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Acting on today's and tomorrow's health care needs: Prebudget submission to the House of Commons Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy14123
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2019-08-02
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission. It provides recommendations to address major pan-Canadian challenges to the health of Canadians: improve how we provide care to our growing elderly population; improve access to primary care across the country; increase digital health literacy to take advantage of the benefits of new health information technologies; and better prepare for and mitigate the health impacts of a changing climate on Canadians. Seniors Care Health systems across the country are currently struggling to meet the needs of our aging population. People aged 85 years and over—many of whom are frail—make up the fastest growing age group in Canadai. Provincial and territorial health care systems (as well as care systems for populations falling under federal jurisdiction) are facing many challenges to meet the needs of an aging population. Canadians support a strong role for the federal government in leading a national seniors strategy and working with the provinces to ensure that all Canadians have the same level of access and quality of services, no matter where they live. The 2017 federal/provincial/territorial funding agreement involving $6 billion over 10 years to improve access to home care services is a welcomed building block. But without greater investment in seniors care, health systems will not keep up. To be truly relevant and effectively respond to Canadians’ present and future needs, our health care system must provide integrated, continuing care able to meet the chronic and complex care needs of our growing and aging population. This includes recognizing the increased role for patients and their caregivers in the care process. The federal government must ensure transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Health transfers are estimated to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.ii Recommendation: The federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer.iii Providing care often comes with a financial cost such as lost income due to the caregiver’s withdrawal from the workforce to provide care. There are also increasing out-of-pocket costs for both caregivers and care receivers for health care-related expenses—privately covered expenditures on home and long-term care for seniors are projected to grow by an average of 5.8 per cent annually—nearly 1.5 times the pace of household disposable income growth. While the federal government offers tax credits that can be claimed by care receivers/caregivers, they are significantly under-utilized. While representing a significant proportion of caregivers, those with low or no income receive little to no federal government support through these programs. Middle-income earners also receive less than those earning high incomes. 4 Recommendation: The federal government create a Seniors Care Benefit that would be an easier, fairer and more effective way to support caregivers and care receivers alike.iv Access to Care Since the mid-1990s, the federal and provincial/territorial governments (FPT) have provided sustained leadership in promoting and supporting the transformation of primary care in Canada. In 2000, the First Ministers concluded the first of three Health Accords in which they agreed to promote the establishment of primary health care teamsv supported by a $800 million Primary Health Care Transition Fund (PHCTF) funded by the federal government, but jointly governed. The PHCTF resulted in large-scale sustained change in primary care delivery models in Ontario, Quebec and Alberta with interest in other jurisdictions as well. However, the job is far from finished. Across Canada, access to primary care is challenging for many Canadians with a persistent shortage of family physicians. In 2017, 4.7 million Canadians aged 12+ reported they did not have a regular health care provider.vi Even those who have a regular provider experience wait time issues. There has been widespread interest in primary care models since the development of the College of Family Physicians of Canada’s (CFPC) vision document Family Practice: The Patient’s Medical Home (PMH), initially launched in 2011vii and recently re-launched.viii The model is founded on 10 pillars depicted in Figure 1. Figure 1. The Patient’s Medical Home, 2019 The updated model places increased emphasis on team-based care and introduces the concept of the patient’s medical neighborhood that sets out connections between the primacy care practice and all delivery points in the surrounding community. While comprehensive baseline data are lacking, it seems 5 safe to conjecture that most Canadians are not enrolled in a primary care model that would measure up to the model’s 10 pillars. Recommendation: The federal government, in concert with provinces and territories, establish a targeted fund in the amount of $1.2 billion to support a new time-limited Primary Health Care Transition Fund that would build on the success of the fund launched in 2000 with the goal of widely introducing a sustainable medical home model across jurisdictions. This would include the following key elements:
Age-sex-weighted per capita allocation across the provinces and territories;
Joint governance of the FPT governments with meaningful stakeholder engagement;
Respect for the Canada Health Act principles;
Common objectives (e.g., modeled on the CFPC Patient’s Medical Home framework);
Operating Principles specifying eligible/ineligible activities;
Reporting provisions and agreed-upon metrics; and
Sustainability plans. Digital/Virtual Care Canada and most industrialized countries will experience a digital health revolution over the next decade with great potential to improve patient and population health. Digital health can be described as the integration of the electronic collection and compilation of health data, decision support tools and analytics with the use of audio, video and other technologies to deliver preventive, diagnostic and treatment services that promote patient and population health. While most Canadian physicians’ offices and health care facilities are now using some form of electronic record keeping and most households have internet access, there remains a large deficit in using virtual care, both within jurisdictions and across provincial/territorial boundaries. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify opportunities for digital health to improve health care delivery, including what regulatory changes are required for physicians to deliver care to patients within and across provincial/territorial boundaries. To take full advantage of digital health capabilities it will be essential for the population to have a functional level of digital health literacy: the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.ix This also includes the capability of communicating about one’s health to health care professionals (e.g., e-consults), self-monitoring health (e.g., patient portals) and receiving treatment online (e.g., Web-based cognitive behavioral therapy).x There are no current data available on health literacy in Canada, let alone digital health literacy. One basic barrier to achieving digital health literacy is access to, and usage of the Internet, which has been termed the “digital divide” (e.g., older Canadians and low income households are less likely to have Internet access).Error! Bookmark not defined. 6 In 2001 the federal government established the Financial Consumer Agency of Canada (FCAC). Its mandate includes informing consumers about their rights and responsibilities in dealing with financial institutions and providing information and tools to help consumers understand and shop for financial products and services.xi In 2014 the FCAC appointed a Financial Literacy Leader who has focused on financial literacy, including activities such as conducting financial capability surveys and the development of a National Strategy for Financial Literacy.xii Considering the anticipated growth of digital/virtual care it would be desirable to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy could serve as a template for digital health literacy. Recommendation: The federal government establish a Digital Health Literacy Secretariat to:
Develop indicators and conducting surveys to measure and track the digital health literacy of Canadians;
Develop tools that can be used both by Canadians and their health care providers to enhance their digital health literacy; and
Assess and make recommendations on the “digital divide” that may exist among some population sub-groups due to a lack of access to information technology and lower digital health literacy. Climate Change and Health Climate change is the public health imperative of our time. There is a high level of concern among Canadians about their changing climate. A 2017 poll commissioned by Health Canada demonstrates a high level of concern among Canadians about their changing climate: 79% were convinced that climate change is happening, and of these, 53% accepted that it is a current health risk, with 40% believing it will be a health risk in the future. The World Health Organization (WHO) has identified air pollution and climate change as one of the biggest threats to global health. Health care professionals see first-hand the devastating health impacts of our changing climate including increased deaths from fine particulate matter air pollution and increased heat-related conditions. Impacts are most common in vulnerable populations such as adults over 65 years, the homeless, urban dwellers and people with a pre-existing disease. Canada’s health care system is already treating the health effects of climate change. A lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of Canada’s health system, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. The federal government must provide leadership to deal with the impact already being felt in Canada and around the world. Recommendation: 7 The federal government make strong commitments to minimize the impact of climate change on the health of Canadians by:
Ensuring pan-Canadian and inter-jurisdictional coordination to standardize surveillance and reporting of climate-related health impacts such as heat-related deaths, develop knowledge translation strategies to inform the public, and generate clinical and public health response plans that minimize the health impacts;
Increasing funding for research on the mental health impacts of climate change and psychosocial adaptation opportunities; and
Ensuring funding is provided to the health sector to prepare for climate change impacts through efforts to increase resiliency (i.e., risk assessments, readiness to manage disease outbreaks, sustainable practice). 8 i Statistics Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2014: Public Health in the Future. Ottawa: Statistics Canada; 2015. Available: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2014/chang-eng.php; (accessed 2016 Sep 19). ii The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018. iii Canadian Medical Association. Meeting the demographic challenge: Investments in seniors care. Pre-budget submission to the House of Commons Standing Committee on Finance. August 3, 2018. https://policybase.cma.ca/documents/Briefpdf/BR2018-16.pdf iv The Conference Board of Canada. Measures to Better Support Seniors and Their Caregivers. March 2019. https://www.cma.ca/sites/default/files/pdf/health-advocacy/Measures-to-better-support-seniors-and-their-caregivers-e.pdf v Canadian Intergovernmental Conference Secretariat. News release – First Ministers’ meeting communiqué on health. September 11, 2000. http://www.scics.ca/en/product-produit/news-release-first-ministers-meeting-communique-on-health/. Accessed 04/22/19. vi Statistics Canada. Primary health care providers, 2017. https://www150.statcan.gc.ca/n1/en/pub/82-625-x/2019001/article/00001-eng.pdf?st=NGPiUkM5. Accessed 04/21/19. vii College of Family Physicians of Canada. A vision for Canada. Family Practice: the patient’s medical home. http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 04/22/19. viii College of Family Physicians of Canada. The patient’s medical home 2019. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf. Accessed 04/21/19. ix Norman C, Skinner H. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res 2006;8(2):e9. Doi:10.2196/jmir.8.2.e9. x Van der Vaart R, Drossaert C. Development of the digital health literacy instrument: measuring a broad spectrum of health 1.0 and health 2.0 skills. J Med Internet Res. 2017;19(1):e27. Doi:10.2196/jmir.6709. xi Financial Consumer Agency of Canada. About FCAC. xii Financial Consumer Agency of Canada. National Strategy for Financial Literacy. Phase 1: strengthening seniors’ financial literacy. https://www.canada.ca/content/dam/canada/financial-consumer-agency/migration/eng/financialliteracy/financialliteracycanada/documents/seniorsstrategyen.pdf. Accessed 06/24/19. https://www.canada.ca/en/financial-consumer-agency/corporate/about.html. Accessed 07/01/19.
