rest of the care continuum. Recommendation 23 That any effort to change the organization or delivery of medical care take into account the impact on the whole continuum of care. 8.1.1 Primary care services In recent years, several government task force and Commission reports have called for primary care reform. Common themes include improving continuity of care (including 24/7 coverage); establishing alternatives to fee-for-service payment of physicians; placing greater emphasis on health promotion and disease prevention; and adopting team models that involve nurse practitioners and other health care providers working collaboratively with physicians. Governments have responded by launching pilot projects to evaluate different models of primary care delivery. It is critical to evaluate these projects before moving ahead with them on a broader scale and to consider the implications of their system-wide implementation. Although some jurisdictions have moved forward with ambitious proposals to change the structure of primary care and the remuneration of physicians, the CMA urges the Commission not to view primary care renewal as a panacea for all that ails Medicare. Primary care renewal should not be used as a pretext for changing how doctors are paid nor should it focus on substituting the lowest cost provider. The focus should be on patient need. Any changes to the delivery of primary care should respect the following principles: * All Canadians should have access to a family physician. * No single model will meet the primary care needs of all communities in all regions of the country. Successful renewal of primary health care delivery cannot be accomplished without also addressing the shortage of family practitioners. Not only is the supply of these physicians affected by an aging physician population and by changes in lifestyle and productivity, but the popularity of primary care as a career choice among medical graduates is also declining. According to the Canadian Resident Matching Service (CaRMS), in 1997, only 10% of positions that were still vacant after the first round of the residency match were in family medicine. By 2000, family medicine’s share of vacant positions after the first iteration peaked at 57%; since then it has remained close to 50%. Furthermore, before 1994, more graduates were choosing family medicine than there were positions available. Since then, the situation has reversed with fewer graduates consistently choosing family medicine than there are positions available.9 A major factor in this trend may be the 1993 change in the residency program, which removed graduates’ ability to do a first-year rotation in family medicine, then have the choice of continuing in the family medicine program or switching into a specialty. Now, any graduate who chooses family medicine is committed to that program. The dramatic shift in the number of graduates choosing family medicine in 1994 is likely due to the assumption that it is easier to switch out of a specialty into family medicine than vice versa. The uncertainty of the future of primary care caused by these constant reform efforts has also contributed to the decline in popularity of family medicine among medical graduates. Efforts must be made to remove these perceived barriers so that the public’s need for primary care services can be met. Multidisciplinary teams, both formal and informal, are common in primary care today. The reliance on the team approach will likely grow because of the increased complexity of care, the exponential growth of knowledge, the greater emphasis on health promotion and disease prevention, and the choice of patients and providers. Although desirable, primary care teams ? physicians, nurses, pharmacists, dieticians and others ? will cost the system more, not less, than the traditional fee-for-service physician approach. Funding these initiatives must not come at the expense of the provision of illness care. The add-on costs of primary care teams, including informational technology (IT) and information systems (IS), must be looked upon as an investment in the health of Canadians. (IT and IS opportunities must also be available to all physicians, regardless of how they are paid or their patterns of practice.) Although multidisciplinary teams may provide a broader array of services, for most Canadians having a family doctor as the central provider of all primary medical care services is a core value. As the College of Family Physicians of Canada (CFPC) indicated in its submission to the Commission on the Future of Health Care in Canada, over 90% of Canadians seek advice from a family physician as their first resource in the health care system. The CPFC also reports that a recent Ontario College of Family Physicians public opinion survey, conducted by Decima, found that 94% of people agree that it is important to have a family physician who provides the majority of primary care and coordinates the care delivered by others.10 A family physician as the central coordinator of medical services promotes the efficient and effective use of resources. This facilitates continuity of care because the family physician generally has the benefit of developing an ongoing relationship with his or her patients and their families and, as a result, can advise and direct the patient through the system so that the patient receives the appropriate care from the appropriate provider. Canada has one of the best primary care systems in the world, but it can be improved through better integration and coordination of care. This requires investment to increase quality and productivity through improved IT and connectivity to support physicians in their expanded roles as information providers, coordinators and integrators of care, and to support the integrated care of primary care teams. Recommendation 24 (a) That governments work with the provincial and territorial medical associations and other stakeholders to draw on the successes of evaluated primary care projects to develop a variety of templates of primary care models that would * suit the full range of geographical contexts and * incorporate criteria for moving from pilot projects to wider implementation, such as cost-effectiveness, quality of care and patient and provider satisfaction. (b) That family physicians remain as the central provider and coordinator of timely access to publicly funded medical services, to ensure comprehensive and integrated care, and that there are sufficient resources available to permit this. 8.1.2 Specialty care services Much of the focus in recent years has been on primary care renewal. Countless reports indicating a major crisis in the area of primary care delivery have overshadowed the problems that are plaguing other areas of the health care continuum. For example, a severe physician shortage is occurring in specialty care at the generalist level. The Royal College of Physicians and Surgeons of Canada reports that a third of general surgeons are aged 55 or older and nearly 40% more general surgeons are retiring than are graduating from medical schools.11 Canada cannot afford to continue to ignore this key segment of the care continuum. A concerted effort must be made to increase the visibility of secondary care specialists and to encourage medical students to enter general specialties. As highly specialized care and technology have advanced, there has been increasing pressure at the tertiary level of the health care system to provide the highest level of care possible. Delivering tertiary care in the ways to which Canadians are accustomed cannot be sustained into the future; and such tertiary care cannot be available in all areas of the country. Alternative approaches to delivering and receiving high-level specialty care are both required and inevitable. The aging population, the challenges posed by Canada’s geography, rapidly expanding high-cost technologies and the lack of a critical mass of highly specialized health care providers necessitate a change in thinking. The health system has reached the point where certain types of care are neither universally nor readily available. The shortage of specialists and the high cost of technology and pharmaceuticals will exacerbate this situation. The future challenge is to design delivery systems that are built around a series of regional centres of excellence, without abandoning the concept of “reasonable” access. As these highly specialized services are realigned interprovincially, resources must also be realigned to accommodate and compensate for the relocation of providers and to ensure that patients have equitable access to treatment. At their January 2002 meeting in Vancouver, the premiers recognized that some types of surgery and other medical procedures are performed infrequently and that the necessary expertise cannot be developed and maintained in each province and territory. Building on the experience in Canada’s three territories and Atlantic Canada, they agreed to share human resources and equipment by developing sites of excellence in such fields as pediatric cardiac surgery and gamma knife neurosurgery. This should lead to better care for patients and more efficient use of health care dollars. At the provincial–territorial level, this strategy has led to regional centres and hospitals with responsibilities for province- and territory-wide programs and services. The concept of centres of excellence can be further supported by the adoption of telemedicine and telehealth technologies which will permit rapid access to or exchange of electronic diagnostic information (e.g., imaging) and enable remote consultation and treatment. Determining where care is available will become an increasingly relevant policy matter ? especially as costs such as travel and lost income could be downloaded onto patients and their families. Efforts will be required to optimize the use of scarce specialist services, improve care and availability, assure continuity and enhance provider morale. In the interests of quality care, patient safety and the economical use of scarce resources interjursidictionally, there is a need for a Canadian Accessibility Fund. This fund would be modeled after the Portability Fund established to support the Federal–Provincial–Territorial Eligibility and Portability Agreements under the Medical Care Act. The cost of the new fund, like the old, would be 50–50 cost-shared by the federal and provincial–territorial governments. It would require an initial investment of $100 million. Access to the fund would be determined by a mutually agreed upon set of criteria, and any monies withdrawn would be used to facilitate access to highly specialized health care services that are not available in the patient’s home province. Recommendation 25 (a) That governments develop a national plan to coordinate the most efficient access to highly specialized treatment and diagnostic services. * This plan should include the creation of defined regional centres of excellence to optimize the availability of scarce specialist services. * Any realignment of services must accommodate and compensate for the relocation of providers. * That the federal government create an accessibility fund that would support interprovincial centres of excellence for highly specialized services. 8.2 Physician Remuneration It is a common misconception that successful renewal of the health care system involves simply changing how physicians are paid ? specifically, abolishing fee-for-service. In their analysis of primary care in Canada, Hutchison and colleagues note that governments’ preoccupation with the “big bang” approach — that typically involves the adoption of inappropriate funding and remuneration methods — is a major contributor to the failure of many primary care projects.12 Every system of remuneration has its strengths and weaknesses. Canadians should not be led to think that movement away from fee-for-service remuneration of physicians will provide them with better care. How physicians (and other health care providers) are paid should be a means to an end, not an end unto itself. Nevertheless, physicians are willing to consider other appropriate methods of remuneration in appropriate circumstances. Physicians must be given a choice about their method of payment. Experience has taught us that a “one size fits all” approach to compensation does not work. Furthermore, any remuneration arrangement must preserve and protect physician autonomy and the ability of the physician to act as an advocate for his or her patients. In 2001, the CMA developed a policy on physician compensation (Appendix K) that is based on the following principles. CMA Policy on Physician Compensation: Basic Principles * Medical practitioners must receive fair, reasonable and equitable remuneration for the full spectrum of their professional activities. * Physicians need to receive reasonable consideration and compensation when facilities and programs are discontinued, reduced or transferred. * Individual medical practitioners have the liberty to choose among payment methods. * Payment systems must not compromise the ability of physicians to provide high-quality cost-effective medical services. * Payment mechanisms must allow for a reasonable quality of life. * Provincial and territorial government resources and funding for physician services must be allocated directly to physicians for services provided. * All physicians, including those indirectly affected, have the right to representation in negotiations on issues of payment, funding, and the terms and conditions of their work. * Paying agencies must fulfill the terms of agreement negotiated with legitimate agents of the medical profession and be obliged to honour a mutually agreed-upon and established process of negotiation with those agents. * In the event of failure of negotiations relating to physician compensation, such disagreement must be resolved by a mutually agreed-upon, timely process of dispute resolution. * The federal minister of health must enforce the provisions of the Canada Health Act relevant to physician compensation (section12.2). Recommendation 26 That governments respect the principles contained in the CMA’s policy on physician compensation and the terms of duly negotiated agreements. 8.3 Rural Health Care Canadian physicians and other health care professionals are greatly frustrated by the impact that health care budget cuts and reorganization have had, and continue to have, on the timely provision of quality care to patients and on general working conditions. For physicians who practise in rural and remote communities, this impact is exacerbated by the breadth of their practice, long working hours, lifestyle restrictions created by on-call responsibilities, geographic isolation and lack of professional backup and access to specialist services. In 2000, the CMA developed a policy statement on rural and remote practice (Appendix L) to help governments, policymakers, communities and others involved in the retention of physicians understand the various professional and personal factors that must be addressed to retain and recruit physicians to rural and remote areas. The 28 recommendations address training, compensation and work and lifestyle support issues. Training for rural practice must span the full medical career lifecycle, from recruitment of candidates likely to enter rural practice to special skills training, retraining and continuing professional development. Compensation must reflect the degree of isolation, level of responsibility, frequency of on-call duty, breadth of practice and additional skills. Consideration must also be given to the broader social issues of the physician and his or her family, as well as the need to facilitate the availability of locum tenens, particularly across jurisdictional boundaries. There is a need to ensure that there is sufficient availability of physicians so that on-call requirements are manageable and that adequate professional backup is provided, e.g., locum services currently offered through provincial and territorial medical associations. We concur with the observation made by the Society of Rural Physicians of Canada in their August 2001 submission to the Commission that Canada needs a national rural health strategy. The aim of the strategy would be to look at the systemic barriers to meeting the needs of rural Canadians and to provide strategic program funding to catalyze change. Recommendation 27 That governments work with universities, colleges, professional associations and communities to develop a national rural and remote health strategy for Canada. 8.4 Emerging and Supportive Roles in Health Care Delivery 8.4.1 Private sector Canada has a mixed system of public–private delivery and public–private financing, as illustrated in the following diagram with all four possible combinations. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Delivery Public Private Financing Public Public delivery/ public financing (e.g., public hospital services) Private delivery/ public financing (e.g., doctor’s office care) Private Public delivery/ private financing (e.g., private room in a public hospital) Private delivery/ private financing (e.g., cosmetic surgery) [TABLE END] No issue in Canadian health policy has generated more controversy than the role of the private sector. As we move forward with the renewal of Medicare, it will be important for Canadians to understand the distinction between private delivery and private funding. The appropriate mix of public and private should not be based on ideology, but rather on the optimal use of resources. Health care is delivered mainly by private providers including physicians, pharmacists, private not-for-profit hospitals, private long-term care facilities, private diagnostic and testing facilities, rehabilitation centres. (In addition, supplies from food and laundry to drugs and technology are provided almost exclusively by the private sector.) This significant level of private-sector delivery has served Canada well. Accordingly, the CMA supports a continuing and major role for the private sector in the delivery of health care. However, we are not proposing a parallel private system. There may be a growing role for private delivery. We would encourage this as long as the services can be provided cost-effectively. As with the public sector, any private-sector involvement in health care must be patient-centred as well as open, transparent and accountable. Furthermore, it must be strictly regulated to ensure that high standards of quality care are being met and monitored. Recommendation 28 That Canada’s health care system make optimal use of the private sector in the delivery of publicly financed health care provided that it meets the same standards of quality as the public system. 8.4.2 Voluntary sector The voluntary sector, including many charities and consumer advocacy groups, has played a critical role in the development of the public health system ? providing and funding services, programs, equipment and facilities. Much of the capital infrastructure development, especially in hospitals, has been made possible through the fundraising efforts of charity foundations and service organizations. In addition, many patient support services such as “Meals on Wheels” exist only because of the efforts of volunteer groups. Although the voluntary sector is a major asset for Canada’s health care system, it is critical for governments to fulfill their obligation to support publicly financed health care. Governments must avoid passing off their responsibilities to the voluntary sector, which is already stretched to the limit. Governments should not abuse the voluntary sector, but should properly fund the public health system’s ongoing operating costs and capital expenditures. The voluntary sector should be formally recognized for the contribution it makes to the health care system. Many of these organizations operate on a shoestring budget with limited capacity to respond to the increasing demands being placed on them. Recommendation 29 That governments examine ways to recognize and support the role of the voluntary sector in the funding and delivery of health care, including enhanced tax credits. 8.4.3 Informal caregivers Informal caregivers ? particularly those who provide care for ailing relatives and friends ? play an essential role in the health care system. The massive off-loading onto these caregivers has gone unrecognized. The costs of providing this kind of care go beyond identifiable dollar amounts such as loss of income. Many indirect costs, including emotional strain on the caregivers and their families, must also be acknowledged with support provided by governments and employers. Patients often prefer to receive their care at home, but it cannot be assumed that care provided at home is better for the patient than that provided within a health care institution. Resources must be made available to ensure that the care patients receive at home is acceptable. Increased financial support should be provided to informal caregivers through the tax system. Refundable tax credits and a program for family leave are two examples of this support. Recommendation 30 That governments support the contributions of informal caregivers through the tax system. Conclusions Canada’s health care system is at a crossroads. We need to act now to ensure that our health care system will be able to meet the current and future health care needs of Canadians. Canadians are looking for real solutions that will have meaningful results. This means not only addressing the most critical issues such as health human resources, infrastructure and delivery mechanisms, but also implementing system-wide structural and procedural changes. It also means involving all key stakeholders in the decision-making process at all levels. In this second submission to the Commission on the Future of Health Care in Canada, the CMA has offered solutions that are patient-centred and reflect Canadian values of a publicly funded system that is sustainable and accountable and provides timely access to high-quality care. These recommendations form a complete, integrated package that should be implemented as a whole to be successful. The CMA would like to thank the Commission for providing this opportunity to submit our Prescription for Sustainability and we wish the Commission every success in developing a concrete plan for revitalizing our cherished Canadian health care system. 1 A recent article by Patrick Monahan and Stanley Hartt published by the C.D. Howe Institute argues that Canadians have a constitutional right to access privately funded health care if the publicly funded system does not provide access to care in a timely way. 2 Although the word “charter” has a legal connotation, it has been used in other contexts. An example is the 1986 Ottawa Charter for Health Promotion, an international call for action on health promotion that has received worldwide acclaim. 3 This could be linked to the equalization provision in Section 36(2) of the Constitution Act (1982). 4 Proclamations are issued by the Queen’s representative in the particular jurisdiction. An example of a proclamation that has been issued this way is the “Proclamation Recognizing the Outstanding Service to Canadians by Employees in the Public Service of Canada in Times of Natural Disaster” (13 May, 1998). 5 100% government-funded without patient cost-sharing. 6 Organisation for Economic Co-operation and Development. Health at a glance. Paris, France: OECD; 2001. 7 CMF membership includes: CMA, Association of Canadian Medical Colleges, College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada, Canadian Federation of Medical Students, Canadian Association of Internes and Residents, Federation of Medical Licensing Authorities of Canada, Medical Council of Canada, and Association of Canadian Academic Healthcare Organizations. 8 See for example the Melbourne Manifesto: A Code of Practice for the International Recruitment of Health Care Professionals, which was adopted at the 5th Wonca World Conference on Rural Health in May 2002. It puts the onus on every country to train enough health professionals to meet their own needs (www.wonca.org). 9 Canadian Resident Matching Service. PGY-1 Match Report 2002. History of family medicine as a career choice of Canadian graduates. [http:// http://www.carms.ca/stats/stats_index.htm]. Ottawa: CaRMS; 2002. 10 College of Family Physicians of Canada. Shaping the Future of Health Care. Submission to the Commission on the Future of Health Care in Canada. Ottawa: CFPC; 25 Oct. 2001. 11 Royal College of Physicians and Surgeons of Canada. Health care renewal through knowledge, collaboration, and commitment. Ottawa: RCPSC; 31 Oct. 2002. 12 Hutchison B, Abelson J, Lavis J. Primary care in Canada: so much innovation, so little change. Health Aff 2001 May/Jun; 20(3):116-31.
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A Public Health Perspective on Cannabis and Other Illegal Drugs : CMA Submission to the Special Senate Committee on Illegal Drugs