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Aligning health and economic policy in the interest of Canadians : CMA’s 2004 Pre-Budget Submission to the Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy1949
Last Reviewed
2012-03-03
Date
2004-11-18
Topics
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2004-11-18
Topics
Health systems, system funding and performance
Text
For the past several years, the Canadian Medical Association (CMA) has been delivering two overall messages to the Standing Committee on Finance. First, we believe that Canadians’ health and their health care system must be recognized as ongoing priorities. Second, we have been making the case that economic policy, including tax policy, must be better aligned with national health policy. This year’s brief provides specific examples of how the federal government can take action to address both of these issues. We begin with an assessment or a “check up” of the health of our health system. We then provide constructive suggestions on how to successfully implement the health agreement reached at the September 13-15, 2004 meeting of First Ministers. Finally, we draw attention to the need for continued investments in public health and healthy public policy. Canadians remain increasingly concerned about the future state of their health care system, particularly in terms of accessing essential care. While their health status has improved over the past decades, international comparisons suggest there is considerable room for improvement. The significant announcements made over the past year related to reinvestments in health care and public health are a welcomed start to support health stakeholders in facing these challenges. The next steps must build on this progress. INVESTING IN HEALTH CARE Build on The First Ministers Meeting Agreement In terms of health care, we must begin by noting that the First Ministers Meeting Agreement (FMM Agreement) was a significant achievement. It represents a positive policy framework to run with, but it must now receive the necessary fiscal, political and legislative follow-through. Legislation should be enacted that specifies the accountability framework for the Agreement. The Wait Times Reduction Fund should be subject to contribution agreements that specify how provinces and territories will use their share of this fund to reduce wait times. Critical to future success is the need for health care stakeholders to be actively involved with all facets of the Agreement, particularly in developing clinically derived wait time benchmarks. Make Health Human Resources a Priority At the same time, the federal government can do more to address accessibility to health care services by making a stronger commitment to increasing Canada’s health human resources capacity. Several strategies are outlined in this brief, beginning with the need to ensure that the Wait Times Reduction Fund in the FMM Agreement is used immediately to address the crisis in health human resources rather than in the last four years of the ten-year Agreement as currently projected. One specific health human resources strategy that the federal government should pursue is providing greater support for the training of students in health care professions as part of an overall health human resources strategy. High student debt is a key health human resource issue. It is estimated that, by the time medical students enter their pre-practice postgraduate training period, many are doing so with a debt of at least $120,000 or more. This high debt load is affecting both the kind of specialty that physicians-in-training choose, and ultimately where they decide to practice. As a result, the CMA calls upon the federal government to implement a national strategy to extend the Canada Student Loans interest payment benefit to eligible health professional students pursuing postgraduate training. Such action would provide a fairer approach and would alleviate some of the problems associated with our current training system of health professionals. ALIGNING TAX POLICY WITH HEALTH POLICY The CMA has highlighted the need to better align tax policy with national health policy goals for some time and we believe this challenge remains a priority. One example of where tax policy and health policy can be better aligned is how the GST is currently applied to the health care sector and to physicians—something the Finance Committee has acknowledged in previous reports. Hospitals in Canada must still pay a portion of the GST on their purchase of goods and services siphoning away millions of dollars that would otherwise be used for patient care. The federal government recognized in the 2004 budget the need to provide a full GST rebate to municipalities, one of the four sectors covered by the so-called “MUSH” formula (Municipalities, Universities, Schools and Hospitals). We call on the government to apply the same logic and provide a full GST rebate to the health care sector. Another problem exists with how the GST is applied to independent health professionals, such as physicians, providing care to Canada’s publicly funded system. By virtue of being “tax exempt” under The Excise Act, physicians cannot claim any input tax credits to offset the GST costs they pay on their purchases of equipment, rent and utilities. Unlike other self-employed people, physicians cannot pass on any of these additional costs. This is a fundamental issue of tax fairness. It can be resolved by zero rating the GST on publicly funded health services provided by independent health providers thereby making them eligible to receive input tax credits. INVESTING IN HEALTH This past year saw many positive developments made to Canada’s public health system. The CMA was pleased to see the creation of the position of Minister of State, Public Health. We commend the Government of Canada for its establishment of the Public Health Agency of Canada and for its selection of Dr. David Butler-Jones as the new Chief Public Health Officer of Canada. However, the government must continue to reinvest in public health to ensure that the country has a system that earns the trust of Canadians. Investing in public health also makes good economic policy. We have seen in recent years the incredible economic impact that public health outbreaks can have on a country’s economy. Close the Naylor Gap in Public Health The National Advisory Committee on SARS and Public Health (the Naylor Report) estimated that approximately $1 billion in annual funding is required to implement and sustain the public health programming that Canada requires. While representing an important reinvestment in this country’s public health system, the funding announced in the 2004 Budget falls well short of this basic requirement. Accordingly, the CMA calls on the federal government to address the $450 million “Naylor Gap” as soon as possible. Establish National Health Goals Guiding this country’s efforts to improve the health of Canadians should be the establishment and monitoring of national health goals. Thus, the CMA fully supports the First Ministers’ call to establish a Pan-Canadian Public Health Strategy that includes the setting of health goals that are independently monitored. These goals should also cover environmental health goals given their direct implication on Canadians’ health status. Invest in Health Not Tobacco Another key area for the CMA where current economic policy is not aligned with national health policy is the Canada Pension Plan’s investment in tobacco stocks. Despite the fact that tobacco continues to kill approximately 45,000 Canadians a year and costs Canadian society approximately $11 billion per year in net cost, the Canada Pension Plan continues to invest millions ($94 million) in the tobacco industry. We strongly believe that the CPP Investment Board should be prohibited from investing in the tobacco industry and that it divest its current tobacco holdings. Other major pension and investment plans have successfully executed this policy including the MD Funds held for Canada’s physicians at MD Management Ltd. a wholly-owned subsidiary of CMA. Accordingly, we call on the Standing Committee on Finance along with the Standing Committee on Health to jointly review the CPP investment policy as it relates to investments in tobacco. The FMM Agreement and last year’s funding announcements for public health must be seen as for what they are—first steps to sustaining Canada’s health care system and its public health infrastructure. Canada’s physicians and the CMA are committed to working with governments and other health care stakeholders to ensure that these financial investments lead to positive and enduring change, and ultimately improved health for all Canadians. RECOMMENDATIONS Recommendation 1 The federal government move quickly to enact legislation to implement the funding and accountability provisions of the First Ministers’ Agreement. The legislation should specify that the $4.5 billion Wait Times Reduction Fund be subject to contribution agreements with the provinces and territories. Recommendation 2 The federal government work with relevant stakeholders to extend interest free status on Canada Student Loans for all eligible health professional students pursuing postgraduate training. Recommendation 3 As part of an effort to ensure that its tax policy is consistent with the goals of its health policy and the sustainability of Canada’s health care system, the federal government should: - increase the GST rebate for publicly funded health care institutions and clinics to 100% ($90 million annually for hospitals) - zero rate GST on publicly funded health services provided by independent health care providers ($75 million annually for medical services). Recommendation 4 The Standing Committees on Finance and Health hold a joint review of the CPP policy as it relates to investments in tobacco (both current and potential) by the CPP Investment Board. II. CMA’S ANNUAL CHECKUP Much has happened over the past year in regards to Canada’s health and health care systems. First, we witnessed the creation of the Health Council of Canada, an institution that can play a significant role in improving the accountability of Canada’s health system. Second, we saw several announcements aimed at rebuilding Canada’s public health system including the establishment of the Public Health Agency of Canada and the subsequent appointment of Canada’s first Chief Public Health Officer. And in September, federal, provincial and territorial First Ministers reached a historic agreement on a 10-year plan to strengthen health care. Canadians no doubt welcome these developments. They have made it known to governments and health care providers alike that access to health care has become their top public policy issue. Not surprisingly, health was the top issue during the recent federal election campaign. For four years, the CMA has been tracking Canadians’ assessment of our health care system through our National Report Card on the Sustainability of Health Care. We are sad to report that the number of Canadians giving the nation's health care system a grade of C or F this year increased by a dramatic 9% over last year. While Canadians still give the system an overall B grade, the percentage of C and F grades was the highest since Ipsos-Reid began conducting the survey on behalf of the CMA in 2001. Moreover, our survey results found that 97% agreed that any discussion to make the system more sustainable needs to guarantee timely access for essential health services. As our fact sheet on Canadians’ health and their health care system illustrates (see Appendix A), improving access remains a major challenge for our health care system. Canada has one of the poorest physician-to-population ratios among all OECD countries. It is therefore not surprising that in 2003, 14% of Canadians reported not having a regular family physician (25% in Quebec). A recent Statistics Canada survey on wait times found that the proportion of patients who considered their wait time unacceptable was 17% for non-emergency surgery, 21% for diagnostic tests and 29% for specialist visits. 1 Over the past year, CMA has been very active in bringing attention to the issue of access and wait times. The CMA co-sponsored a colloquium on managing wait times last April that culminated in the recently released report, The Taming of the Queue: Toward a Cure for Health Care Wait Times. 