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

https://policybase.cma.ca/en/permalink/policy1972
Last Reviewed
2020-02-29
Date
2002-01-29
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2002-01-29
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) welcomes the opportunity to appear before the Sub-Committee on the Status of Persons with Disabilities to discuss issues related to the Disability Tax Credit (DTC). This tax measure, which is recognition by the federal government that persons with a severe disability may be affected by having reduced incomes, increased expenses or both, compared to those who are not disabled i, helps to account for the intangible costs associated with a severe and prolonged impairment. It also takes into account disability-related expenses that are not listed in the medical expense deduction or which are excluded by the 3% threshold in the Medical Expense Tax Credit. Physicians are a key point of contact for applicants of the DTC and, given the way the program is structured, a vital participant in its administration. It is for these reasons that we come before you today to address specific concerns related to the program’s performance. In addition, we would like to discuss the broader issue of developing a coherent set of tax policies in support of health and social policy. The Integration of Tax Policy with Health Policy and Social Policy The federal government, through a variety of policy levers such as taxation, spending, regulation and information, has played a key role in the development of our health care and social systems. To date however, discussion about the federal role in these areas has centered largely on federal transfers to the provinces and territories and the Canada Health Act. However, in looking at how to renew Canada’s health and social programs, we should not limit ourselves to these traditional instruments. Today we have a health system that is facing a number of pressures that will challenge its sustainability. These pressures range from an aging and more demanding population in terms of the specialty care services and technology they will seek; the cry for expanding the scope of medicare coverage to include homecare and pharmacare; and a shortage of health personnel. These are only some of the more immediate reasons alternative avenues of funding health care, and thus ensuring the health and well-being of our citizens, must be explored. In our pre-budget consultation document to the Standing Committee on Finance ii, the CMA recommended that the federal government establish a blue ribbon National Task Force to study the development of innovative tax-based mechanisms to synchronize tax policy with health policy. Such a review has not been undertaken in over 25 years since the Royal Commission on Taxation in 1966 (Carter Commission). The CMA is echoing its call for a National Task Force to develop new and innovative ways to synchronize tax policy with health policy and social policy. A study of this nature would look at all aspects of the taxation system, including the personal income tax system, in which the DTC is a component. The remainder of our brief addresses issues specific to the DTC. Physician Involvement in the DTC Program The CMA has in the past provided input with respect to the DTC program. Our working relationship on the DTC program with the Canada Customs and Revenue Agency (CCRA) has been issue-specific, time-limited and constructive. Our first substantive contact in regard to the DTC program was in 1993 when the CMA provided Revenue Canada with a brief review of the program and the T2201form. It is interesting to note what our observations were in 1993 with regard to this program because many of them still hold true today. Here are just some of the issues raised by the CMA in 1993 during our initial review of the program: * The tax credit program may not address the needs of the disabled, it is too hit and miss. The DTC program should be evaluated in a comprehensive way to measure its overall effectiveness in meeting the needs of persons with disabilities. * The program should be called the “Severe Disability Tax Credit Program” – or something equivalent to indicate that not everyone with a disability is eligible. * The program puts physicians in a potential conflict with patients—the responsibility of the physician to advocate for the patient vs. gate-keeper need for Revenue Canada. The physician role should be to attest to legitimate claims on the patients’ behalf. * Revenue Canada should clarify the multiplicity of programs. There are numerous different federal programs and all appear to have varying processes and forms. These overlapping efforts are difficult for patients and professionals. * A major education effort for potential claimants, tax advisers and physicians should be introduced. * A suitable evaluation of claimant and medical components of the process should be undertaken. The CMA does not have a standardized consultative relationship with the CCRA in regard to this program. An example of this spotty relationship is the recent letter sent by the CCRA Minister asking current DTC recipients to re-qualify for the credit. The CMA was not advised or consulted about this letter. If we had been advised we would have highlighted the financial and time implications of sending 75 to 100 thousand individuals to their family physician for re-certification. We also would have worked with the CCRA on alternative options for updating DTC records. Unfortunately, we cannot change what has happened, but we can learn from it. This clearly speaks to the need to establish open and ongoing dialogue between our two organizations. Policy Measure: The CMA would like established a senior level advisory group to continually monitor and appraise the performance of the DTC program to ensure it is meeting its stated purpose and objectives. Representation on this advisory group would include, at a minimum, senior program officials preferably at the ADM level; those professional groups qualified to complete the T2201 Certificate; various disability organizations; and patients’ advocacy groups. We would now like to draw the Sub-committee’s attention to three areas that, at present, negatively impact on the medical profession participation in the program, namely program integrity, program standardization (e.g., consistency in terminology and out-of-pocket costs faced by persons with disabilities) and tax advisor referrals to health care providers. Program Integrity A primary concern and irritation for physicians working with this program is that it puts an undue strain on the patient-physician relationship. This strain may also have another possible side effect, a failure in the integrity of the DTC program process. Under the current structure of the DTC program, physicians evaluate the patient, provide this evaluation back to the patient and then ask the patient for remuneration. This process is problematic for two reasons. First, since the patient will receive the form back immediately following the evaluation, physicians might receive the blame for denying their patient the tax credit—not the DTC program adjudicators. Second, physicians do not feel comfortable asking for payment when he or she knows the applicant will not qualify for the tax credit. For the integrity of the DTC program, physicians need to be free to reach independent assessment of the patient’s condition. However, due to the pressure placed by this program on the patient-physician relationship, the physician’s moral and legal obligation to provide an objective assessment may conflict with the physician’s ethical duty to “Consider first the well-being of the patient. There is a solution to this problem it’s a model already in use by government, the Canadian Pension Plan (CPP) Disability Program. Under the CPP Disability Program, the evaluation from the physician is not given to the patient but, it is sent to the government and the cost to have the eligibility form completed by a physician is subsumed under the program itself. Under this system, the integrity of patient-physician relationship is maintained and the integrity of the program is not compromised. Policy Measure: The CMA recommends that the CCRA take the necessary steps to separate the evaluation process from the determination process. The CMA recommends the CPP Disability Program model to achieve this result. Fairness and Equity The federal government has several programs for people with disabilities. Some deal with income security (e.g., Canada Pension Plan Disability Benefits), some with employment issues (e.g., Employability Assistance for People with Disabilities), and some through tax measures (e.g., Disability Tax Credit). These government transfers and tax benefits help to provide the means for persons with disabilities to become active members in Canadian society. However, these programs are not consistent in terms of their terminology, eligibility criteria, reimbursement protocols, benefits, etc. CMA recommends that standards of fairness and equity be applied across federal disability benefit programs, particularly in two areas: the definition of the concept of “disability”, and standards for remuneration to the physician. These are discussed in greater detail below. 1) Defining “disability” One of the problems with assessing disability is that the concept itself is difficult to define. In most standard definitions the word “disability” is defined in very general and subjective terms. One widely used definition comes from the World Health Organization’s International Classification of Impairments, Disabilities and Handicaps (ICIDH) which defines disability as “any restriction or inability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being.” The DTC and other disability program application forms do not use a standard definition of “disability”. In addition to the inconsistency in terminology, the criteria for qualification for these programs differ because they are targeted to meet the different needs of those persons with disabilities. To qualify for DTC, a disability must be “prolonged” (over a period of at least 12 months) and “severe” i.e. “markedly (restrict) any of the basic activities of daily living” which are defined. Though CPP criteria use the same words “severe” and “prolonged” they are defined differently (i.e., “severe” means “prevents applicant from working regularly at any job” and “prolonged” means “long term or may result in death”). Other programs, such as the Veterans Affairs Canada, have entirely different criteria. This is confusing for physicians, patients and others (e.g., tax preparers/advisors) involved in the application process. This can lead to physicians spending more time than is necessary completing the form because of the need to verify terms. As a result if the terms, criteria and the information about the programs are not as clear as possible this could result in errors on the part of physicians when completing the forms. This could then inadvertently disadvantage those who, in fact, qualify for benefits. Policy Measures: The CMA would like to see some consistency in definitions across the various government programs. This does not mean that eligibility criteria must become uniform. In addition, the CMA would like to see the development of a comprehensive information package for health care providers that provides a description of each program, its eligibility criteria, the full range of benefits available, copies of sample forms, physical assessment and form completion payment information, etc. 2) Remuneration The remuneration for assessment and form completion is another area where standardization among the various government programs would eliminate the difficulties that some individuals with disabilities currently face. For example, applicants who present the DTC Certificate Form T2201 to their physicians must bear any costs associated with its completion out of their own pockets. On the other hand, if an individual is applying to the CPP Disability Program, the cost to have the eligibility form completed by a physician is subsumed under the program itself. Assessing a patient’s disabilities is a complex and time-consuming endeavour on the part of any health professional. Our members tell us that the DTC Certificate Form T2201 can take as much time and effort to complete as the information requested for CPP Disability Program forms depending, of course, on the patient and the nature of the disability. In spite of this fact, some programs acknowledge the time and expertise needed to conduct a proper assessment while other programs do not. Although physicians have the option of approaching the applicant for remuneration for the completion of the DTC form, they are reluctant to do so because these individuals are usually of limited means and in very complex cases, the cost for a physician’s time for completing the DTC Form T2201 can reach as much as $150. In addition, physicians do not feel comfortable asking for payment when he/she knows the applicant will not qualify for the tax credit. Synchronizing funding between all programs would be of substantial benefit to all persons with disabilities, those professionals completing the forms and the programs’ administrators. Policy Measure: We strongly urge the federal government to place disability tax credit programs on the same footing when it comes to reimbursement of the examining health care provider. Tax Advisor Referrals With the complexity of the income tax system today, many individuals seek out the assistance of professional tax advisors to ensure the forms are properly completed and they have received all the benefits they are entitled to. Tax advisors will very often refer individuals to health professionals so that they can be assessed for potential eligibility for the DTC. The intention of the tax advisors may be laudable, but often, inappropriate referrals are made to health professionals. This not only wastes the valuable time of health care professionals, already in short supply, but may create unrealistic expectations on the part of the patient seeking the tax credit. The first principle of the CMA’s Code of Ethics is “consider first the well-being of the patient.” One of the key roles of the physician is to act as a patient’s advocate and support within the health care system. The DTC application form makes the physician a mediator between the patient and a third party with whom the patient is applying for financial support. This “policing” role can place a strain on the physician-patient relationship – particularly if the patient is denied a disability tax credit as a result a third-party adjudicator’s interpretation of the physician’s recommendations contained within the medical report. Physicians and other health professionals are not only left with having to tell the patient that they are not eligible but in addition advising the patient that there may be a personal financial cost for the physician providing this assessment. Policy Measure: Better preparation of tax advisors would be a benefit to both patients and their health care providers. The CMA would like CCRA to develop, in co-operation with the community of health care providers, a detailed guide for tax preparers and their clients outlining program eligibility criteria and preliminary steps towards undertaking a personal assessment of disability. This would provide some guidance as to whether it is worth the time, effort and expense to see a health professional for a professional assessment. As raised in a previous meeting with CCRA, the CMA is once again making available a physician representative to accompany DTC representatives when they meet the various tax preparation agencies, prior to each tax season, to review the detailed guide on program eligibility criteria and initial assessment, and to highlight the implications of inappropriate referral. Conclusion The DTC is a deserving benefit to those Canadians living with a disability. However, there needs to be some standardization among the various programs to ensure that they are effective and meet their stated purpose. Namely, the CMA would like to make the following suggestions: 1. The CMA would like established a senior level advisory group to continually monitor and appraise the performance of the DTC program to ensure it is meeting its stated purpose and objectives. Representation on this advisory group would include, at a minimum, senior program officials preferably at the ADM level; those professional groups qualified to complete the T2201 Certificate; various disability organizations; and patient advocacy groups. 2. The CMA recommends that the CCRA take the necessary steps to separate the evaluation process from the determination process. The CMA recommends the CPP Disability Program model to achieve this result. 3. That there be some consistency in definitions across the various government programs. This does not circumvent differences in eligibility criteria. 4. That a comprehensive information package be developed, for health care providers, that provides a description of each program, its eligibility criteria, the full range of benefits available, copies of sample forms, physical assessment and form completion payment information, etc. 5. That the federal government applies these social programs on the same footing when it comes to their funding and administration. 6. That CCRA develop, in co-operation with the community of health care providers, a detailed guide for tax advisors and their clients outlining program eligibility criteria and preliminary steps towards undertaking a personal assessment of disability. 7. That CCRA employ health care providers to accompany CCRA representatives when they meet the various tax preparation agencies to review the detailed guide on program eligibility criteria and personal assessment of disability, and to highlight the implications of inappropriate referral. These recommendations would certainly be helpful to all involved - the patient, health care providers and the programs’ administrators, in the short term. However what would be truly beneficial in the longer term would be an overall review of the taxation system from a health care perspective. This could provide tangible benefits not only for persons with disabilities but for all Canadians as well as demonstrating the federal government’s leadership towards ensuring the health and well being of our population. i Health Canada, The Role for the Tax System in Advancing the Health Agenda, Applied Research and Analysis Directorate, Analysis and Connectivity Branch, September 21, 2001 ii Canadian Medical Association, Securing Our Future… Balancing Urgent Health Care Needs of Today With The Important Challenges of Tomorrow”, Presentation to the Standing Committee on Finance Pre-Budget Consultations, November 1, 2001.
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Notes for an address by Dr. Peter Barrett, Past-President, Canadian Medical Association : Public hearings on primary care reform : Presentation to the Standing Senate Committee on Social Affairs, Science and Technology