2 But what about the state of Canadians’ health itself? Certainly our health status has improved greatly over the past decades. However, while Canadians are among the healthiest people in the world, citizens in several industrialized countries are enjoying better health status. For example, disability-free life expectancy, that is quality of life years lived, for Canadian males is 18th among the 30 OECD countries and 16th for Canadian females. Canada’s rate of infant mortality—deaths during the first year of life—is among the highest in the OECD. But we need not compare ourselves to other countries to find differences in levels of health status. Significant discrepancies in health status also exist among Canadians, be it between provinces, between regions, between communities or between neighbourhoods. For example, there remain significant inequities in health status between Aboriginal Canadians and non-Aboriginal Canadians—the incidence of hepatitis and tuberculosis among Aboriginal Canadians are five and ten times higher respectively than for other Canadians. It has now been over a year since the Report of the National Advisory Committee on SARS and Public Health or the “Naylor Report” was released. The report has lead to some positive developments in rebuilding Canada’s public health system. It will be needed as some serious public health issues continue to face the country including: * the spread of infectious diseases (e.g., C. difficile bacterium); * the rise in the number of Canadians with unhealthy body weights including rising levels of obesity; * high levels of physical inactivity; * smoking, particularly among youth; * relatively low rates of immunization; and * threats to environmental health including those that threaten our clean air, and safe food and drinking water. In summary, notwithstanding all that has transpired this year, Canadians’ health and their health care system remain high public priorities. While their health status has improved over the past decades, there is considerable room for improvement, some of which can be addressed through public health measures and better access to care. The significant announcements made over the past year related to health system and public health financing are a welcomed start to support health stakeholders in facing these challenges. III. THE FIRST MINISTERS’ MEETING AGREEMENT The CMA closely followed the September 13-15, 2004 First Ministers Meeting on the Future of Health Care. In fact, we worked with our health care colleagues leading up to the meeting to identify possible strategies for improving the system. 3 For instance, we recommended the development and adoption of pan-Canadian benchmarks for wait times based on clinical evidence and the creation of a special Canada Health Access Fund to support Canadians’ access to medically necessary care in other regions. While not all of our proposals were accepted, the September First Ministers’ Meeting Agreement (herein referred to as the FMM Agreement) features many aspects that the CMA has been championing for some time and is certainly a positive achievement. In particular, we are happy to see a desire “to make timely access to quality care a reality for all Canadians.” We applaud the leadership shown by the government in this regard. We also believe that the Agreement provides an opportunity for a new era of cooperative medicare by engaging physicians and other providers meaningfully. Contrary to belief, health care providers have not been offered many opportunities to participate at federal, provincial and territorial planning tables. We therefore welcome the opportunity to work collaboratively on identifying clinically derived wait time benchmarks. Canada’s physicians can and desire to play a significant role in this regard. We therefore believe the FMM Agreement is a necessary first step or “a framework to go with” towards strengthening our health care system. But as we said in September following the release of the Agreement, “the real heavy lifting begins now.” Accordingly, we believe that a number of requirements are necessary to ensure this Agreement fulfills its objectives. We see these requirements as putting words to actions for realizing the full potential of the FMM Agreement. Enact Legislation to Confirm Financial Support and Accountability Provisions The CMA supports enacting federal legislation to confirm the budgetary allocations in the Agreement ($18 billion over 6 years and $41 billion over 10 years). This includes a 6% escalator to the Canada Health Transfer (CHT) that will provide predictable funding for provincial and territorial health care systems. This is a provision that we have been recommending for many years. While $41 billion is a lot of money, we must remind ourselves that this amounts to little more than a 3% increase over 10 years of provincial government health expenditures based on projections of current government spending. Moreover, we estimate that the Agreement will add only .2% to Canada’s spending levels per GDP during this period. In other words, the FMM Agreement, while necessary and appreciated, will not propel Canada into the top echelon of health care spenders among the leading industrialized countries. As health care has become a dominant public policy issue, we expect to see future high level discussions in coming years on both future funding levels and on the direction of health care reform efforts. We are also pleased to see a new Equalization agreement that will complement the FMM Agreement. The Equalization program plays a key role in ensuring that all provinces have adequate and comparable levels of health care and other social services. The issue of Equalization payments to the provinces was identified in discussions leading up to the September First Ministers Meeting over concern that increased federal transfers to health care could be offset by decreases in Equalization payments. The subsequent agreement on Equalization will therefore serve to support the FMM Agreement given that increases in health care transfers to provinces will not be offset by decreases in equalization payments while providing predictable multi-year funding. A strong accountability framework also needs to be included in the legislation. The FMM Agreement specifies several process accountabilities such as a commitment by governments to report on access indicators and establish wait time benchmarks by December 31, 2005. The CMA believes that the Wait Times Reduction Fund should be subject to contribution agreements that specify how provinces and territories will use their share of this fund to reduce wait times. For the Agreement to mean something commitments have to backed up—financial and/or political consequences must follow if commitments are not met. It will be important to have an independent, third party organization assess progress in an open and transparent manner. The Health Council of Canada, identified in the FMM Agreement, could be the body to undertake an annual independent assessment, providing it receives the necessary resources to do so. The Canadian Institute for health Information also has an important role to play in ensuring comparable indicators are used to measure progress. It is essential to involve practicing physicians throughout the implementation of the FMM Agreement, particularly in the development of clinically derived wait time benchmarks. The determination of clinically derived wait time benchmarks means just that—they must be clinically derived and must not be based on political or financial considerations. To this end, the CMA will play a leadership role in developing consensus with physicians and other expert organizations on acceptable wait-time standards and protocols based on the best available clinical evidence. RECOMMENDATION 1 The federal government move quickly to enact legislation to implement the funding and accountability provisions of the First Ministers’ Agreement. The legislation should specify that the $4.5 billion Wait Times Reduction Fund be subject to contribution agreements with the provinces and territories. Improve Access by Addressing Health Human Resources The CMA is pleased to see the First Ministers acknowledge for the first time the current and worsening shortage of health human resources (HHR) in this country. However, the FMM Agreement does not adequately provide a strategy for addressing this crisis beyond the development of health human resources action plans and support for an Aboriginal Health Human Resources Initiative. The CMA believes that the lack of immediate action on HHR is one area where the Agreement falls short. As noted in our fact sheet, Canada is currently experiencing a shortage in health human resources. Canada’s ratio of 2.1 physicians per 1,000 population remains one of the lowest among OECD countries and below the OECD average of 2.9. Initial results from the 2004 National Physician Survey—the largest census survey of physicians ever conducted in Canada—find that up to 3,800 physicians will retire in the next two years, more than double the existing rate. Furthermore, 26% of physicians intend to reduce the number of hours they work. 4 One must remember that timely access to health care services is first and foremost about the people who provide quality care and the tools and infrastructure they need to meet the growing demand for medical services in Canada. In order for the FMM Agreement to be successful in improving access to care, governments must make health human resources a major priority beginning by ensuring that the Wait Times Reduction Fund is used immediately to address the crisis in health human resources rather than in the last four years of the ten-year Agreement as currently projected. 5 Given the current shortages in health human resources, action on HHR must begin now—not in 2010. In addition, the CMA calls upon the federal government to play a key role in improving the availability of health human resources by developing a pan-Canadian HHR strategy that includes the involvement of health care providers. Specifically, we need a three pronged pan-Canadian HHR strategy that would address: (1) HHR planning; (2) increasing the supply of health professionals; and, (3) retention issues. Planning Despite the large sum of funding that governments invest in health care, they do so without having the benefit of a national long-term health human resources strategy. Canada has 14 provincial/territorial and federal health care systems in operation. Yet, our immigration policies are largely conducted on a national basis and there is a high degree of labour mobility between provinces. Presently, there is no overall national coordinating committee to assist provinces and territories in the planning of health human resources, particularly one that includes all pertinent stakeholders including physicians and other health care professionals. We believe a National Coordinating Committee for Health Human Resources involving representation from health care professions should be established for such purposes—something both the Romanow and Senator Kirby reports recommended. Research is required to support long-term planning in HHR. The CMA has previously proposed the creation of an arm’s length Health Institute for Human Resources (HIHuR) that would promote collaboration and the sharing of HHR research among the well-known university-based centres of excellence as well as research communities within professional associations and governments. Supply Canada’s HHR policy goal should be to ensure Canada is self-sufficient in the supply of physicians and other health care professionals. Several strategies are required to fulfill this goal. They include: * Dedicating a specific fund to increase enrollment in undergraduate and postgraduate medical education (especially re-entry positions). Medical school enrollment should be increased to a minimum of 2,500 positions by 2007. * Expanding the post-MD system to accommodate the increase in graduates for training including the several hundred international medical graduates (IMGs) in Canada who have been deemed eligible for post-MD training here. The goal should be to increase the number of first-year residency training positions to a level of 120% of the graduates produced annually by Canadian medical schools. See Appendix B for how this can be implemented. The estimated cost of adding 500 positions is $75 million over five years. In fact, this government’s election platform included a commitment to provide funding to top-up training for 1,000 foreign trained medical professionals. * Expediting the integration of international medical graduates by funding a fast-track on-line assessment program administered by the Medical Council of Canada. It would determine the suitability and eligibility of IMGs for completion of post-MD training (estimated cost $20 million over 5 years). * Implementing a national strategy to extend the Canada Student Loans interest payment benefit to postgraduate trainees in medicine. High student debt impacts both the kind of specialty that physicians-in-training choose, and ultimately where they decide to practice—making it a key health human resource issue (see box below). The Canadian Medical Association commends the federal government for its commitment to reduce the financial burden on students in health care professions, as announced in the FMM Agreement. Did you know? Becoming a full-fledged, practicing physician is an arduous and expensive endeavor. It requires a minimum of 9 years (6) of post-secondary education and training that is often financed through sizeable government and private loan debt, such as lines of credit. It is estimated that, by the time medical students enter their pre-practice postgraduate training period, many are doing so with a debt of at least $120,000 (7) or more. RECOMMENDATION 2 The federal government work with relevant stakeholders to extend interest free status on Canada Student Loans for all eligible health professional students pursuing postgraduate training. Retention Retention remains a major concern for the health care workforce including physicians. We speak not only in terms of losing physicians to other countries but to other professional pursuits as well (i.e., opportunities away from the front line delivery of care). There is little point in recruiting new physicians at the front end if we