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

https://policybase.cma.ca/en/permalink/policy13925
Last Reviewed
2020-02-29
Date
2018-07-25
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Last Reviewed
2020-02-29
Date
2018-07-25
Topics
Population health/ health equity/ public health
Text
Dear Minister Freeland: We are a national consortium of experts who serve and advocate for the needs and rights of older people. We are delighted by the recent appointment of a new Minister of Seniors, and send our congratulations to the Honourable Filomena Tassi. We are also encouraged by our Government’s commitment to support the health and economic well-being of all Canadians, and heartened by your promise to listen to, and to be informed by feedback from Canadians. It is in this spirit that we are writing today regarding the need for Canada to provide support and leadership with a goal of developing and ratifying a United Nations (UN) Convention on the Rights of Older Persons. In the context of massive global demographic shifts and an aging population, insightful and careful reflection by the leaders of our organizations has led to universal and strong support for the creation and implementation of a UN Convention to specifically recognize and protect the human rights of our older persons. A UN Convention on the Rights of Older Persons will:
enshrine their rights as equal with any other segment of the population with the same legal rights as any other human being;
categorically state that it is unacceptable to discriminate against older people throughout the world;
clarify the state’s role in the protection of older persons;
provide them with more visibility and recognition both nationally and internationally, which is vitally important given the rate at which Canadian and other societies are ageing;
advance the rights of older women at home and as a prominent factor in Canada’s foreign policy;
have a positive, real-world impact on the lives of older citizens who live in poverty, who are disproportionately older women, by battling ageism that contributes to poverty, ill-health, social isolation, and exclusion;
support the commitment to improve the lives of Indigenous Peoples; members of the LGBTQ community, and visible and religious minorities; and,
provide an opportunity for Canada to play a leadership role at the United Nations while at the same time giving expression to several of the Canadian government’s stated foreign policy goals. We have projected that the cost and impact of not having such a Convention would have a significant negative impact on both the physical and mental health of older Canadians. The profound and tragic consequence would have a domino effect in all domains of their lives including social determinants of health, incidence and prevalence of chronic diseases, social and psychological functioning, not to mention massive financial costs to society. There is recognition of this need internationally and ILC-Canada, along with other Canadian NGOs and organizations have been active at the UN to help raise awareness of the ways a UN Convention on the Rights of Older Persons would contribute to all countries. Changes have already been implemented by our Government that are consistent and aligned with a UN Convention, such as improving the income of vulnerable Canadian seniors, funding for long term care and support for community based dementia programs. These initiatives are all in keeping with support for a Convention on the Rights of Older Persons. They are also reflective of our country’s commitment to engage more fully with the United Nations and provide Canada the stage to demonstrate leadership on a vital international issue. It is an opportunity to champion the values of inclusive government, respect for diversity and human rights including the human rights of women. Scientific evidence demonstrates that human rights treaties help to drive positive change in the lives of vulnerable groups of people. In many countries in the world, older people are not adequately protected by existing human rights law, as explicit references to age are exceedingly rare. Even in countries like Canada, where there are legal frameworks that safeguard older people, a Convention would provide an extra layer of protection, particularly if the Convention has a comprehensive complaints mechanism. Older adults need to be viewed as a growing but underutilized human resource. By strengthening their active role in society including the workforce, they have tremendous capacity, knowledge, and wisdom to contribute to the economy and general well-being of humankind. We are requesting you meet with our representatives, to discuss the vital role of a UN Convention on the Rights of Older Persons and the role your government could play in improving the lives of older people in Canada and around the world. The fact that Canada is ageing is something to celebrate. We are all ageing, whether we are 20 or 85. This is a ”golden opportunity” to showcase Canada as a nation that will relentlessly pursue doing the “right thing” for humanity by supporting a UN Convention that ensures that our future is bright. Please accept our regards, and thank you for your attention to this request. We await your response. Sincerely, Margaret Gillis, President, International Longevity Centre Canada Dr. Kiran Rabheru, Chair of the Board, International Longevity Centre Canada Linda Garcia, Director, uOttawa LIFE Research Institute cc: The Right Honourable Justin Trudeau Prime Minister of Canada The Honourable Filomena Tassi Minister of Seniors The Honourable Jean Yves Duclos Minister for Families, Children and Social Development Ambassador Marc-Andre Blanchard Permanent Representative to Canada at the United Nations The Honourable Ginette Petitpas Taylor Health Minister Margaret Gillis President International Longevity Centre Canada Dr. Kiran Rabheru Chair of the Board, International Longevity Centre Canada Linda Garcia, PhD Director LIFE Research Institute Dr. Laurent Marcoux President Canadian Medical Association Andrew Padmos, BA, MD, FRCPC, FACP Chief Executive Officer Dani Prud’Homme Directeur général FADOQ Peter Lukasiewicz Chief Executive Officer Gowling WLG Dr. Dallas Seitz, MD, FRCPC President, CAGP Dr. Frank Molnar President, Canadian Geriatrics Society Dr. David Conn Co-Leader Canadian Coalition for Senior’s Mental Health Claire Checkland Director - Canadian Coalition for Seniors’ Mental Health Joanne Charlebois Chief Executive Officer, Speech-Language & Audiology Canada Claire Betker President Canadian Nurses Association Janice Christianson-Wood, MSW, RSW Title/Organization: President, Canadian Association of Social Workers / Présidente, l’Association canadienne des travail- leurs sociaux François Couillard Chief Executive Officer/Chef de la direction Ondina Love, CAE Chief Executive Officer Canadian Dental Hygienists Association Jean-Guy Soulière President/Président National Association of Federal Retirees /Association nationale des retraités fédéraux Sarah Bercier Executive Director Laura Tamblyn Watts National Initiative for the Care of the Elderly Dr. Keri-Leigh Cassidy Founder Fountain of Health Dr. Beverley Cassidy Geriatric Psychiatris Seniors Mental Health Dalhousie University Dept of Psychiatry Jenny Neal and Janet Siddall CO Chairs, Leadership Team Grandmothers Advocacy Network (GRAN) Kelly Stone President and CEO Families Canada Dr. Becky Temple, MD, CCFP, CCPE President, CSPL Medical Director Northeast, Northern Health Medical Lead Privilege Dictionary Review, BCMQI J. Van Aerde, MD, MA, PhD, FRCPC Clinical Professor of Pediatrics - Universities of Alberta & British Columbia, Canada Associate Faculty - Leadership Studies - Royal Roads Univ, Victo- ria, BC, Canada Past-President - Canadian Society of Physician Leaders Editor-in-Chief / Canadian Journal of Physician Leadership Dr. Rollie Nichol, MD, MBA, CCFP, CCPE Vice-President, CSPL Associate Chief Medical Officer, Alberta Health Services Dr. Shannon Fraser, MSc, FRCSC, FACS Secretary / Treasurer, CSPL Chief General Surgery Jewish General Hospital Linda Gobessi MD FRCPC Medical Director Geriatric Psychiatry Community Services of Ottawa Ottawa Vickie Demers Executive Director / Directrice générale Services communautaires de géronto- psychiatrie d’ Ottawa Geriatric Psychiatry Community Services of Ottawa Ging-Yuek Robin Hsiung, MD MHSc FRCPC FACP FAAN Associate Professor Ralph Fisher and Alzheimer Society of BC Professor Director of Clinical Research Director of Fellowship in Behavioural Neurology UBC Hospital Clinic for Alzheimer and Related Disorders Division of Neurology, Department of Medicine University of British Columbia Adriana Shnall Senior Social Worker Baycrest Health Sciences Harinder Sandhu, D.D.S., Ph.D Professor and Past Director Schulich Dentistry & Vice Dean, Schulich School of Medicine & Dentistry Western University Dr. Christopher Frank, Chair of Geriatric Education and Recruitment Initiative Jennie Wells, MD Associate Professor, University of Western Ontario Department of Medicine Chair/Chief Division of Geriatric Medicine Parkwood Institute Laura Diachun, MD Program Director, Undergrad Geriatric Education University of Western Ontario Department of Medicine, Division of Geriatric Medicine Parkwood Institute Sheri-Lynn Kane, MD Program Director Internal Medicine Dept of Medicine Education Office Victoria Hospital Niamh O’Regan, MB ChB, Assistant Professor, University of Western Ontario Parkwood Institute Michael Borrie, MB ChB, FRCPC Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine Parkwood Institute Jenny Thain, MRCP (Geriatrics) Assistant Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine Victoria Hospital Peter R. Butt MD CCFP FCFP Assoc. Professor, Department of Family Medicine, College of Medicine, University of Saskatchewan Mamta Gautam, MD, MBA, FRCPC, CCPE Dept of Psychiatry, University of Ottawa Psychiatrist, Psychosocial Oncology Program, The Ottawa Hospital President and CEO, PEAK MD Inc. Dr. Shabbir Amanullah Chair, ICPA Arun V. Ravindran, MBBS, MSc, PhD, FRCPC, FRCPsych Professor and Director, Global Mental Health and the Office of Fellowship Training, Department of Psychiatry, Graduate Faculty, Department of Psychology and Institute of Medical Sciences, University of Toronto Sarah Thompson, MD, FRCPC Geriatric Psychiatrist Seniors’ Mental Health Team Addictions and Mental Health Program Louise Plouffe, Ph.D. Director of Research, ILC Canada (retired) Kimberley Wilson, PhD, MSW Assistant Professor, Adult Development & Aging, Department of Family Relations & Applied Nutrition, University of Guelph Andrew R. Frank M.D. B.Sc.H. F.R.C.P.(C) Cognitive and Behavioural Neurologist Medical Director, Bruyère Memory Program Bruyère Continuing Care Ottawa, Canada Diane Hawthorne Family Physician BSc, MD, CCFP, FCFP Dr. Ken Le Clair Prof Emeritus Queens University and. Lead Policy Physician Consultant to Ontario. Seniors Behavioral Support Initative Queens University
Documents
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Physician resource planning (updated 2015)