lose sight of how to keep them once they are highly skilled and are in their most productive years. Retention issues are crosscutting. Indeed, a major frustration for physicians today are the difficulties faced trying to access other types of care for their patients such as diagnostic testing, specialty care or community services. Thus, improving access to a comprehensive range of health care providers and services and reducing wait times—as previously addressed—can help. We also believe that investments in information technologies (IT) can help improve the coordination of health care and allow physicians to spend more time with their patients to provide quality care. There is currently limited connectivity among community-based physicians, community based services, specialists, hospitals and diagnostic facilities. IT investments can improve the integration of care, improve patient safety and improve the management of wait times. They can link regional and provincial wait time management systems while supporting more comprehensive scheduling systems. Prescriptions can be sent electronically to the local pharmacist while public health warnings can be sent electronically to physicians’ offices. We recognize that investments in IT are already occurring and systems will be put in place over the next decade. However, we believe that by accelerating IT investments today, system efficiencies and savings can be achieved sooner along with improvements to health care delivery and coordination. The application of tax policy to the health care sector is another retention issue that greatly frustrates physicians. This issue is discussed in the next section. Align Tax Policy With Health Policy The CMA continues to advocate for a review of the relationship between federal tax policy and health care policy in Canada. Taxation is a powerful instrument of public policy. Good tax policy should reinforce and support good health care policy. Yet, it has been 40 years since the federal government last undertook an overarching review of Canada’s tax system (the 1962-1966 Royal Commission on Taxation -the Carter Commission). Standard public finance theory suggests that two objectives of effective tax policy are distributive equity and correcting inefficiencies in the private sector. 8 For some time, the CMA has expressed concern over inequities in tax policy and inconsistencies between national health policy goals and tax policy. We are aware that the committee is looking for ideas on tax changes that can lead to a more productive economy. At the same time, we recognize that the government is committed to improving Canadians’ access to health care. Ensuring this country’s tax policy is supporting our health care system is a good way to achieve both objectives. Specifically, the CMA calls on the federal government to remove the application of the Goods and Services Tax (GST) to the health care sector. Currently, not-for-profit hospital services receive an 83% rebate on the GST they pay on goods and services, while not-for-profit health organizations receive a rebate of 50%. Health care professionals working in free-standing clinics do not qualify for any GST relief (discussed below). The estimated portion of funding paid by hospitals alone back to the federal government in the form of GST revenue is estimated to be $90 million per year. That is the equivalent of the purchase cost of almost 40 MRI machines! The CMA believes that all publicly funded health care services should be spared from having to use scarce health care resources to remit GST and should receive the full GST rebate. Would this be setting a precedent? The answer is “no”. Prescription drugs, a significant proportion of total health care costs, have been zero-rated since 1996. Furthermore, the 2004 federal budget confirmed that municipalities would be able to recover 100% of the GST and the federal component of the harmonized sales tax (HST) immediately. As part of the “MUSH” sector (municipalities, universities, schools and hospitals), we believe the time has come to extend the full rebate to the health care sector. The federal government must stop taxing publicly funded health care. The uneven application of the GST rebate to different health services is also impeding efforts to renew and reorient the delivery of health services. Currently, community-based services such as clinics and nursing homes receive a GST rebate of only 50% while hospitals receive a rebate of 83%. Does it make sense that a nursing home or a home care service should pay more for GST than a hospital, particularly when trying to move to a more accessible community-based system? The variability of GST rebates makes no sense for organizations such as regional health authorities that oversee a range of health services but which pay differing rates. The government acknowledged in its 2003 Budget that there was a need to review how the GST is applied to care settings outside of hospitals. We await this review. Such inconsistencies distort the efficiency of the health care sector yet are relatively simple to address. 9 Physician services, on the other hand, are deemed “tax exempt” under The Excise Act. This means that physicians cannot claim any input tax credits despite the fact they must pay GST on their purchases of equipment, rent and utilities. And unlike other self-employed individuals or small businesses, physicians cannot pass on any of these additional costs as approximately 98% of physician compensation is from government health insurance plans. To date, provincial governments have been unwilling to provide funding to reflect the additional costs associated with the GST (insisting that it is a federal matter). Physicians are not asking for special treatment. They are looking for fairness within the tax system. If physicians, as self-employed individuals, are considered small businesses for tax purposes, then it only seems reasonable that they should have the same tax rules extended to them that apply to other small businesses (i.e., eligibility to receive input tax credits). This is a fundamental issue of tax fairness. In fact, this committee has twice before acknowledged the need to reassess the application of the GST on physician services. 10 The unfair manner in which the GST is applied to the health care sector has been an on-going source of major frustration to the physician community and remains unresolved. We believe that addressing this matter would be helpful in the country’s efforts to retain its physicians. Other self-employed health care providers that provide publicly funded services face a similar problem. RECOMMENDATION 3 As part of an effort to ensure that its tax policy is consistent with the goals of its health policy and the sustainability of Canada’s health care system, the federal government should: - increase the GST rebate for publicly funded health care institutions and clinics to 100% ($90 million annually for hospitals) - zero rate GST on publicly funded health services provided by independent health care providers ($75 million annually for medical services). IV PUBLIC HEALTH: HEALTHY PUBLIC As previously noted, much has happened over the past year with respect to Canada’s public health system. The CMA was pleased to see the creation of the position of Minister of State, Public Health. We commend the Government of Canada for its establishment of the Public Health Agency of Canada and for its selection of Dr. David Butler-Jones as the new Chief Public Health Officer of Canada. The 2004 Budget’s commitment to approximately $665 million for investments for public health over the next 3 years was also a welcomed announcement. The CMA will provide its full support to work with Dr. Butler-Jones and the Public Health Agency of Canada, Ministers Bennett and Dosanjh to develop a coordinated and integrated plan to manage and improve public health in Canada. These developments certainly represent a good step towards rebuilding the country’s public health system. Address the “Naylor Gap” In spite of these initiatives, it remains essential to remind this government and Canadians that further attention to public health is necessary. As a member of the Canadian Coalition for Public Health in the 21st Century (CCPH21), the CMA calls on the federal government to enhance its financial commitment to the renewal of Canada’s public health system The public health system is a vital component of a sustainable health system by reducing pressures on the health care system and providing a net benefit to society. 11 Two thirds of total deaths in Canada are due to chronic diseases such as cardiovascular disease, cancer, lung disease and diabetes (Type II melitus)—many of which are preventable. Investing in public health also makes good economic policy. We have seen in recent years the incredible economic impact that public health outbreaks can have on a country’s economy. For instance, it has been estimated that the SARS outbreak cost the Canadian economy over $1.5 billion in 2003 alone with its impact still being felt. 12 As stated in the Report of the National Advisory Committee on SARS and Public Health (the Naylor Report), “we are constantly a short flight away from serious epidemics.” 13 Accordingly, we were pleased to hear the government’s Speech from the Throne state that the government will proceed with the development of the Pan-Canadian Public Health Network. But we have to overcome several years of inattention to public health issues and the public health infrastructure—something that cannot be rectified in a year. Spending levels on public health in Canada are meager. International comparisons are difficult to find and to compare, but it appears that this is one instance where Canada could learn from its neighbour to the south with its higher level of spending on public health (see Box comparing public health spending between Canada and the United States). 14 While the role of public health was referred to in the FMM Agreement, no additional funding for public health was included. Comparing Levels of Public Health Spending: Canada vs. the United States Using data from CIHI and the US Centers for Medicare and Medicaid Services, the CMA has developed the following comparative estimates of spending on public health in Canada versus the United States in 2002. [TABLE CONTENT DOES NOT DISPLAY POPERLY. SEE PDF FOR PROPER DISPLAY] Canada United States 1. Per capita spending on public health services ($CDN, PPP adjusted) $138 $207 2. Share of spending on public health as a % of public health care spending 5.5% 7.2% 3. Share of spending on public health as a % of total health care spending 3.9% 3.3% [TABLE END] The United States spends approximately 50% more on public health than Canada when comparing per capita payments. The United States also spends more on public health when considering public health spending as a percentage of all publicly funded services (due in part to a proportionately smaller publicly funded sector). Conversely, Canada spends more on public health if looking at the percentage of spending on public health as a percentage of total health care spending. This is due in part to a proportionately larger privately funded sector in the United States. Since public health is predominately a public good paid by governments, we believe it is most appropriate to compare the results from the first two indicators. The Naylor Report estimated that public health in Canada accounted for 2.6% to 3.5% of total publicly funded health expenditures in Canada and 1.8% to 2.5% of total health expenditures. While these estimates are lower than those provided above, they still support our observation that public health spending in Canada is lower than in the United States. The Naylor report provided a blue print for action and reinvestment in the public health system for the 21st century. It estimated that approximately $1 billion in annual funding would be required to implement and sustain the public health programs that Canada requires. In its submission to the National Advisory Committee on SARS and Public Health, the CMA also identified an essential range of comprehensive public health programming and initiatives totaling an estimated $1.5 billion over 5 years. 15 The federal government has thus far committed approximately $665 million in new programming (one-time funding, over 2 years, and over 3 years), well short of Dr. Naylor’s $1 billion per year. This “Naylor Gap” of approximately $450 million per year is identified below in Table A. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table A: Estimating “The Naylor Gap” Naylor Funding Recommendations (by 2006-07) Budget 2004 Naylor Gap Public Health Agency of Canada Related Funding - $300 million per year core budget of PPHB and other related federal services to be transferred to new agency - core functions to be expanded by $200 million per year within 3-5 years - $404 million transferred from Health Canada to Agency - $165 million over 2 years to assist in setting up new agency, increase emergency response capacity, enhance surveillance, establish regional centres of excellence, expand laboratory capacity, strengthen international coordination and collaboration $117.5 million per year ($200 million by Naylor minus $82.5 million per year committed by the federal government averaged out). Moreover, nothing earmarked beyond 2005-06. System Funding 3 programs of transfers at a cost of $500 million per year: - $300 million for Public Health Partnerships Program to build capacity at local level - $100 million for communicable disease surveillance - $100 million to bolster national immunization strategy - $100 million (one-time) to Canada Health Infoway to pay for real-time public health surveillance system - $400 million over three years for: - $300 million for national immunization strategy - $100 million for provinces to address immediate gaps in capacity Approximately $333 million per year ($500 million per year request by Naylor less Budget 2004 commitments of $500 million over 3 years or $167 million per year averaged out.) Total: $1 billion per year $404 million annually plus $665 million in new programming (one-time funding, over 2 years, or over 3 years) Total “Naylor Gap”: $450.5 million per year [TABLE END} We acknowledge that the Public Health Agency of Canada is just being created. We also recognize that Budget 2004 noted that: “The Government of Canada expects to make further investments once the new Canada Public Health Agency is operational, the Chief Public Health Officer has developed a comprehensive public health plan, and the Government has had the opportunity to evaluate the need for additional resources.” 16 Nevertheless, it is critical that reinvestment in Canada’s public health system continue as soon as possible to protect and promote the health of Canadians. These additional investments are needed to fully implement Dr. Naylor’s recommendations. This includes operating costs for a real time communication system for front line public health providers during health emergencies. It would ensure a two-way flow of information between front-line health care providers and public health professionals at the local public health unit, the provincial public health department and the Public Health Agency of Canada. The CMA has recently submitted a proposal to Canada Health Infoway to develop a system (the Health Emergency Communication and Co-ordination Initiative) that would link Canada’s physicians with governmental authorities. The additional investments should also be used to help address the recruitment and retention of public health practitioners. 17 In contrast with other areas of health expenditures, we know very little about how public health dollars are allocated and with what results. Presently, public health expenditures are lumped together with some health system administration costs. We believe there is a need for a better tracking and public reporting of public health expenditures. Set and Meet National Health Goals The CMA was pleased to see support by First Ministers in the FMM Agreement to establish a Pan-Canadian Public Health Strategy and health goals that are independently monitored. We believe health goals are a key component in addressing the serious public health challenges that lie ahead. Goals stimulate action and improve system accountability. Unlike Canada, many other countries—including the United States, the UK and Australia—have set health goals for their populations at the national level. At the CMA’s August 2004 General Council meeting, physicians agreed on health goals for physical activity, healthy body weights and obesity (see box below). These goals are already having an effect. Recently, the BC Minister of Health, Colin Hansen, accepted the challenge from the President of the British Columbia Medical Association, Dr. Jack Burak, to increase fitness levels by 10 per cent by 2010. We also need to be more preoccupied with setting, meeting and monitoring environmental health goals. Let us look at drinking water for example. As hard as it may be for Canadians to believe, a safe supply of water is a key health concern for Canadians today just as it was at the turn of the 20th century. The polluting of our water supply—including the presence of antibiotic-resistant bacteria through the use of antibiotics in human and animal health—and a lack of adequate water treatment infrastructure systems have contributed to the problem. Above all, we as Canadians need to recognize that a large natural supply of water and other natural resources do not eliminate the need for strong environmental governance. Public health officials play an important role in this respect. But it is pointless to set goals without any intention of meeting them. Resources will be necessary to meet the selected health goals such as the training and hiring of public health workers, as well as funding to support public advertising and marketing campaigns. Physical Activity and Healthy Body Weight Goals for Canada (Endorsed at CMA General Council, August 2004, Toronto) The Canadian Medical Association urges all levels of government to commit to a comprehensive, integrated and collaborative national strategy for increasing the physical activity levels of all Canadians, with a target of a 10% increase in each province and territory by the year 2010. The Canadian Medical Association calls on all stakeholders to develop, as an urgent priority, an action plan to address the obesity epidemic in Canada, with a goal of increasing by 15% within ten years the proportion of Canadians who are at a healthy weight. Invest in Health Not in Tobacco Improving health status is more than promoting healthy lifestyle behaviour. A healthy society also requires public policy that supports health (e.g. adequate income and education, proper housing, adequate nutrition, a clean and safe environment.) Tobacco use is a good example of a health risk that has been significantly reduced with the help of public policy measures, such as higher tobacco taxes, continued restrictions on tobacco advertising and promotion, and restrictions on smoking in public places. But there remains inconsistency in Canada's public policies—in this case between the investment policies of the CPP Investment Board and Canada's health policy goals. Canadians are very proud of their public pension plan, the Canada Pension Plan (CPP). It is a well-supported social program that has been viewed as a best practice model by several countries. Yet, despite the fact that tobacco continues to kill approximately 45,000 Canadians a year and costs Canadian society approximately $11 billion per year in net cost, (18) the Canada Pension Plan holds $94 million worth of tobacco investments. Canada’s physicians see the toll that tobacco consumption creates. We see the physical and mental suffering that tobacco-caused diseases bring to patients and their families. Accordingly, the CMA has consistently recommended a wide range of measures to control tobacco use such as higher tobacco taxes, continued restrictions on tobacco advertising and promotion, restrictions on smoking in public places, enforcement of bans on sales to minors, reduction of the level of toxic ingredients in tobacco and the provision of smoking cessation programs. We are pleased with the efforts to date but we are by no means finished in our battle. As our fact sheet shows, there are still segments of the population, particularly among our youth, that have high rates of smoking. The federal government in recent years has spent hundreds of millions of dollars on a tobacco reduction strategy that, when combined with efforts being taken by the provinces and municipalities, is making a difference for Canadians. However, the CPP Investment Board is investing and voting as shareholders in a pattern that is inconsistent with both public health policy, and the tobacco reduction measures being implemented across Canada. It is inconsistent and illogical for one arm of government to expend many millions of dollars of public money in an effort to reduce tobacco use, while another arm invests many millions of dollars of money in tobacco companies and supports these companies in their drive to be profitable. Resolution of the Canadian Medical Association General Council, August 2004: …the government amend the Canada Pension Plan Investment Board Act so that CPP investments in the tobacco industry are prohibited and the CPP Investment Board divests itself of existing tobacco holdings. The CMA is prepared to back up what it is prescribing—MD Management Ltd’s “MD Funds” which are managed for Canada’s physicians has followed this policy for almost ten years. Other major pension and investment plans have successfully followed this policy as well including several US State retirement and pension funds and the American Medical Association Pension Fund. While the CMA clearly believes that the CPP Investment Board should not invest in the tobacco industry and that existing tobacco holdings should be divested, we recognize that this committee might want to look at the matter in greater context to assess its full impact. We suggest that this be done in conjunction with the Standing Committee on Health. RECOMMENDATION 4 The Standing Committees on Finance and Health hold a joint review of the CPP policy as it relates to investments in tobacco (both current and potential) by the CPP Investment Board. IV. CONCLUSION The Finance Committee’s last report on the pre-budget hearings noted that the CMA’s submission identified relatively small, one-time investments that can support the health care system. 19 This year’s submission once again puts forward strategic investments that we believe support Canada’s health policy goals and which serve to effectively implement the FMM Agreement. Our recommendations are also directed at improving the alignment of Canada’s economic policy with its health policy. It is natural to think of an agreement as an end point. But in reality, the FMM Agreement and last year’s funding announcements for public health must be seen as for what they are—first steps to sustaining Canada’s health care system and its public health system. Canada’s physicians and the CMA are committed to working with governments and other health care stakeholders to ensure the financial investments announced over the past year lead to positive and enduring change, and ultimately improved health for all Canadians. END NOTES 1 Claudia Sanmartin et al. Access to Health Care Services in Canada, 2003. Statistics Canada, 2004. 2 Canadian Medical Association. The Taming of the Queue: Toward a Cure for Health Care Wait Times. Discussion Paper. July 2004. Ottawa. 3 CMA, Better Access for Better Health, September 2004; Canadian Healthcare Association, Canadian Medical Association, Canadian Nurses Association, Canadian Pharmacists Association. “Common Vision for the Canadian Health System,” September, 2004. 4 National Physician Survey, “Initial Data Release of the 2004 Physician Survey”, October 2004. 5 A note listed under the funding schedule indicates that moneys flowing to the Wait Times Reduction Fund for health human resources ($250 million for four years) will come only during the final four years of the Agreement. 6 Average duration. Only 2/16 medical schools have a 3 (versus 4) year program. 7 This estimate is based on federal government actual and estimated costs as well as current actual national average tuition fees in undergraduate programs in medicine. Data sources: (1) Statistics Canada, The Daily, April 26, 2004, National Graduates Survey: Student Debt, p. 3. (2) Government of Canada, Canlearn. Saving for your child's education, The projected cost of your child's education. University Tuition. Typical 1996 university cost living away from home: $13,000 - $3,500 tuition = $9,500 x 24% (8 years x 3% inflation cited in reference above) = $11 780. see: http://www.canlearn.ca/financing/saving/guaranteefuture/clcos.cfm?langcanlearn=en (3) Association of Canadian Medical Colleges for tuition 8 For a further discussion of the role of taxation in public policy, refer to Musgrave, Richard A. and Peggy B. Musgrave’s Public Finance in Theory and Practices. 1973. New York: McGraw-Hill. 9 Canadian Medical Association, Tax and Health—Taking Another Look. Discussion Paper, May 2002. 10See Keeping the Balance, 1997 Report of the Standing Committee on Finance; Facing the Future: Challenges and Choices for a New Era, 1998 Report of the Standing Committee on Finance. 11 See for example, Laurie J. Goldsmith, Brian Hutchinson and Jeremiah Hurley, Economic Evaluation Across the Four Faces of Prevention: A Canadian Perspective. (Hamilton: Centre for Health Econoimcs and Policy Analysis, McMaster University), May 2004. 12 The Conference Board of Canada, “The Economic Impact of SARS”, Ottawa, May 2003. 13 Report of the National Advisory Committee on SARS and Public Health, Learning From SARS: Renewal of Public Health in Canada, October 2003. 14 Based on data from the Center for Medicare and Medicaid Services (http://www.cms.hhs.gov/statistics/nhe/). 15 Canadian Medical Association, Answering the Wake Up Call: CMA’s Public Health Action Plan. Submission to the National Advisory Committee on SARS and Public Health, June 2003. 16Government of Canada, Department of Finance Canada, The Budget Plan 2004, p. 101. 2004. 17 See Answering the Wake-up Call: CMA’s Public Health Action Plan for other initiatives that should be funded to rebuild Canada’s public health system. 18 Adapted from estimates provided by Murray J. Kaiserman, “The Cost of Smoking in Canada, 1991”, Chronic Diseases in Canada, Vol. 18, No. 1, 1997. Available at http://www.phac-aspc.gc.ca/publicat/cdic-mcc/18-1/c_e.html. 19 Report of the Standing Committee on Finance, Canada: People, Places and Priorities, November 2002.