https://policybase.cma.ca/en/permalink/policy11533
Last Reviewed
2019-03-03
Date
2015-05-30
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2015-05-30
Replaces
Physician resource planning (Update 2003)
Topics
Health human resources
Text
PHYSICIAN RESOURCE PLANNING (Updated 2015) The purpose of this policy statement is to identify the key elements required to properly undertake physician resource planning to support the delivery of appropriate medical care to all Canadians. A sustainable health care system requires effective physician resource planning and training that ensures an appropriate specialty mix that is responsive to population needs. CMA supports the need for the establishment of a coordinated national approach toward physician resource planning and an appropriately responsive undergraduate and postgraduate education system. CMA supports supply- and demand- projection models for health human resources using standardized approaches. National specialty societies should be actively engaged in physician resource planning for their respective discipline. Governments must work cooperatively with the medical profession to meet the needs of the population they serve in an affordable manner including funding the necessary infrastructure to support the appropriate number and mix of physicians. Recommendations: 1. Physician resource planning requires a pan-Canadian supply and needs-based projection model. 2. Infrastructure and resources as well as physician resources need to match the needs-based projection. 3. Strategies should be used throughout the undergraduate and postgraduate training system to address the current challenges matching physician resources to population needs. 4. Changing models of care delivery must be taken into consideration when developing physician resource projection models. Introduction The purpose of this policy statement is to identify the key elements required to properly undertake physician resource planning to support the delivery of appropriate medical care to all Canadians.1 Ensuring an adequate supply of physician human resources is a major tenet of the Canadian Medical Association's (CMA) Health Care Transformation initiative.2 While the number of students enrolled in Canadian medical schools increased by over 60 percent between 2001-02 and 2011-12, some enrollment reductions are now occurring despite significant physician resource issues remaining, affecting patient care delivery across the country. Currently, four to five million Canadians do not have a family physician. For older family physicians who may retire soon or wish to reduce their practice workload, there may be no colleagues able to take on new patients. Many new family physicians do not take on as large a roster of patients as those retiring. Even where overall supply has improved, recruiting and retaining physicians in underserved areas remains a challenge. Canada continues to license International Medical Graduates (IMGs) with 25% of practicing physicians receiving their medical degree from outside of the country3-the distribution of this group varies throughout Canada. Physician disciplines in short supply vary by jurisdiction. Some new physicians (especially those dependent on hospital based resources) are finding it hard to secure employment in their discipline.4 Concern for the future has spread to postgraduate residents and medical students. Completing fellowships, to make physicians more marketable, are now commonplace. A major contributor to underemployment in some specialties is a lack of infrastructure and related human resources (e.g., operating room time, nursing care). A sustainable health care system requires effective physician resource planning and training that ensures an appropriate specialty mix that is responsive to population needs. At present, there is no pan-Canadian system to monitor or manage the specialty mix. Few jurisdictions engage in formal health human resources planning and little cross-jurisdictional or pan-Canadian planning takes place. Currently, few Canadian jurisdictions have a long-term physician resource plan in place, particularly one that employs a supply and needs-based projection model. It has been almost four decades since the federal government has completed a needs-based projection of physician requirements in Canada.5 Physician resource planning must consider the population's health care needs over a longer term as the length of time to train a physician can be over a decade long depending on the specialty; this also means that practice opportunities can change during the period of training. The consequences of the lack of monitoring and management of the physician specialty mix can be long-lasting. A 2014 comparison of posted physician practice opportunities across Canada versus the number of post-graduate exits suggests a supply and demand mismatch for both family physicians (more positions posted than post-grad exits) and for medical and surgical specialists (more post-grad exits than available positions posted).6 Overall goal and considerations of physician resource planning The overall goal of physician resource planning is to produce a self-sustaining workforce that will effectively serve the health needs of Canadians by providing an adequate supply of clinicians, teachers, researchers and administrators. Physician resource planning should recognize the following considerations: * Physicians in training have a dual role of learner and clinical care provider.7 * Shifts in service delivery can occur with the development of new technologies, the changing prevalence of some disease states, the emergence of new illnesses and shifting public expectations (see Appendix A: The impact of emerging health technologies and models of care on physician resource planning). * Rural and remote communities possess unique challenges of not only attracting physicians but also in the nature of skills required to provide services. * Physicians are required for services to patient populations who fall under federal jurisdiction including members of the Canadian Armed Forces, First Nations and Inuit, refugees and refugee claimants, veterans, and prisoners in federal penitentiaries; this includes consideration of how they are attracted and the skills they require. * The full use of national medical services should be utilized instead of outsourcing to other countries. In instances where outsourcing of medical services occurs, Canadian training and certification standards must be met. * The emphasis from governments and the public for 24/7 access to a wide scope of physician and health care services must be balanced with the possibility of more fragmented care from multiple physicians involved in the care of a single patient. * There is a need for more clearly defined scopes of professional activity and optimal interactions among primary care physicians including family physicians who acquire enhanced/advanced skills to meet community needs, general specialists and subspecialists, particularly in the large urban areas where these three broad groups co-exist. * It is also relevant to define the role and most appropriate interactions of physicians with other healthcare professionals, including but not limited to physician assistants, specially trained nurses, dieticians, therapists and pharmacists. * The current shift to alternate payment plans and collaborative care models may, increase or decrease the non-clinical portion (e.g., research, teaching) of a physician's workload and thus increase the need for additional physicians. * The scheduling for the provision of after-hours care can have an effect on the use of physician resources (See CMA's policy statement on Management of Physician Fatigue for more information). * High tuition fees affect the social demographic mix of those seeking medical degrees while higher debt loads and the opportunity to practice in various models of care can influence specialty choice. 8 Similarly, advice from supervising faculty role models, negative/positive experiences during training, perceived lifestyle of the discipline, personal finances and earning potentials of medical disciplines all influence a medical student's specialty choice and in turn what health services will be available to future populations. Reliable and valid information on the current and future needs of the Canadian population can help trainees to make evidence-based decisions that allow them to select careers that match the needs of their patients. * Patterns in the transition of retiring physicians' practices need to be identified. It is essential to project not only the number of physicians but also some measure of their likely level of professional activity. Practice patterns may vary in response to changes in lifestyle among physicians, changing health technologies, group practices, interdisciplinary care models, and increased specialization of many generalist specialists and family physicians. Training The academic sector must ensure the provision of high-quality undergraduate, postgraduate and continuing education programs, and remain internationally competitive in the recruitment and retention of a first-class teaching and research community. Structured mentorship programs and formal career counseling should be a required component of all undergraduate and postgraduate curricula in Canada.9 Teaching institutions and postgraduate accreditation authorities need to recognize the risk in requiring students to make critical career choices before exploring all the options and should develop strategies to mitigate those risks, which may include tools for assessing aptitudes. Formal career counseling throughout medical education and training can boost employment success. Results of supply projection models should also be readily available to students and advisors so an informed choice can be made. There is a need to ensure flexibility at the undergraduate, postgraduate, and re-entry levels of medical education, with the recognition that the requirements for specialist services may change. It also allows room for standardized transfers of residents between programs and locations and for the integration of international medical graduates (IMGs). CMA recommends that a ratio of 120 postgraduate training positions per 100 medical graduates be re-established and maintained. Canadians studying medicine abroad and other IMGs who are permanent residents or citizens of Canada must be explicitly factored into the planning for the capacity of the post-MD training system. CMA supports measures to facilitate the acculturation of IMGs. The objective of seeking reasonable self-sufficiency for the full range of physician services must be paramount.10 Self-sufficiency is defined as ensuring that the annual output of the undergraduate and postgraduate sectors of Canadian medical schools meets the medical service needs of the Canadian public. This will reduce the need to attract physicians from countries that face a higher burden of disease whose requirements for physician services exceed those of Canada. It is important to facilitate the retention of physicians who train in the Canadian postgraduate system. There must be adequate human and physical infrastructure to support physician training. An adequate supply of clinical educators is required to prevent training bottlenecks. Strategies that utilize untapped health infrastructure resources within and outside the academic community such as satellite or distributive medical education training sites should be considered for not only training reasons but for retention purposes as well. Effectively matching supply to societal needs Residency training positions should reflect current and emerging population needs and if possible, job availability at the national level. Mechanisms should be in place to assist medical training programs to adjust to changing health needs in a timely manner. Physician resource planning can benefit from enhanced evaluation of community health needs, as established by thorough determinations of health status, epidemiological studies, input from communities and other needs assessments. In recent years, attention has been given to augmenting the provision of care to properly respond to Canada's growing seniors' population. This will require an assessment of physician resource trends among specialties that focus on seniors' care including the capacity to deliver quality palliative end-of-life care throughout Canada. To address geographic maldistribution, programs should train physicians in the wide spectrum of practice that is required for underserved communities-both rural and urban-as well as incorporate the involvement of the communities throughout the medical trainee life cycle. Programs to attract and retain physicians, including those from rural and underservice areas, need flexible incentives to address the professional and personal needs of physicians. Financial incentives, locum support, spousal employment, children's education and support from other specialists are key factors that need to be addressed. Also, the attraction and retention of physicians to underserved areas requires the presence of adequate technical equipment and personnel. Exposure to patterns of community practice-including generalist training-outside large urban tertiary/quaternary centres may help attract individuals into specialties best suited for rural and regional centres. CMA encourages family physicians to maintain their skills in comprehensive family medicine, while supporting their choice to acquire additional skills that will better serve the needs of their community. It is important to strive and budget for a critical mass of physicians required to deliver basic services to given populations to permit reasonable life-style management and the avoidance of professional isolation. Coercive measures that restrict physicians' choice of location and subsequent geographic mobility are not supported. Concentrated efforts are needed to assist new graduates of Canadian residency programs and established physicians find optimal employment in their discipline within Canada. The issue of facilitating the mobility of physicians among provinces and territories (including locum work) requires dialogue with and cooperation from individual provincial and territorial licensing authorities. CMA supports supply- and demand- projection models for health human resources using standardized approaches. Physician human resource plans should be reviewed on an ongoing basis, examining current supply and attrition patterns to determine if new policies are required or changes are needed to the undergraduate and postgraduate complement. Collaborative approach to physician resource planning Physician resource planning is complex, requiring the involvement of provincial/territorial medical associations, national specialty societies, the Royal Canadian Medical Service (Canadian Armed Forces), special medical interest groups, the medical education sector, the health care facilities sectors, governments, other health care professionals and other key stakeholders. CMA is committed to promoting a collaborative and respectful interaction among all the disciplines within the medical profession and recognition of the unique contributions of each to an efficient, high-quality and cost-effective health care delivery system. Governments must work cooperatively with the medical profession to meet the needs of the population they serve in an affordable manner including funding the necessary infrastructure to support the appropriate number and mix of physicians. National specialty societies should be actively engaged in physician resource planning for their respective discipline. CMA supports the establishment of a coordinated national approach toward physician resource planning and an appropriately responsive undergraduate and postgraduate education system. The recruitment and retention policies available at the provincial level can play a significant role in health human resources distribution and evolution. The federal government in conjunction with the provincial Deputy Ministers and Deans of Medicine, should continue to fund a pan-Canadian supply based planning model as laid out by the Physician Resource Planning Taskforce and extend its support to the second phase which is a comprehensive needs based planning model that will be accessible to governments and the profession. Given the importance of a planned, open and professional approach to physician resource planning, the CMA encourages all stakeholders to permit researchers, policy planners and other relevant organizations access to their physician resources database at the national and jurisdictional level while protecting the privacy of individual physicians. The CMA will continue to seek input into the design and structure of any such national databases. Appendix A: The impact of emerging health technologies and models of care on physician resource planning As in the past, a number of technological developments11 will alter the future demand for medical services and how medicine is practiced. Examples of such technological developments include: health information technologies (HITs); technologies to support distance care and self-monitoring (e.g., telemedicine, implantable or wearable sensors); surgical robotics; advanced diagnostic testing; genomic technologies; integrated care teams; and new funding models. It is important to consider how these developments will affect future supply and training (i.e., skill sets) of physicians as part of physician resource planning. There is little evidence about whether new technologies increase or reduce working hours.12 However, the adoption of new technologies can lead to new roles and opportunities for physicians as well as for other staff. New technologies can also lead to a greater role for patients in taking responsibility for their own health. There is extensive evidence that new technologies can improve the quality of patient care, especially when used in addition to existing care rather than as a substitution.13 A key factor in assessing the impact of new health technologies on physician resource planning is the rate of adoption and diffusion of new technologies. The rate can vary widely depending on an extensive range of factors including ease of use, safety, cost (both in terms of acquiring the technology and to train the clinician), compatibility and culture/attitudes. Not all new technologies are successfully adopted or lead to positive outcomes. Moreover, unlike other sectors, the adoption of health care technologies does not often lead to lower costs.14 The adoption can also be influenced by broader factors such as changing patient needs and the government's fiscal resources. One key impact of emerging health technologies is a shift in the location where care is received. For instance, less invasive surgery will lead to greater use of community services for follow up care rather than in-hospital care. Likewise, the technologies can support the provision of more specialized services in small and remote communities by family physicians with the appropriate training and support. Emerging health technologies can also impact the type of care provided. The literature suggests the impact will be felt more in sub-specialty areas with care shifting from one subspecialty to another.15 Advances in non-invasive surgical interventions will continue to drive practice convergence such as seen with cardiac related procedures.16 The accelerated use of HITs specifically could have the greatest overall impact on health human resources due to such factors as: the need for increased training to use HITs; and an increased need for health informatics specialists (both medical and non-medical).15 Automated knowledge work tools will almost certainly extend the powers of many types of workers and help drive top-line improvements with innovations and better decision making.17 The move to more collaborative care models, particularly in primary care, can be expected in the coming years. Common characteristics of these models include comprehensive chronic disease prevention, population-based services and programs, full use of electronic medical records, quality monitoring, dedicated time to team building and collaboration, and a wide range of health care providers functioning to their full scope of practice.18 Multi-disciplinary teams could also involve a wider range of providers such as IT specialists, bio-engineers and genetic counselors. While CMA has previously called for funding models to be in place to allow physicians and other health care providers to practice within the full scope of their professional activities,19 a significant issue will be how such collaborative care models can be funded by governments on a sustained basis. Physicians and other health care providers need to be trained to effectively adopt any new technology. The literature is clear that physicians must be engaged in any discussions regarding new and current health technologies to ensure their proper assessment and successful implementation.20 Previously, CMA has called for: * A flexible medical training system based on informed career choice to accommodate changes in medical practice and physician resource needs; * A sufficient and stable supply of re-entry positions within the postgraduate training system to enable practicing physicians to enhance their skills or re-enter training in another discipline.21 * Recognition that scopes of practice must reflect these changes in societal needs (including the need of the public for access to services), societal expectations, and preferences of patients and the public for certain types of health care providers to fulfill particular roles and functions, while at the same time reflecting economic realities.22 References 1 This policy is to be used in conjunction with CMA's policy statements on Management of Physician Fatigue (2014), Flexibility in Medical Training (Update 2009), Physician Health and Well-Being (1998), Tuition Fee Escalation and Deregulation in Undergraduate Programs in Medicine (Update 2009), and Rural and Remote Practice Issues (1998). 2 Canadian Medical Association. Health Care Transformation in Canada. Change That Works, Care That Lasts. Ottawa: The Association; 2010. Available: http://www.hpclearinghouse.ca/pdf/HCT-2010report_en.pdf (accessed 2015 May 04). 3 Canadian Institute for Health Information. Physicians in Canada, 2013: Summary Report Ottawa: The Institute; 2013 Sep. 4 College of Family Physicians of Canda, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada. National Physician Survey 2013. Backgrounder. Available: http://nationalphysiciansurvey.ca/wp-content/uploads/2013/10/OFFICIAL-RELEASE_NPS-2013-Backgrounder_EN.pdf 5 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. 6 Research conducted by the Canadian Medical Association. Fall 2014. 7 National Steering Committee on Resident Duty Hours. Fatigue, risk and excellence: Towards a Pan-Canadian consensus on resident duty hours. Ottawa: Royal College of Physicians and Surgeons of Canada. 2013. 8 Canadian Medical Association. Tuition fee escalation and deregulation in undergraduate programs in medicine (update 2009). Ottawa" The Association; 2003 June. Available: http://policybase.cma.ca 9 The Canadian Association of Internes and Residents. CAIR Position Paper on Mentorship. June 2013. http://residentdoctors.ca/wp-content/uploads/2014/12/CAIR-Position-Paper-on-Mentorship_June-2013_en.pdf (accessed 2015 Apr 29). 10 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. 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. The policy is also consistent with the World Medical Association and the World Health Organization (The WHO Global Code of Practice of the International Recruitment of Health Personnel). http://www.who.int/hrh/migration/code/code_en.pdf?ua=1 11 Definition of Health Technologies (World Health Organization): "The application of organized knowledge and skills in the form of devices, medicines, vaccines, procedures and systems developed to solve a health problem and improve quality of lives." 12 Evidence Centre for Skills for Health, How do technologies impact on workforce organisation? Bristol (UK): The Centre. Available: www.skillsforhealth.org.uk/index.php?option=com_mtree&task=att_download&link_id=101&cf_id=24 (accessed 2015 Feb 02). 13 Evidence Centre for Skills for Health, How do technologies impact on workforce organisation? Bristol (UK): The Centre. Available: www.skillsforhealth.org.uk/index.php?option=com_mtree&task=att_download&link_id=101&cf_id=24 (accessed 2015 Feb 2) 14 Skinner J. "The costly paradox of health-care technology". MIT Technology Review. 2013 Sep 5. 15 Anvari M. Impact of information technology on human resources in healthcare. Healthcare Quarterly, 10(4) September 2007:84-88. 16 Social Sector Metrics Inc., Health Intelligence Inc. Physician resource planning: a recommended model and implementation framework. Final report submitted to the Nova Scotia Department of Health and Wellness. 2002 Jan 31. Available: www.doctorsns.com/site/media/DoctorsNS/PhysicianResourcePlanning-finalreport.pdf (accessed 2015 Feb 2). 17 McKinsey Global Institute, Disruptive technologies: Advances that will transform life, business, and the global economy. McKinsey & Company 2013. 18 Social Sector Metrics Inc., Health Intelligence Inc. Physician resource planning: a recommended model and implementation framework. Final report submitted to the Nova Scotia Department of Health and Wellness. 2002 Jan 31. Available: www.doctorsns.com/site/media/DoctorsNS/PhysicianResourcePlanning-finalreport.pdf (accessed 2015 Feb 02). 19 Canadian Medical Association. The Evolving Professional Relationship Between Canadian Physicians and Our Health Care System: Where Do We Stand? Ottawa: The Association; 2012 20 Steven A. Olson et al., Healthcare technology: Physician collaboration in reducing the surgical cost. Clinical Orthopaedics and Related Research. (2013) 471:1854-64. 21 Canadian Medical Association. Flexibility in Medical Training (update 2009) Ottawa: The Association; 2009. 22 Canadian Medical Association. Scopes of practice. Ottawa: The Association; 2002.
Documents
Less detail