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Answering the Wake-up Call: CMA’s Public Health Action Plan : CMA submission to the National Advisory Committee on SARS and Public Health

https://policybase.cma.ca/en/permalink/policy1960
Last Reviewed
2010-02-27
Date
2003-06-25
Topics
Health systems, system funding and performance
Health care and patient safety
Population health/ health equity/ public health
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2010-02-27
Date
2003-06-25
Topics
Health systems, system funding and performance
Health care and patient safety
Population health/ health equity/ public health
Text
The public health system in Canada lies at the heart of our community values. It is the quintessential “public good” and is central to the continued good health of our population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong — like the Walkerton tragedy or when we are faced with a new threat like SARS — is the integral, ongoing role of public health really recognized. The Canadian Medical Association (CMA) has been warning that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to the latest crises. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. Our public health system is the first — and often the only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health armaments must be in a constant state of “battle readiness.” In today’s climate of SARS, West Nile Virus, mad cow disease and monkey pox, even the thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians. Physicians have always been an integral part of the public health system serving as medical officers of health, community health specialists and other related roles. Indeed public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians. In this submission, we reflect on the lessons to be learned from our recent experience with SARS and reflect on the longer-term needs of the public health system as a whole. The objectives of the pan-Canadian Public Health Action Plan proposed by the CMA are, first to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies; and, second, to enhance the system’s capacity to respond to public health threats across the country (see recommendations, below, and Appendix 1). To achieve these twin objectives, three broad strategies are presented for immediate attention. They are legislative reform; capacity enhancement; and research, surveillance and communications. Legislative reform (see recommendations 1–3) The country’s response to SARS has brought into stark relief the urgent need for national leadership and coordination of public health activity across the country, especially during a health crisis. The apparent reluctance to act quickly to institute screening at airports, the delay in unifying the practice community for a concerted response and the appalling communications confusion worked against optimum handling of the outbreak — despite the best efforts of health care professionals. This is a wake-up call that highlights the need for comprehensive legislative reform to clarify the roles of governments with respect to the management of public health threats. A renewed and enhanced national commitment to public health should be anchored in new federal legislation to be negotiated with the provinces and territories. Specifically, the CMA recommends an Emergency Health Measures Act, to deal with emergent situations in tandem with the creation of a Canadian public health agency headed by a Chief Public Health Officer of Canada. Capacity enhancement (see recommendations 4–7) The SARS crisis has demonstrated the diminished capacity within the public health system. The Greater Toronto Area (GTA), with one of Canada’s most sophisticated public and acute health systems, has not been able to manage the SARS crisis adequately and carry on other health programs. The acute care system virtually ground to a halt in dealing with SARS. There was little or no surge capacity in Canada’s largest city. We should be grateful that SARS did not first strike a smaller centre in a far less-advantaged region of Canada. A critical element of the public health system is its workforce and the health professionals within the acute care system, such as hospital-based infectious disease specialists and emergency physicians who are the front-line interface. Let there be no doubt that the ongoing efforts of the GTA front-line providers are nothing short of heroic. However, the lack of coordinated contingency planning of hospital and community-based disease control efforts was striking. The overall shortage of critical care professionals and the inability of governments to quickly deploy the required professionals to areas of need contributed to the enormous strain on the public and health care system. Considering the importance of the public health system and its clearly limited capacity to protect and promote the health of Canadians, it is incomprehensible that we do not know how much is actually spent on the system. It is imperative that public health expenditures and capacity, in terms of both physical and human resources, be tracked and reported publicly. The CMA recommends a $1-billion, 5-year capacity-enhancement program to be coordinated with and through the new Canadian public health agency. Research, surveillance and communications (see recommendations 8–10) Canada’s ability to respond to public health threats and acute events, such as SARS, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications. A concerted pan-Canadian effort is required to take full advantage of our capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. New-millennium challenges require moving beyond old-millennium responses. Enhanced surveillance is an overdue and integral part of public health, performing an essential function in early detection and response to threats of infectious diseases. Mandatory national reporting of identified diseases by all provinces and territories is critical for national and international surveillance. During times of crisis, rapid communication to the public, public health staff and front-line clinicians is of critical importance, but in many jurisdictions impossible. We tested our systems during the SARS outbreak and they came up short. The CMA recommends a one-time federal investment to enhance technical capacity to allow for real-time communication. Conclusion The CMA believes that its proposed three-pronged strategy, as set out in the attached recommendations, will go a long way toward addressing shortfalls of the Canadian public health system. Action now will help to ensure that Canadians can once again be confident that they are protected from any future threat of new infectious diseases. Action now will help Canada regain its position as a leader in public health. We wish the advisory committee well in its deliberations and offer the CMA’s assistance at any time in clarifying the strategies set out in our submission. Recommendations to the National Advisory Committee on SARS and Public Health Legislative reform ($20 million / 5 years*) 1. The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. 2. The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government. 3. The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan. Capacity enhancement ( $1.2 billion / 5 years*) 4. The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals. 5. The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies. 6. Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the proposed Canadian Office for Disease Surveillance and Control. 7. Federal government funding in the amount of $1 Billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions. Research, surveillance and communications ($310 million / 5 years*) 8. An immediate, sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. 9. The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and intervention. 10. The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies. *See Appendix 2: Estimated cost of implementing recommendations. PURPOSE The CMA prepared this submission in response to an invitation from Dr. Naylor to provide input to the National Advisory Committee on SARS and Public Health. We applaud this initiative and welcome the opportunity to present the views of Canada’s medical community to the committee. The CMA’s basic message is that our health protection laws are woefully outdated and the public health system is stretched beyond capacity. This submission draws on our long history of engagement in public health in Canada and our experience both post-September 11, 2001 and with SARS. It builds on the knowledge and experience of our members, national specialist affiliated societies and provincial and territorial divisions. (We acknowledge, in particular, the outstanding efforts of the Ontario Medical Association and the Canadian Association of Emergency Physicians in battling SARS.) In this submission, we examine the lessons to be learned from our experience with the SARS outbreak and reflect on both the immediate and longer-term needs of the public health system as a whole. The objectives of the public health action plan proposed by the CMA are, first, to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies and, second, to enhance the system’s capacity to respond to public health threats across the country, including those posed by preventable chronic disease. INTRODUCTION The public health system in Canada lies at the heart of our community values. It is the quintessential “public good” and is central to the continued good health of the population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong — like the contamination of the blood supply in the 1980s, the Walkerton tragedy or SARS — is the integral, ongoing role of public health recognized. Our public health system is the first — and often the only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health system must be in a constant state of “battle readiness.” We can ill afford any weakness in our public health preparedness. In today’s climate of SARS, West Nile Virus, mad cow disease and monkey pox, the mere thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians. Physicians have always been an integral part of the public health system serving as medical officers of health, specialists in infectious disease and community medicine (who will not remember the stalwart efforts of Dr. Donald Low on SARS?) and in other related roles. Indeed, public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians. The CMA has been warning for some time that our system is stretched to capacity in dealing with everyday demands, let alone responding to crises. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. For example, the CMA’s submission to the House of Commons Standing Committee on Finance’s prebudget consultations on October 22, 2001 called for substantial investments in public health and emergency response as a first step to improve the public health system infrastructure and its surge capacity. This submission not only reiterates our previous recommendations, but also outlines specific actions that the CMA believes must be taken to ensure a strong public health system in Canada. The Enduring Impact of Severe Acute Respiratory Syndrome SARS (Severe Acute Respiratory Syndrome): in February 2003, these four letters sent massive shock waves around the world, causing widespread fear and confusion among health care officials and citizens of many countries. The “fear factor” extended across Canada as people realized the full threat of SARS. Since SARS was first identified in a patient in Toronto in March 2003, 438 probable or suspected cases have been reported to Health Canada and 38 people have died (as of June 23, 2003). However, these numbers do not reflect the full impact of the outbreak. The number of indirect deaths due to system shutdown will never be known. Local public health authorities across the country went on high alert. Those in the Greater Toronto Area (GTA) as well as their provincial counterparts diverted almost all of their resources to respond to the crisis. Acute care services were adversely affected as stringent infection-control and screening measures were put into place to control the spread of SARS. In the GTA, the health system — acute and public — was brought to its knees. Over half of the reported SARS cases involved front-line providers as the outbreak largely affected health care settings. Approximately 20 physicians in Ontario contracted SARS and close to 1000 were quarantined. Thousands of nurses and other health care workers also faced quarantine, some more than once. Institutions closed their doors, limiting access to emergency departments, clinics and physicians’ offices. Intensive care units were full and surgeries were cancelled. Front-line health care professionals involved in critical care were stretched to their physical and mental limits. Others found themselves underutilized due to the impact of the infection-control measures on their practice settings. Feast and famine co-existed. Although the outbreak was mainly confined to health care settings, the entire GTA felt the effects. Upwards of 20,000 people entered voluntary quarantine. Businesses were affected. The tourism industry is still reeling. The disruption that SARS caused continues to reverberate through health care systems and economies. In response to urgent requests from both the Ontario Medical Association and Health Canada, the CMA mobilized its membership and assisted in the country’s response to SARS. Everything that could be done was done to facilitate bringing in qualified personnel to relieve those on the front line and make appropriate information available in real time. The CMA has learned its own lessons, both positive and negative. A full chronology of CMA activity is attached as Appendix 3. It has become abundantly clear that Canada’s public health system was ill prepared to deal with the SARS outbreak. If not for the heroic efforts of public health officials, health care providers and research scientists, Canada’s experience would have been much worse. Public health in Canada Public health is the science and art of protecting and promoting health, preventing disease and injury, and prolonging life. It complements the health care system, which focuses primarily on treatment and rehabilitation, sharing the same goal of maximizing the health of Canadians. However, the public health system is distinct from other parts of the health system in two key respects: its primary emphasis is on preventing disease and disability and its focus is on the health needs of populations rather than those of specific individuals. Public health is the systematic response to infectious diseases. It also ensures access to clean drinking water, good sanitation and the control of pests and other disease vectors. Further, it is immunization clinics and programs promoting healthy lifestyles. But it is also there to protect Canadians when they face a public health crisis like SARS. If the public health system is fully prepared to carry out essential services, then communities across the country will be better protected from acute health events. The reality in Canada today is that a strong, consistently and equitably resourced and integrated public health system does not exist. Public health systems across Canada are fragmented — a patchwork of programs, services and resources across the county. In reality, it is a group of multiple systems with varying roles, strengths and linkages. Each province has its own public health legislation. Most legislation focuses on the control of communicable diseases. Public health services are funded through a variable mix of provincial and municipal funding formulae, with inconsistent overall strategies and results, and with virtually no meaningful role for input from health professionals via organizations such as the CMA, or the federal level, in terms of strategic direction or resources. Federal legislation is limited to the blunt instrument of the Quarantine Act and a variety of health protection-related acts. (e.g., Food and Drugs Act, Hazardous Products Act, Controlled Drugs and Substances Act, Radiation Emitting Devices Act) Some of the laws, such as the Quarantine Act, date back to the late 19th century. Taken as a whole, the legislation does not clearly identify the public health mandate, roles and responsibilities of the different levels of government. In many cases, the assignment of authorities and accountabilities is anachronistic. Moreover, there is little information available on the functioning and financing of Canada’s public health system. There is no “one-stop shopping” for authoritative information on public health issues. In 2001, a working group of the Federal, Provincial and Territorial Advisory Committee on Population Health assessed the capacity of the public health system through a series of key informant interviews and literature reviews. The consistent finding was that public health had experienced a loss of resources and there was concern for the resiliency of the system infrastructure to respond consistently and proactively to the demands placed on it. Significant disparities were observed between “have” and “have-not” provinces and regions in their capacity to address public health issues. The report’s findings are consistent with previous assessments by the Krever Commission and the Auditor General of Canada. In 1999, the Auditor General said that Health Canada was unprepared to fulfill its responsibilities in public health; communication between multiple agencies was poor; and weaknesses in the key surveillance system impeded the effective monitoring of injuries and communicable and non-communicable diseases. In 1997, Justice Horace Krever reported that the “public health departments in many parts of Canada do not have sufficient resources to carry out their duties.” The Challenges Ahead The 21st century brings with it an awesome array of new public health risks and ancient foes. Not all of them can be identified at the present time. New diseases (e.g., SARS, West Nile Virus) will likely continue to emerge. Dr. Alan Bernstein, President of the Canadian Institutes of Health Research, recently noted that SARS is here to stay. Old threats, such as contamination of a community water supply (e.g., Walkerton), can strike quickly if vigilance is relaxed or delegated to third parties. This century will likely bring greater focus on threats from the physical environment. Our social environment is also a source of illness as shown by the recent epidemic trends in obesity and type 2 diabetes mellitus. A substantial minority of Canadians continue to smoke. In short, there is no lack of public health threats to Canadians. Although for each of these issues, there is a clear role for clinical care, it is the public health system that will identify and monitor health threats and provide interventions to prevent disease and injury and improve health. The system will also be at the front lines in any response to a biological, chemical or nuclear event. The public health system must have the infrastructure to respond to a range of threats to health, including emergencies. The experience with SARS has reaffirmed that we do not have the system flexibility to respond to these events after they have occurred. It is vital that we take steps now “to embrace not just the essential elements of disease protection and surveillance but also new strategies and tactics capable of addressing global challenges.”<1> CMA’S PROPOSED PUBLIC HEALTH ACTION PLAN No one policy instrument can possibly address the multiple factors involved in meeting the public health challenge head on. Similarly, no one level of government or constituency (e.g., community medicine) can or should shoulder all of the responsibilities. Although we need to restore public confidence quickly, we must also do what it takes to get it right. Accordingly, the CMA is proffering a three-pronged approach to meet the challenge: * A legislative reform strategy * A capacity enhancement strategy * A research, surveillance and communication strategy. These three broad strategies make up the CMA’s proposed 10-point Public Health Action Plan. Taken together, the CMA believes the Plan, if adopted, will serve us very well in the future. Legislative Reform Our experience with SARS — and the seeming lack of coordination between international, federal, provincial and local system levels — should be a massive wake-up call. It highlights the need for legislative reform to clarify the roles of governments with respect to the management of public health issues and threats. Four years ago, national consultations on renewing federal health protection legislation<2> resulted in a recommendation that * “The federal government must be given, either through legislation or through memoranda of understanding among provincial and territorial governments, the authority it needs to effectively address any outbreak of a communicable disease, where the health risk extends beyond provincial borders. * “Federal health protection legislation should be amended to give Health Canada authority to act quickly and decisively in the event of a national health emergency... if it poses a serious threat to public health; affects particularly vulnerable segments of the population; exceeds the capacity of local authorities to deal with the risk; and involves pathogens that could be rapidly transmitted across national and international borders.” Such legislative reform is consistent with the federal government’s well-recognized responsibility to act to protect public health and safety. It fits well with Health Minister McLellan’s recently announced plans to act now to review and update health protection legislation. The SARS outbreak has provided further experience to support these, and in our view, even stronger recommendations. There is ample historical evidence to support the federal government’s role in the management of communicable disease, a role that dates back to the time of confederation. The quarantine power was the initial manifestation of this authority in 1867 under Section 91 of the British North America Act and it gave the federal government the responsibility for ensuring the containment of infectious diseases. The outbreak of the Spanish Flu epidemic in 1918 further highlighted the need for coordinated national efforts and (at the urging of the CMA and others) resulted in the creation of the federal Department of Health in 1919. It would be reasonable to assume that legislators at the time had an expansive view of the need for centralized authority to deal with pan-Canadian health threats. One hundred and thirty-five years after confederation, we have a highly mobile global community. This mobility and the attendant devastating speed with which diseases can spread demand a national response. Currently, there is tremendous variation in public health system capacity among the various provinces and territories and, more particularly, among municipalities and local authorities. Inconsistencies in provincial approaches to public health matters have resulted in significant disparities between and within the provinces.<3> Health Canada’s mandate as set out in its enabling legislation states that “[t]he powers, duties and functions of the Minister extend to and include all matters over which Parliament has jurisdiction relating to the promotion and preservation of the health of the people of Canada.” The CMA believes that it is time for the federal government to take responsibility for public health matters that touch the lives of all Canadians. The legal staffs at CMA, in consultation with external experts, have conducted a detailed review of existing legislation. We have concluded, as Health Minister McLellan recently announced, that there is a long overdue need to consolidate and rationalize current related laws. We also believe there is now public support and a demonstrable need to enhance the powers afforded the federal government. We recognize that the government has put forward Bill C-17, the Public Safety Act and a review of health protection legislation is underway. We believe that amending and updating existing legislation is necessary but not sufficient to address today’s public health challenges. The CMA is calling for the enhancement of the federal government’s “command and control” powers in times of national health emergencies. Specifically we are recommending a three-pronged legislative approach. 1. The CMA recommends The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. The existing Emergencies Act gives the federal government the authority to become involved in public welfare emergencies when regions of the country are faced with “an emergency that is caused by a real or imminent... disease in human beings... that results or may result in a danger to life or property... so serious as to be a national emergency.” However, to use this power, the federal government must declare a “national emergency,” which itself has political and economic ramifications, particularly from an international perspective, and mitigates against its use. The CMA believes that this all-or-nothing approach is not in the public’s best interest. The concept of emergency in the context of public health requires a different response from governments in the future. Although we recognize that provincial and municipal governments currently have preplanned sets of responses to health threats, the CMA is proposing new legislation to allow for a rapid federal response to public health emergencies. The proposed Emergency Health Measures Act clarifies the roles and authority of governments and ensures a consistent and appropriate response with sufficient human and financial resources to protect Canadians faced with a public health emergency. Of utmost importance, all Canadians, regardless of their location, can be assured that the response to a health emergency will be delivered systematically by experts who can sustain the effort as needed. The proposed legislation would be founded on a graduated approach that would give the federal government the powers necessary to deal with a crisis, in an appropriately measured way, as it escalates. As the emergency grows, the government could implement stronger measures as required to meet the challenge — in principle, akin to the Unites States’ homeland security levels, which increase as the level of threat increases (see Appendix 4 for a description of the Canadian Emergency Health Alert System). The CMA strongly believes that the federal government must have jurisdiction to act when the ability of the provinces to respond to public health emergencies is so disparate. The inability of one province to stop the spread of virulent disease would have serious implications for the health of residents in the rest of the country. The federal government and the provinces must work together to ensure the safety of all our citizens. 2. The CMA recommends The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government. Although some provinces have established centres of public health expertise, considering the breadth of public health issues, the relative population sizes and differences in wealth, it will never be feasible to have comprehensive centres of public health expertise for each province and territory. Even if one achieved this, there would increasingly be issues of economies of scale and unnecessary duplication among centres. This issue is not unique to Canada.1 The CMA is proposing the development of a Canadian Office for Disease Surveillance and Control (CODSC) operating at arm’s length from any level of government. CODSC would have overall responsibility for protecting the health of Canadians. The Office would provide credible information to enhance health decisions and promote health by developing and applying disease prevention and control, environmental health and health promotion and education activities. CODSC would enable a consistent and coordinated approach to public health emergencies as well as play a key role in the prevention and control of chronic diseases and injuries. It would provide national health surveillance, apolitical scientific expertise, system development including standards and guideline development, development and dissemination of an evidence base for public health interventions, skills training and transfer of expertise (i.e., through secondment of staff) and resources, including funding for core programs, to other levels of the system (e.g., provincial and local). 3. The CMA recommends The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan. Many national or federal–provincial–territorial committees play an important role in recommending public health strategies or actions. The National Advisory Committee on Immunization and the Federal, Provincial and Territorial Advisory Committee on Population Health are two excellent examples. But there is currently no single credible public health authority in whom is vested, through legislation or federal–provincial–territorial agreement, the overall responsibility for pan-Canadian public health issues. Therefore, the CMA is recommending the appointment of a Chief Public Health Officer of Canada. Potential roles for this officer may include: * Serve as the head of the Canadian Office for Disease Surveillance and Control * Serve as the national spokesperson for public health with the independence to comment on critical public health issues * Report annually on the health of the population * Develop, implement and report independently to parliament on public health system performance measures * Lead processes to identify and address gaps in the nation’s public health system. Capacity enhancement The public health system infrastructure is the foundation that supports the planning, delivery and evaluation of public health activities. In March 2001, the Federal, Provincial and Territorial Advisory Committee on Public Health<3> reported, In the view of respondents the system ‘is lacking in depth.’ This means that a sustained crisis would seriously compromise other programming. While the research does not indicate that the public health system in Canada is strained beyond capacity, there does appear to be agreement that there is a capacity to manage just one crisis at a time. However, just 2 years later, the GTA, an area with one of Canada’s most sophisticated public and acute care health systems, was not able to manage the SARS crisis and carry on any other programs. The Ontario government recognized this state of affairs when, on 12 June, Ontario’s Health Minister Tony Clement said, “I was concerned that if we had one additional large-scale crisis, that the system would crash.” Important public health issues ranging from immunization to suicide prevention went virtually unaddressed, as the public health capacity in Toronto was overwhelmed. In the absence of a mechanism to share resources within the system and a general lack of overall system surge capacity, the city of Toronto and the province competed with each other to recruit trained staff from other health departments. The SARS outbreak has shown there is no surge capacity in Canada’s largest city. The acute care system in Toronto virtually ground to a halt in dealing with SARS. We must ask ourselves what would have happened if SARS had struck first in a smaller centre in a far less-advantaged region of Canada. Clearly Canada is not fully prepared. We should not have needed a crisis to tell us this. The CMA sees several components to rebuilding the capacity of the public health system. Public health human resources For the essential functions of the public health system to be realized, public health agencies need a workforce with appropriate and constantly updated skills. Canada’s public health workforce is extremely thin. There appear to be too few graduate-level public health professionals (i.e., those holding a master’s degree and physicians who are certified specialists in community medicine); those who do exist are not distributed equitably across jurisdictions. The scarcity of hospital-based infection control practitioners and emergency physicians within the acute care system and the lack of integration of hospital and community-based disease control efforts have been particularly striking during the SARS outbreak. The knowledge and skills required for effective public health practice are not static. They continually evolve as new evidence is identified. However, continuing education programming for public health practitioners is woefully underdeveloped in Canada. Health Canada has made some limited progress in this area, but the issue needs to be addressed much more substantively. 