Obesity as a chronic medical disease

https://policybase.cma.ca/en/permalink/policy11700
Last Reviewed
2019-03-03
Date
2015-10-03
Topics
Population health/ health equity/ public health
Resolution
GC15-99
The Canadian Medical Association recognizes obesity as a chronic medical disease.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2015-10-03
Topics
Population health/ health equity/ public health
Resolution
GC15-99
The Canadian Medical Association recognizes obesity as a chronic medical disease.
Text
The Canadian Medical Association recognizes obesity as a chronic medical disease.
Less detail

CMA’s formal submission to the Federal External Panel on assisted dying

https://policybase.cma.ca/en/permalink/policy11750
Last Reviewed
2019-03-03
Date
2015-10-19
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2015-10-19
Topics
Ethics and medical professionalism
Text
Dear Members of the Federal External Panel: On behalf of the Canadian Medical Association (CMA), I appreciate the opportunity to provide input toward the Federal External Panel's national consultation to support the federal government's legislative response following the Supreme Court of Canada's ruling in Carter v. Canada. As the national professional association representing Canada's physicians, the CMA has played an important role in leading the public dialogue on end-of-life care, including assisted dying. In 2014, the CMA led a national consultation on end-of-life care which included a series of public and member town hall consultations across the country. This national dialogue focused on three main issues: advance care planning, palliative care, and physician-assisted dying. As highlighted in the summary report (enclosed as Appendix 1), the Canadian public emphasized the need for strict protocols and safeguards if the law on physician-assisted dying were to change. This initial consultation provided valuable insights to inform the concurrent CMA's in-depth and comprehensive consultation with its membership as well as medical and health stakeholders as an intervener before the Supreme Court and following the Carter decision. This consultation included engagement of the CMA's Ethics Committee, policy debates as part of the CMA's Annual Meetings in 2014 and 2015, in-person member forums across the country, and an online dialogue. The consultation was critical to the development of the CMA's Principles-based Recommendations for a Canadian Approach to Assisted Dying (enclosed as Appendix 2). These recommendations, guided by a set of ten foundational principles, address patient eligibility for access to and assessment for assisted dying, procedural safeguards for eligibility criteria, the roles and responsibilities of the attending and consulting physicians, and the issue of conscientious objection. Taken together, these recommendations form the CMA's position on the forthcoming legislative and regulatory framework to govern assisted dying in Canada. In addition to our recommendations, we would like to highlight key points that are of particular relevance to physicians: NATIONAL, PAN-CANADIAN LEGISLATIVE AND REGULATORY FRAMEWORK The CMA strongly recommends the establishment of national and coordinated legislative and regulatory processes and systems in response to the Carter decision. The CMA is deeply concerned that in the absence of federal action to support the establishment of national guidelines for assisted dying, a patchwork of differing and potentially conflicting approaches could emerge across jurisdictions. Legislative action at the federal level is needed to provide further clarity for physicians and their patients and support the promulgation of a coordinated and consistent approach across all jurisdictions in Canada. The CMA has been working with the medical regulatory colleges at the national level to mitigate this risk through the development of the CMA's Principles-based Recommendations for a Canadian Approach to Assisted Dying which has encouraged similar efforts by the regulatory colleges. In addition to these initiatives, federal action is required. CONSCIENTIOUS OBJECTION As the Federal External Panel is aware, the Carter decision emphasizes that any regulatory or legislative response must seek to reconcile the Charter rights of patients (wanting to access assisted dying) and physicians (who choose not to participate in assisted dying on grounds of conscientious objection). The notion of conscientious objection is not monolithic. While some conceptions of conscience encompass referral, others view referral as being connected to, or as akin to participating in, a morally objectionable act. It is the CMA's position that an effective reconciliation is one that respects, and takes account of, differences in conscience, while facilitating access on the principle of equity. To this end, the CMA's membership strongly endorses the recommendation on conscientious objection as set out in section 5.2 of the CMA's enclosed Principles-based Recommendations for a Canadian Approach to Assisted Dying. ADDITIONAL SUPPORTS The CMA recognizes, and supports addressing, the need to develop education materials for physicians. To this end, the CMA is actively developing education modules for physicians following an environmental scan of existing courses and discussions with other jurisdictions (e.g., the Royal Dutch Medical Association). The CMA has the support of the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada, and the Canadian Medical Protective Association to lead this initiative. Finally, as previously stated, the CMA strongly encourages the federal government to make the report of the Federal External Panel publicly available once final. The CMA urges the members of the Federal External Panel to support this recommendation to the federal government. Thank you once again for the opportunity to provide input. The CMA looks forward to our meeting with the Federal External Panel on October 20, 2015. Sincerely, Cindy Forbes, MD, CCFP, FCFP President Jeff Blackmer MD, MHSc, FRCPC Vice-President, Medical Professionalism Enclosed: Appendix 1 - Summary Report: End-of-Life Care A National Dialogue (please see pdf for link to document) Appendix 2 - CMA's Principles-based Recommendations for a Canadian Approach to Assisted Dying Principles-based Recommendations for a Canadian Approach to Assisted Dying On Feb. 6, 2015, the Supreme Court of Canada unanimously struck down the law prohibiting assisted dying. The court suspended that decision for 12 months. This has provided an opportunity for the Canadian Medical Association (CMA) to build on its past work and pursue further consultation with provincial and territorial medical associations, medical and non-medical stakeholders, members, legislatures and patients for processes, whether legal, regulatory or guidelines, that respect patients' needs and reflects physicians' perspectives. The goal of this process is twofold: (a) discussion and recommendations on a suite of ethical-legal principles and (b) input on specific issues that are particularly physician-sensitive and are worded ambiguously or not addressed in the Court's decision. The touch points are reasonable accommodation for all perspectives and patient-centeredness. For purposes of clarity, CMA recommends national and coordinated legislative and regulatory processes and systems. There should be no undue delay in the development of these laws and regulations. The principles are not designed to serve as a tool for legislative compliance in a particular jurisdiction or provide a standard of care. Rather, the CMA wishes to provide physicians with guidance and a vision of what physicians might strive for to further their professional and legal obligations in a complex area. The CMA recommends adopting the following principles-based approach to assisted dying in Canada: Foundational principles The following foundational principles underpin CMA's recommended approach to assisted dying. Proposing foundational principles is a starting point for ethical reflection, and their application requires further reflection and interpretation when conflicts arise. 1. Respect for patient autonomy: Competent adults are free to make decisions about their bodily integrity. Specific criteria are warranted given the finality of assisted dying. 2. Equity: To the extent possible, all those who meet the criteria for assisted dying should have access to this intervention. Physicians will work with relevant parties to support increased resources and access to high quality palliative care, and assisted dying. There should be no undue delay to accessing assisted dying, either from a clinical, system or facility perspective. To that end, the CMA calls for the creation of a separate central information, counseling, and referral service. 3. Respect for physician values: Physicians can follow their conscience when deciding whether or not to provide assisted dying without discrimination. This must not result in undue delay for the patient to access these services. No one should be compelled to provide assistance in dying. 4. Consent and capacity: All the requirements for informed consent must clearly be met, including the requirement that the patient be capable of making that decision, with particular attention to the context of potential vulnerabilities and sensitivities in end of life circumstances. Consent is seen as an evolving process requiring physicians to continuously communicate with the patient. 5. Clarity: All Canadians must be clear on the requirements for qualification for assisted dying. There should be no "grey areas" in any legislation or regulations. 6. Dignity: All patients, their family members or significant others should be treated with dignity and respect at all times, including throughout the entire process of care at the end of life. 7. Protection of patients: Laws and regulations, through a carefully designed and monitored system of safeguards, should aim to minimize harm to all patients and should also address issues of vulnerability and potential coercion. 8. Accountability: An oversight body and reporting mechanism should be identified and established in order to ensure that all processes are followed. Physicians participating in assisted dying must ensure that they have appropriate technical competencies as well as the ability to assess decisional capacity, or the ability to consult with a colleague to assess capacity in more complex situations. 9. Solidarity: Patients should be supported and not abandoned by physicians and health care providers, sensitive to issues of culture and background, throughout the dying process regardless of the decisions they make with respect to assisted dying. 10. Mutual respect: There should be mutual respect between the patient making the request and the physician who must decide whether or not to perform assisted dying. A request for assisted dying is only possible in a meaningful physician-patient relationship where both participants recognize the gravity of such a request. Recommendations Based on these principles, the Supreme Court decision in Carter v. Canada (2015)1 and a review of other jurisdictions' experiences, CMA makes the following recommendations for potential statutory and regulatory frameworks with respect to assisted dying. We note that this document is not intended to address all potential issues with respect to assisted dying, and some of these will need to be captured in subsequent regulations. 1. Patient eligibility for access to assisted dying 1.1 The patient must be a competent adult who meets the criteria set out by the Supreme Court of Canada decision in Carter v. Canada (2015. 1.2 Informed decision * The attending physician must disclose to the patient information regarding their health status, diagnosis, prognosis, the certainty of death upon taking the lethal medication, and alternatives, including comfort care, palliative and hospice care, and pain and symptom control. 1.3 Capacity * The attending physician must be satisfied that: - the patient is mentally capable of making an informed decision at the time of the request(s) - the patient is capable of giving consent to assisted dying, paying particular attention to the potential vulnerability of the patient in these circumstances - communications include exploring the priorities, values and fears of the patient, providing information related to the patient's diagnosis and prognosis, treatment options including palliative care and other possible interventions and answering the patient's questions * If either or both the attending physician or the consulting physician determines that the patient is incapable, the patient must be referred for further capacity assessment. * Only patients on their own behalf can make the request while competent. 1.4 Voluntariness * The attending physician must be satisfied, on reasonable grounds, that all of the following conditions are fulfilled: - The patient's decision to undergo assisted dying has been made freely, without coercion or undue influence from family members, health care providers or others. - The patient has a clear and settled intention to end his/her own life after due consideration. - The patient has requested assisted dying him/herself, thoughtfully and repeatedly, in a free and informed manner. 2. Patient eligibility for assessment for decision-making in assisted dying Stage 1: Requesting assisted dying 1. The patient submits at least two oral requests for assisted dying to the attending physician over a period of time that is proportionate to the patient's expected prognosis (i.e., terminal vs non-terminal illness). CMA supports the view that a standard waiting period is not appropriate for all requests. 2. CMA recommends generally waiting a minimum of 14 days between the first and the second oral requests for assisted dying. 3. The patient then submits a written request for assisted dying to the attending physician. The written request must be completed via a special declaration form that is developed by the government/department of health/regional health authority/health care facility. 4. Ongoing analysis of the patient's condition and ongoing assessment of requests should be conducted for longer waiting periods. Stage 2: Before undertaking assisted dying 5. The attending physician must wait no longer than 48 hours, or as soon as is practicable, after the written request is received. 6. The attending physician must then assess the patient for capacity and voluntariness or refer the patient for a specialized capacity assessment in more complex situations. 7. The attending physician must inform the patient of his/her right to rescind the request at any time. 8. A second, independent, consulting physician must then also assess the patient for capacity and voluntariness. 9. Both physicians must agree that the patient meets eligibility criteria for assisted dying to proceed. 10. The attending physician must fulfill the documentation and reporting requirements. Stage 3: After undertaking assisted dying 11. The attending physician, or a physician delegated by the attending physician, must take care of the patient until the patient's death. 3. Role of the physician 3.1 The attending physician must be trained to provide assisted dying. 3.2 Patient assessment * The attending physician must determine if the patient qualifies for assisted dying under the parameters stated above in Section 1. * The attending physician must ensure that all reasonable treatment options have been considered to treat physical and psychological suffering according to the patient's need, which may include, independently or in combination, palliative care, psychiatric assessment, pain specialists, gerontologists, spiritual care, and/or addiction counseling. 3.3 Consultation requirements * The attending physician must consult a second physician, independent of both the patient and the attending physician, before the patient is considered eligible to undergo assisted dying. * The consulting physician must - Be qualified by specialty or experience to render a diagnosis and prognosis of the patient's illness and to assess their capacity as noted in Stage 2 above. 3.4 Opportunity to rescind request * The attending physician must offer the patient an opportunity to rescind the request at any time; the offer and the patient's response must be documented. 3.5 Documentation requirements * The attending physician must document the following in the patient's medical record: - All oral and written requests by a patient for assisted dying - The attending physician's diagnosis and prognosis, and their determination that the patient is capable, acting voluntarily and has made an informed decision - The consulting physician's diagnosis and prognosis, and verification that the patient is capable, acting voluntarily and has made an informed decision - A report of the outcome and determinations made during counseling - The attending physician's offer to the patient to rescind the request for assisted dying - A note by the attending physician indicating that all requirements have been met and indicating the steps taken to carry out the request 3.6 Oversight body and reporting requirements * There should be a formal oversight body and reporting mechanism that collects data from the attending physician. * Following the provision of assisted dying, the attending physician must submit all of the following items to the oversight body: - Attending physician report - Consulting physician report - Medical record documentation - Patient's written request for assisted dying * The oversight body would review the documentation for compliance * Provincial and territorial jurisdictions should ensure that legislation and/or regulations are in place to support investigations related to assisted dying by existing provincial and territorial systems * Pan-Canadian guidelines should be developed in order to provide clarity on how to classify the cause on the death certificate 4. Responsibilities of the consulting physician * The consulting physician must verify the patient's qualifications including capacity and voluntariness. * The consulting physician must document the patient's diagnosis, prognosis, capacity, volition and the provision of information sufficient for an informed decision. The consulting physician must review the patient's medical records, and should document this review. 5. Moral opposition to assisted dying 5.1 Moral opposition by a health care facility or health authority * Hospitals and health authorities that oppose assisted dying may not prohibit physicians from providing these services in other locations. There should be no discrimination against physicians who decide to provide assisted dying. 5.2 Conscientious objection by a physician * Physicians are not obligated to fulfill requests for assisted dying. There should be no discrimination against a physician who chooses not to participate in assisted dying. In order to reconcile physicians' conscientious objection with a patient's request for access to assisted dying, physicians are expected to provide the patient with complete information on all options available to them, including assisted dying, and advise the patient on how they can access any separate central information, counseling, and referral service. 1 Carter v. Canada (Attorney General), [2015] 1 SCR 331, 2015 SCC 5 (CanLII)
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The health of Aboriginal peoples 2002

https://policybase.cma.ca/en/permalink/policy163
Last Reviewed
2019-03-03
Date
2002-12-07
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2002-12-07
Topics
Population health/ health equity/ public health
Text
HEALTH OF ABORIGINAL PEOPLES 2002 A CMA Policy Statement Recommendation #1 That the federal government adopt a comprehensive strategy for improving the health of Aboriginal peoples that involves a partnership among governments, non-governmental organizations, universities and the Aboriginal communities. 2) The Need to Address Health Determinants The health status of Canada’s Aboriginal peoples is a result of a broad range of factors: social, biological, economic, political, educational and environmental. The complexity and interdependence of these health determinants suggest that the health status of Aboriginal peoples is unlikely to be improved significantly by increasing the quantity of health services. Instead, inequities within a wide range of social and economic factors should be addressed; for example: income education employment interactions with the justice system racism and social marginalization environmental hazards water supply and waste disposal housing quality and infrastructure cultural identity, (for example, long-term effects of the residential school legacy.) Recommendation #2 That all stakeholders work to improve provision for the essential needs of Aboriginal peoples and communities that affect their health (e.g. housing, employment, education, water supply). 3) The Importance of Self-Determination One characteristic of successful Aboriginal communities is a high degree of self-efficacy and control over their own circumstances. This empowerment can take many forms, from developing community-driven health initiatives to determining how to use lands. It is increasingly recognized that self-determination in cultural, social, political and economic life improves the health of Aboriginal peoples and their communities, and that Aboriginal peoples can best determine their requirements and the solutions to their problems. Therefore, the CMA encourages and supports the Aboriginal peoples in their move toward increasing self-determination and community control. A just and timely settlement of land claims is one means by which Aboriginal communities can achieve this self-determination and self-sufficiency. Recommendation #3 That governments and other stakeholders: Settle land claims and land use issues expeditiously; Work toward resolving issues of self-determination for Aboriginal peoples and their communities in areas of cultural, social, political and economic life. 4) Community Control of Health Services Control by Aboriginal peoples of health and social services is increasing across Canada as part of a broader transfer of control of political power, resources and lands. This transfer has not progressed at the same pace across all Aboriginal communities; the needs of Urban Aboriginal peoples, for example, are only beginning to be addressed. CMA supports the development of community-driven models for delivery of health care and health promotion, responsive to the culture and needs of individual communities. Successful community-driven models of health care delivery generally recognize that the Aboriginal concept of health is holistic in nature, incorporating mental, emotional and spiritual as well as physical components. Translating this concept into practice may involve: Development of primary care models that are grounded within Aboriginal culture at a local level; Integration of disease treatment services with health promotion and health education programs, and with traditional healing practices; Integration of health and social services; Interprofessional collaboration within a multi-disciplinary team. CMA also supports programs to increase the involvement of Aboriginal peoples in professional and other decision-making roles affecting the health of their community – for example, increased representation in health-care management positions, and on health facility boards where there is a significant Aboriginal population. Recommendation #4 That all stakeholders actively encourage the development of integrated, holistic primary care service delivery relevant to the needs and culture of Aboriginal communities and under community control. 5) Cultural Responsiveness in the Patient/Physician Relationship As mentioned above, the concept of “health” in Aboriginal culture is holistic and incorporates many components. The concepts of continuity, wholeness and balance within and among people are important to Aboriginal culture, as is a close affinity with the natural environment – both in practical and spiritual senses , which emphasises the importance of stewardship of the land as a component of individual and community health maintenance for present and future generations. Physicians should work in collaboration with Aboriginal peoples and groups to promote a greater understanding and acceptance of their respective philosophies and approaches. This could include: an openness and respect for traditional medicine and traditional healing practices (e.g. sweat lodges, herbal medicines, healing circles). This should be balanced with a recognition that not all Aboriginal people, whether First Nation, Métis or Inuit, adhere to or understand their traditional ceremonial practices. improved cross-cultural awareness in physicians, which could be facilitated by greater contact with their local Aboriginal communities, better understanding of local Aboriginal cultures, history and current setting, development of cross-cultural patient-physician communication skills. Recommendation #5 a) That educational initiatives in cross-cultural awareness of Aboriginal health issues be developed for the Canadian population, and in particular for health care providers, b) that practice tools and resources be developed to support physicians (Aboriginal and non-Aboriginal) and other health care professionals practicing in Aboriginal communities. 6) Access to Health Services Canada is often considered to have one of the best health care systems in the world and is typically described as providing “universal access”. However, our system does not provide equal access to services for all people living in Canada – the most underserviced being those in northern Canada, which contains many Aboriginal communities. Several kinds of access problems exist in Aboriginal communities: Lack of access to employment, adequate housing, nutritious food, clean water and other social or economic determinants of health. Factors that impede access to health care services, particularly in remote locations; for example, language and cultural differences, and the difficulty of transporting patients to tertiary centres. Lack of specific services (for example, mental health services) for Aboriginal peoples in many regions of Canada. Specific groups, such as women and the elderly, have unique and distinct needs that should be addressed. Program delivery that involves multiple federal, provincial and municipal funding agencies. Physicians and patients alike have trouble obtaining information about and entry into existing programs and funding for new programs because of jurisdictional confusion. CMA has previously recommended that the Canadian health system develop and apply agreed-upon standards for timely access to care. This includes the need to increase timely and appropriate access by Aboriginal peoples to health care and health promotion services, geared to different segments of the population according to their needs. Recommendation #6 a) That governments and other stakeholders simplify and clarify jurisdictional responsibilities with respect to Aboriginal health at the federal, provincial and municipal level, with a goal of simplifying access to service delivery. b) That strategies be explored to increase access to health services by remote communities; for example, through the use of technology (e.g. Web sites, telemedicine) to connect them with academic medical centres. 7) Health Human Resources There is an urgent need to increase the training, recruitment and retention of Aboriginal health care providers. The 1996 Royal Commission on Aboriginal Peoples recommended that a cadre of 10,000 Aboriginal health care and social service workers be trained to meet the needs of a complex and diverse community. While progress has been made in recent years, an intensive focus on recruitment, training and retention is required in order to achieve this goal. A comprehensive health human resource strategy should be developed, to increase the recruitment, training and retention of Aboriginal students in medicine and other health disciplines. Such a strategy could include: Outreach programs to interest Aboriginal young people in the health sciences. Access and support programs for Aboriginal medical students. Residency positions for recently graduated Aboriginal physicians or physicians wishing to practice in Aboriginal populations, including re-entry positions for physicians currently in practice. Mentoring and leadership-development programs for Aboriginal medical students, residents and physicians. Programs to counter racism and discrimination in the health-care system. Initiatives to recruit and train Community Health Representatives/ Workers, birth attendants and other para-professionals within Aboriginal communities. Recommendation #7 a) That CMA and others work to develop a health human resource strategy aimed at improving the recruitment, training, retention of Aboriginal physicians and other health-care workers; b) That medical and other health faculties increase access and support programs to encourage enrollment of Aboriginal students. 8) Health Information Information about the health status and health care experience of Aboriginal peoples, is essential for future planning and advocacy. For Aboriginal peoples to effectively develop self-determination in health care delivery, they should have access to data that can be converted into useful information on their population. The “OCAP” principle (ownership, control, access to and possession of health data) is seen as integral to First Nation community empowerment, but may prove acceptable to other Aboriginal groups as well. A considerable amount of data currently exists, though there are gaps in coverage, particularly regarding Métis, Inuit and urban and rural off-reserve First Nations populations. This data can come from a variety of federal and provincial/territorial sources, including periodic surveys, federal censuses, Aboriginal Peoples Survey data holdings, and also regional physician and hospital utilization statistics. However, jurisdictional and ownership issues have hindered Aboriginal people from accessing and making use of this data. CMA supports the development and maintenance of mechanisms to systematically collect and analyze longitudinal health information for Aboriginal people, and the removal of barriers that prevent Aboriginal organizations from fully accessing information in government databases. Aboriginal health information should be subject to guarantees of privacy and confidentiality. The CMA urges relevant government departments to ensure that revisions to the Indian Act do not infringe on the privacy of health information of Aboriginal peoples in Canada. Recommendation #8 That the Government of Canada support the First Nations and Inuit Regional Longitudinal Health Survey Process, and the First Nations and Inuit Health Information System, and parallel interests for the Métis and Inuit. These programs should be operated under the control of their respective Aboriginal communities 9) Research The CMA supports culturally relevant research into the determinants of Aboriginal health and effective treatment and health-promotion strategies to address them. Specifically, the CMA supports the efforts of the Institute of Aboriginal Peoples’ Health at the Canadian Institute for Health Research, in addressing the needs of Canada’s Aboriginal peoples. Aboriginal peoples should be involved in research design, data collection and analysis; research should support the communities as they build capacity and develop initiatives to address their health needs. Ideally, research should address not only determinants of ill health but also the reasons for positive health outcomes. The CMA also acknowledges the need to communicate research results to Aboriginal communities to help them develop and evaluate health programs. In particular there is an urgent need among Aboriginal communities for the sharing of successes. Recommendation #9 That government and other stakeholders Support Aboriginal peoples and communities in the development of Aboriginal research and the means of interpreting its findings. Make public communication of health research results a priority in order to facilitate its use by Aboriginal communities. CMA’S CONTINUED COMMITMENT The Canadian Medical Association, consistent with its mandate to advocate for the highest standards of health and health care in Canada, will continue to work with the Aboriginal community and other stakeholders on activities addressing the following issue areas: Workforce Enhancement: Research and Practice Enhancement:. Public and Community Health Programming:. Leadership Development:. Advocacy for healthy public policy. Page 5 November 15, 2002
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A national action plan for mental illness and mental health : a call for action

https://policybase.cma.ca/en/permalink/policy171
Last Reviewed
2019-03-03
Date
2002-12-07
Topics
Health care and patient safety
  1 document  
Policy Type
Policy endorsement
Last Reviewed
2019-03-03
Date
2002-12-07
Topics
Health care and patient safety
Text
A National Action Plan for Mental Illness and Mental Health : A Call for Action This consensus statement was drafted at the National Summit on Mental Illness and Mental Health held on October 3, 4, 2002. The consensus statement was ratified subsequently by each of the signatory organizations. VISION We envision a country where all Canadians enjoy good mental health. Canadians with mental illnesses*, their families and care providers must have access to the care, support and respect to which they are entitled and in parity with other health conditions. PRINCIPLES We are committed to a National Action Plan that upholds the following principles: 1. Mental illness and mental health issues must be considered within the framework of the determinants of health and recognizes the important linkages among mental, neurological and physiological health. 2. Given the impact of mental health issues and mental illness (i.e. on the suffering of Canadians, on mortality, especially from suicide, on the economy, on social services such as health, education and criminal justice), Canadian governments and health planners must address mental health issues commensurate with the level of their burden on society. 3. Mental health promotion and the treatment of mental illnesses must be timely, continuous, inter-disciplinary, culturally appropriate, and integrated across the full life cycle and the continuum of care (i.e. physical and mental health; social supports and tertiary care to home/community care). KEY ELEMENTS OF A NATIONAL ACTION PLAN 1. National Mental Health Goals. These goals would provide a framework to, for example, evaluate both processes and outcomes, set minimum standards, and assess systemic change. 2. A Policy Framework. The framework must provide for a comprehensive health promotion and service delivery plan, an enhanced research program, a surveillance and national data/information system, a public education strategy, a health human resources plan, and an innovations fund that embraces both mental illness and mental health promotion as well as the principles of recovery and citizenship. 3. Dedicated, Sustained and Adequate Resources tied to the National Mental Health Goals and specific outcomes. 4. An Accountability Mechanism, such as annual reporting on, for example, access, mental health status, systemic change and the application of best practices. * NOTE: The use of the term "mental illness" in this "Call for Action" includes diseases, disorders, conditions or problems. It also includes the spectrum of addictions. A CALL FOR LEADERSHIP AND ACTION We, the undersigned, urge the federal, provincial and territorial governments to work together with federal leadership to recognize and act upon the compelling moral, social and economic case for mental health promotion and mental illness care. SIGNATORY ORGANIZATIONS Canadian Medical Association Canadian Psychiatric Association NATIONAL ORGANIZATIONS REPRESENTED AT THE OCTOBER 2002 SUMMIT Autism Society of Canada Canadian Academy of Child Psychiatry Canadian Alliance on Mental Illness & Mental Health Canadian Association for Suicide Prevention Canadian Association of Occupational Therapists Canadian Association of Social Workers Canadian Coalition for Seniors Mental Health Canadian Council of Professional Psychology Programs Canadian Federation of Mental Health Nurses Canadian Health Care Association Canadian Medical Association Canadian Mental Health Association Canadian Psychiatric Association Canadian Psychiatric Research Foundation Canadian Psychological Association College of Family Physicians of Canada Mood Disorders Society of Canada National Network for Mental Health Native Mental Health Association of Canada Schizophrenia Society 1
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Principles concerning physician information

https://policybase.cma.ca/en/permalink/policy208
Last Reviewed
2019-03-03
Date
2002-06-02
Topics
Health information and e-health
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2002-06-02
Topics
Health information and e-health
Ethics and medical professionalism
Text
Principles concerning physician information (CMA policy – approved June 2002) In an environment in which the capacity to capture, link and transmit information is growing and the need for fuller accountability is being created, the demand for physician information, and the number of people and organizations seeking to collect it, is increasing. Physician information, that is, information that includes personal health information about and information that relates or may relate to the professional activity of an identifiable physician or group of physicians, is valuable for a variety of purposes. The legitimacy and importance of these purposes varies a great deal, and therefore the rationale and rules related to the collection, use, access and disclosure of physician information also varies. The Canadian Medical Association (CMA) developed this policy to provide guiding principles to those who collect, use, have access to or disclose physician information. Such people are termed “custodians,” and they should be held publicly accountable. These principles complement and act in concert with the CMA Health Information Privacy Code (1), which holds patient health information sacrosanct. Physicians have legitimate interests in what information about them is collected, on what authority, by whom and for what purposes it is collected, and what safeguards and controls are in place. These interests include privacy and the right to exercise some control over the information; protection from the possibility that information will cause unwarranted harm, either at the individual or the group level; and assurance that interpretation of the information is accurate and unbiased. These legitimate interests extend to information about physicians that has been rendered in non-identifiable or aggregate format (e.g., to protect against the possibility of individual physicians being identified or of physician groups being unjustly stigmatized). Information in these formats, however, may be less sensitive than information from which an individual physician can be readily identified and, therefore, may warrant less protection. The purposes for the use of physician information may be more or less compelling. One compelling use is related to the fact that physicians, as members of a self-regulating profession, are professionally accountable to their patients, their profession and society. Physicians support this professional accountability purpose through the legislated mandate of their regulatory colleges. Physicians also recognize the importance of peer review in the context of professional development and maintenance of competence. The CMA supports the collection, use, access and disclosure of physician information subject to the conditions outlined below. Purpose(s): The purpose(s) for the collection of physician information, and any other purpose(s) for which physician information may be subsequently used, accessed or disclosed, should be precisely specified at or before the collection. There should be a reasonable expectation that the information will achieve the stated purpose(s). The policy does not prevent the use of information for purposes that were not intended and not reasonably anticipated if principles 3 and 4 of this policy are met. Consent: As a rule, information should be collected directly from the physician. Subject to principle 4, consent should be sought from the physician for the collection, use, access or disclosure of physician information. The physician should be informed about all intended and anticipated uses, accesses or disclosures of the information. Conditions for collection, use, access and disclosure: The information should: be limited to the minimum necessary to carry out the stated purpose(s), be in the least intrusive format required for the stated purpose(s), and its collection, use, access and disclosure should not infringe on the physician’s duty of confidentiality with respect to that information. Use of information without consent: There may be justification for the collection, use, access or disclosure of physician information without the physician’s consent if, in addition to the conditions in principle 3 being met, the custodian publicly demonstrates with respect to the purpose(s), generically construed, that: the stated purpose(s) could not be met or would be seriously compromised if consent were required, the stated purpose(s) is(are) of sufficient importance that the public interest outweighs to a substantial degree the physician’s right to privacy and right of consent in a free and democratic society, and that the collection, use, access or disclosure of physician information with respect to the stated purpose(s) always ensures justice and fairness to the physician by being consistent with principle 6 of this policy. Physician’s access to his or her own information: Physicians have a right to view and ensure, in a timely manner, the accuracy of the information collected about them. This principle does not apply if there is reason to believe that the disclosure to the physician will cause substantial adverse effect to others. The onus is on the custodian to justify a denial of access. 6. Information quality and interpretation: Custodians must take reasonable steps to ensure that the information they collect, use, gain access to or disclose is accurate, complete and correct. Custodians must use valid and reliable collection methods and, as appropriate, involve physicians to interpret the information; these physicians must have practice characteristics and credentials similar to those of the physician whose information is being interpreted. 7. Security: Physical and human safeguards must exist to ensure the integrity and reliability of physician information and to protect against unauthorized collection, use, access or disclosure of physician information. 8. Retention and destruction: Physician information should be retained only for the length of time necessary to fulfill the specified purpose(s), after which time it should be destroyed. 9. Inquiries and complaints: Custodians must have in place a process whereby inquiries and complaints can be received, processed and adjudicated in a fair and timely way. The complaint process, including how to initiate a complaint, must be made known to physicians. 10. Openness and transparency: Custodians must have transparent and explicit record-keeping or database management policies, practices and systems that are open to public scrutiny, including the purpose(s) for the collection, use, access and disclosure of physician information. The existence of any physician information record-keeping systems or database systems must be made known and available upon request to physicians. 11. Accountability: Custodians of physician information must ensure that they have proper authority and mandate to collect, use, gain access to or disclose physician information. Custodians must have policies and procedures in place that give effect to the principles in this document. Custodians must have a designated person who is responsible for monitoring practices and ensuring compliance with the policies and procedures. (1) Canadian Medical Association. Health Information Privacy Code. CMAJ 1998;159(8):997-1016.
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Scopes of practice

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

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

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

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

https://policybase.cma.ca/en/permalink/policy14018
Policy Type
Policy document
Date
2018-12-08
Replaces
CMA Guidelines on Court Interventions
Text
The CMA’s stance on intervention and judicial advocacy is to bring an evidence-based perspective to assist in relation to the decision-making of issues at hand. CMA’s strategic plan and guiding principles opens the possibility that there may be circumstances when legal advocacy, and in particular judicial advocacy, may be leveraged strategically and proactively as a further tool in CMA’s advocacy toolbox to bring a non-partisan, evidence-based perspective to the courtroom that would further the organization’s vision for “a vibrant professional and a healthy population”. Purpose and Scope of Policy Given CMA 2020, and informed by knowledge of past experiences, the purpose of this policy is to provide guidelines to assist with decision making as to whether CMA should use legal action, as part of its advocacy toolbox, to move CMA’s work forward on a cause or issue. Cases Deemed Appropriate for CMA Judicial Advocacy – General Principles 1. Stage and Venue of Proceedings a) Generally, CMA will only engage in a proposed case at an appellate level or in the highest forum in which a matter is likely to be finally decided. b) Exceptionally, the CMA may engage in a proposed case at a lower court or a court of first instance where: i) circumstances justify engagement, such as an invitation from the court or where physicians’ expertise is necessary to create a trial record that supports the CMA’s policy position(s) or provides added relevant information that is not otherwise being provided or would highlight a critical issue that requires attention or would attract the attention of relevant parties. c) Exceptionally, CMA may leverage international fora (e.g., United Nations treaty bodies) where involvement could help advance a specific cause or issue being championed by the CMA. 2. CMA’s Role in Proceedings With some rare exceptions , , the CMA will only assume the role of intervener in a proposed case. The CMA will intervene where the CMA may bring a non-partisan, evidence-based analysis to an issue and where there are compelling reasons for doing so, considering the evaluation criteria contained in the Reference Guide in Appendix 1 of this policy. 3. Relevance to Existing CMA Policy a) The CMA may engage in a proposed case where engagement would constitute a significant contribution to the consideration of the issue or issues involved and only when the position sought to be advanced is: i. supported by and consistent with previously adopted policy of CMA; or ii. a matter of compelling public or professional interest which the Board of Directors then adopts as CMA policy following appropriate consultation. b) Where there is CMA policy that is clear, relevant to the proposed case and a matter of record, the policy should be cited and explained (e.g., in factum or affidavit). c) If the CMA’s proposed stance in a case proceeding supports a position which the CMA has not previously adopted as policy, the CMA Board of Directors must adopt the position as policy before authorizing the activity. 4. Issue of National, Special and/or Unifying Significance to Profession a) The CMA will generally only engage in a proposed case of special and unifying significance to the medical profession. b) The CMA will not engage in a proposed case where the matter is only of local or regional concern or of a private nature with no public interest or compelling professional or public policy component. 5. Potential Case Outcome(s) and Effect(s) Prior to engagement, the CMA must consider the potential impact(s) (both favourable and unfavourable) of the legal precedent that may set by the proposed case on members of the medical profession and patients. 6. Collaboration with Provincial/Territorial Associations, Affiliates and other Organizations a) In the spirit of community building and collaborating with those who share our vision, the CMA welcomes opportunities to collaborate with provincial or territorial associations, affiliates and other organizations provided that these Guidelines are followed and that the other organizations i. share positions on the issues at stake in the case that are consistent with CMA policy. ii. can follow through on tasks, deadlines and communication needs related to collaboration. b) While not mandatory, CMA would expect mutual assistance in funds and in kind when it collaborates with another organization (in relation to a judicial proceeding) or is asked to intervene. 7. Reputational Risk and Stakeholder Relations Implications The CMA will consider as a general principle whether involvement in a proposed case: a) may present the CMA with reputational risk(s) (e.g., inconsistent with mission and values, controversial, too political). b) may impact relations with other stakeholders, including provincial/territorial medical associations, associates, affiliates and other organizations. 8. Financial and Resource Implications The CMA will consider as a general principle the financial and resource implications of involvement in a proposed case such as the affordability of the proceeding, or competing demands for limited resources and staff availability. To the extent possible, the CMA will seek pro bono external legal assistance. Authorization to Engage in Judicial Advocacy CMA’s Senior Management Team will generally perform a preliminary analysis of the proposal to engage in a proposed case and may use the Reference Guide appended to these guidelines as a decision-making tool (see Appendix 1). The decision to engage in a proposed case must be ultimately authorized by the CMA Board of Directors. Once the Board has authorized the application, CMA staff will follow established internal protocol and procedures in the preparation of the required documentation according to the appended Working Draft Protocol (see Appendix 3). CMA staff will regularly provide the CMA Board with updates of the Court proceeding. Appendix 1: Reference guide for determining if appropriate for CMA to engage in judicial advocacy on a matter, in accordance with CMA Guidelines on Judicial Advocacy Degree to which criterion favours proposed judicial advocacy initiative (please provide reasons for choice) Strongly favours Somewhat favours Mildly favours Does not favour Stage and venue of proceedings Court of highest level? If yes, mark as “strongly favours” Appellate level? If yes, mark as “somewhat favours” If not court of highest level or other appellate court, indicate jurisdiction Relevance of matter to existing CMA policy Is matter consistent with previously adopted policy? Is matter of compelling public interest that may be adopted as policy? Is matter of compelling professional interest that may be adopted as policy? Issue of National, Special or Unifying Significance to the Profession Does matter have impact beyond local/regional level? Does matter have special or unifying significance for medical profession? Collaboration or Request for Involvement Co-intervention? Other request for involvement? Practical Considerations Financial implications Reputational risk Stakeholder relations implications Appendix 2: Contents of Request for CMA to Intervene 1. Requests for CMA to intervene in court proceedings can arrive from multiple sources (internally – CMA Board, CMA provincial or territorial associations, affiliates, another organization, an individual member, etc.). CMA’s Legal Services Department may also monitor judicial developments and identify cases of special interest to CMA. 2. Unless there are exceptional circumstances, the request for CMA to intervene in a court proceeding shall contain the following: (i) The style or caption of the case, identification of the last court to render a decision in the case and the court in which it is proposed to intervene. A copy of the decision or order appealed from, any accompanying reasons and other relevant documentation must be attached to (or linked from) the proposal; (ii) The date by which the proposed application for leave to intervene and factum must be filed; (iii) The issues before the Court and potential outcomes, dissenting views and likelihood of success, including policy implications for CMA depending on the various outcomes; (iv) The position sought to be advanced on CMA’s behalf and how this position is consistent with existing CMA policy. If there is no existing CMA policy, the request should state why CMA should adopt the policy prior to intervention; (v) If the request relates to a local or regional matter, an explanation of how the position to be taken is not inconsistent with CMA policy and the broader interests and concerns of CMA; (vi) Consultations undertaken, if any, on why the matter warrants CMA intervention as a compelling issue of public policy and special interest to the medical profession; (vii) A list of other organizations that might have an interest in the intervention or co-intervening with CMA; (viii) Disclosure of any personal or professional interest, in the matter on the part of any individual or organization participating in the decision to seek the Board of Directors’ authorization to intervene; and (ix) Budget development. 3. Where the request to intervene arises in a case where there is no existing CMA policy on the issue, the party making the request should demonstrate the urgency and importance of adopting the policy position to be advanced. Appendix 3: Working Draft Protocol and Procedures for Court Intervention Document Preparation
CMA staff will prepare the application documents for leave to intervene in concert with expert litigation legal counsel.
Depending on the issues before the Court, the President or Chair or the CMA Board may review the contents of the application documents for leave to intervene and the actual factum prior to filing with the Court. Alternatively, the application documents and factum will be shared as information items with the CMA President and Board after filing. The decision to obtain the President and/or Chair and/or Board approval or not prior to filing lies with the CMA CEO.
CMA staff may also consult with the President and Chair on the choice of individual filing the affidavit (called the “affiant”) on CMA’s behalf. The affiant will in most circumstances be a physician, usually at the elected level, with experience and expertise on the issues before the Court.
All CMA Departments will consult with and co-ordinate with the CMA Legal Department. For example, the content of any Communication Strategy documents (e.g. press releases, media alerts, news articles, etc.) as part of the court proceeding must be consistent with the contents of CMA’s application for leave to intervene documents and factum. Approved by the CMA Board of Directors Dec 2018
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Health Canada consultation on Canadian drugs and substances strategy

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