4. The CMA recommends The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals. Canada has world-class expertise in public health. However, it does not have the depth of other countries, partly because we do not have a national multidisciplinary school of public health of the calibre of Harvard in Boston, Johns Hopkins in Baltimore and the School of Hygiene and Tropical Medicine in London. A national school of public health, which might be based on a virtual network of centres nationwide, could * Develop a plan to assess and address the substantial educational needs of new and existing public health staff * Address the coordination of the various academic training programs to meet the needs of the field * Ensure self-sufficiency of our public health workforce. 5. The CMA recommends The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies. The SARS outbreak clearly demonstrated the need for a pre-planned approach to supporting and augmenting the public health and acute care workforce during a crisis. When health professionals in the GTA were overwhelmed, we were ill prepared to move health professionals in from other jurisdictions to help. Health professional associations like the CMA took the first steps in investigating and overcoming obstacles regarding licensure and insurance. We were taken aback when we found that the Ontario government had unilaterally awarded an exclusive contract to a for-profit company to arrange for emergency relief. The further delay caused by concerns about privacy, confidentiality and harmonizing fees hampered relief efforts. The deployment of health professionals during health emergencies is too important to be left in the hands of for-profit organizations as it was during the SARS experience. An established Canadian Public Health Emergency Response Service, operating on a non-profit basis, would * Maintain a “reserve” of public health professionals who are fully trained and could be deployed to areas of need during times of crisis * Co-ordinate the logistics of issues such as portable licensing, malpractice and disability insurance * Identify funding for staff training and a more equitable distribution of numbers and skills among jurisdictions. Investment in public health Considering the importance of the public health system and its capacity to protect and promote the health of Canadians, it is amazing that we have no reliable or comprehensive information about how much money is actually spent on the system or what public health human resources are available across Canada. This is partially due to the lack of uniform definitions, service delivery mechanisms and accounting practices. Even in the absence of reliable data on public health expenditures, there is ample evidence that the public health system continues to operate under serious resource constraints across Canada. 6. The CMA recommends Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the Canadian Office for Disease Surveillance and Control. In its latest report on health system expenditures, the CIHI states that 6% of total expenditures in 2000 were spent on “public health and administration.”<4> The inclusion of administrative costs in this figure means that public health funding is substantially less than 6% of health system expenditures.2 Federal Government Estimates report that Health Canada allocated $433 million in 2003–2004 for health promotion and prevention activities with spending scheduled to decrease to $308 million by 2005–2006 or by almost 30%. This decrease in spending exemplifies a decade that has seen tremendous fluctuations in spending on public health activities. The situation is alarming when looked at from a current-dollar basis; there was an 8.8% decrease in funding of public health activities between 1994–1995 and 1997–1998. In fact, federal spending on public health on a constant dollar basis did not regain its 1994–1995 level until 2000–2001. Although the late 1990s saw some reinvestment in public health initiatives, the most recent 2003–2004 estimates suggest that, once again, federal investment in public health will decrease dramatically over the next few years. Indeed, public health continues to represent only a small fraction of total federal direct spending on health (9.7% in 2002–2003). At the provincial level, although we cannot distance public health from administration, we know that it fell victim to the brutal climate of fiscal retrenchment of the 1990s, when in real terms provincial–territorial per capita health spending declined for 5 consecutive years after 1991–1992. During this period, public health was further destabilized by regionalization. According to the Survey of Public Health Capacity in Canada most provincial and territorial officials reported reductions in programming as a result of the transfer of funding and responsibility to regional structures. Although Ontario did not regionalize, in 1997 public health funding was downloaded to municipalities, which left public health departments scrambling to find funds to meet existing programs as well as new services that were mandated by the provincial Health Protection and Promotion Act. Whether talking about federal or provincial–territorial jurisdictions, we can no longer afford to have funding for health and safety subject to the vagaries of financial cycles. However, what perhaps is most alarming is the potentially large economic impact of underinvestment in this area. Although the net cost of the SARS outbreak in Ontario is not yet known, recent estimates suggest that it could be as high as $2.1 billion.3 Given this, the proverbial ounce of prevention that is worth a pound of cure comes to mind suggesting that a relatively modest increase in funding for public health could potentially result in substantial savings in the longer term. 7. The CMA recommends Federal government funding in the amount of $1 billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions. The best way to ensure that the public health system is capable of addressing the range of public health threats, including emergencies, is to significantly increase investment in its capacity. This investment must assist all levels of the system to fulfill essential public health functions, with particular attention to local and regional agencies. The strategic national leadership that we are calling for includes the development of new mechanisms for federal cost sharing of basic public health services and the guarantee of a basic core set of local programs serving everyone in Canada, regardless of where they live. The system also needs to receive targeted funds so that it can do its work smarter and more effectively. Priority areas for this targeted funding should include development of an integrated information system and staff training. Research, surveillance and communications Canada’s ability to respond to emerging public health threats and acute events, such as the SARS outbreak, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications. 8. The CMA recommends An immediate sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. Similar to the efforts in clinical care to support the use of evidence-based practices, interventions in public health must be based on research, evidence and best practices. A national effort should be undertaken to develop and make widely available, on an ongoing basis, a comprehensive and up-to-date review of the evidence base for public health programs. This information would support effective practice, enhance public health research capacity and support other infrastructure elements (e.g., minimum programs and services, performance measurement, system funding). It could also reduce unnecessary duplication of efforts by different public health agencies. We applaud the tremendous work of the unique trans-Canada partnership of 4 CIHR-funded research teams who, in just 11 weeks, discovered the complete DNA sequence of the coronavirus associated with SARS. This is a perfect example of what can be accomplished when our talented research teams work together. The recent announcement by the CIHR of an integrated national strategy for research on SARS reflects the intent of this recommendation for other public health challenges. 9. The CMA recommends The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and interventions. Public health surveillance is defined as the ongoing, systematic collection, analysis and interpretation of health data necessary for designing implementing and evaluating public health programs. It is an integral part of the public health system and performs an essential function in early detection and response to threats to human health. Current surveillance systems for communicable and noncommunicable diseases are inadequate to allow public health professionals to detect and react to major health issues. For effective public health management, surveillance must be a continuous process covering a range of integrated data sources to provide useful and timely information. 10. The CMA recommends The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies. In today’s world, international travel, business and migration can move infectious diseases around the world at jet speed. But during the SARS experience, governments and public health authorities were unable to communicate in real time with health professionals on the front lines. Gaps in the basic communication infrastructure prevent public health agencies from talking with each other in real time, and also hinder exchanges between public health staff, private clinicians and other sources of information about emerging new diseases. In response to requests from both the Ontario Medical Association and Health Canada, the CMA mobilized its communication networks to provide physicians with critical information about public health management of SARS. In less than 48 hours, via email and fax, we reached over 45,000 physicians with authoritative information. Through the good offices of the Canadian Council of Health Services Accreditation, this information was also made available to over 1500 accredited health facilities across Canada. Although necessity caused the limits of the system to be tested, SARS highlighted the fact that we do not have information systems in place to facilitate real-time communication with health professionals. Information is the key to effective response during times of emergency. Information in real time is also essential for effective day-to-day health care to provide, for example, information on adverse drug reactions. CONCLUSION SARS brought out the best in Canada and Canadians’ commitment to one another. It also turned a bright, sometimes uncomfortable spotlight on the ability of this country’s health care system to respond to a crisis, be it an emerging disease, a terrorist attack, a natural disaster or a large-scale accident. We must learn from the SARS experience and quickly move to rebuild the infrastructure of a strong public health system. The CMA believes that this 10-point Public Health Action Plan will go a long way toward addressing shortfalls in the Canadian public health system. Action now will help to ensure that Canadians can be confident once again that their governments are doing all they can to protect them from the threat of new infectious diseases. We wish the advisory committee well in its deliberations and offer the CMA’s assistance at any time in clarifying the strategies set out in our submission. APPENDIX 1: THE CMA’S PUBLIC HEALTH ACTION PLAN [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [TABLE END] APPENDIX 2: ESTIMATED COST OF IMPLEMENTING THE RECOMMENDATIONS [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Recommendation Estimated cost over 5 years Legislative and institutional reform 1. Canada Emergency Health Measures Act N/A 2. Canadian Office for Disease Surveillance and Control (CODSC) ? $20 million 3. Chief Public Health Officer of Canada Capacity enhancement 4. Canadian Centre of Excellence for Public Health $100 million 5. Canadian Public Health Emergency Response Service $35 million 6. Canadian Institute for Health Information and Statistics Canada $35 milliona 7. Surge capacity $1 billionb Research, surveillance and communications 8. Canadian Institutes of Health Research $200 millionc 9. Mandatory reporting Included under 2 and 3 above 10. Enhanced reporting $110 million TOTAL $1.5 billion a. Work is currently underway to break-out public health from the current category of “public health and administration.” b. This is an incremental investment in addition to funding currently available under Health Canada’s Health Promotion and Prevention Strategic Outcome area. c. Funding must be sequestered specifically for new initiatives related to public health. Additional money could also be acquired through funding from the Canadian Foundation for Innovation, which received an additional $500 million in 2002–2003 (announced in the 2003 federal budget) to enhance the Foundation’s support of public health infrastructure. [TABLE END] APPENDIX 3: CHRONOLOGY OF THE CMA’S RESPONSE TO SARS 2002 November 16 * First known case of atypical pneumonia (SARS) occurs in Guangdong province, China 2003 February 11 * World Health Organization (WHO) receives reports from the Chinese Ministry of Health about SARS; 305 persons affected and 5 deaths February 13 * Canadian index case arrives in Hong Kong for a family visit February 18-21 * Canadian index case is a guest at the Metropole hotel in Kowloon February 21 * A medical doctor from Guangdong checks into Metropole hotel in Kowloon. The physician, who became ill a week before staying at the hotel, is considered to be the original source of the infection * This leads subsequently to outbreaks in Vietnam, Hong Kong, Singapore and Canada after guests leave the hotel and return home February 23 * Canadian index case returns home to Toronto March 5 * Canadian index patient dies in Toronto, 9 days after the onset of her illness March 12 * WHO issues global alert about SARS March 13 * National and international media reports begin appearing about SARS * The Canadian index patient’s son, Canada’s second SARS victim, dies 15 days after the onset of his illness March 14 * First reports from Toronto about deaths from SARS March 16 * Health Canada receives notice of SARS patients in Ontario and British Columbia; begins regular updates on SARS on its website * Health Canada initiates its pan-Canadian communication infrastructure, based on its pandemic influenza contingency plans March 17 * CMA calls Health Canada to offer assistance and request “real time information.” CMA immediately placed on list of participants in daily pan-Canadian teleconferences. * CMA adds a SARS page to its website home page (cma.ca) with CMA Shortcuts to expert information and daily updates March 19 * CMA alerts all its divisions and affiliates to the Health Canada and CMA SARS web pages * eCMAJ includes SARS updates on its website March 20 * CMA divisions add a link to SARS information for health professionals to their websites * Health Canada requests CMA’s assistance to inform physicians of the public health management guidelines for SARS March 28 * CMA sends an email to 33,000 members (copied to divisions and affiliated societies) to alert them to Health Canada’s SARS public health management documents and SARS web page April 1 * CMA CEO initiates cross-directorate task force and deploys dedicated staff resources. Some other CMA programs deferred/delayed. Task force begins daily staff SARS Working Group meetings * CMA communicates with the Ontario Medical Association on a daily basis April 2 * CMA holds teleconference with divisional communication directors re: SARS April 3 * CMA contacts the British Medical Association to establish whether we can secure a supply of masks from European sources * CMA organizes a teleconference among national health care organizations to discuss SARS developments April 7 * CMA posts electronic grand rounds on SARS for clinicians on cma.ca; * CMA sends email and fax communication to physicians to raise awareness of SARS e-grand rounds on cma.ca * Working with the Mental Health Support Network of Canada, CMA prepares and posts on cma.ca, fact sheets for health professionals and the public on coping with the stress caused by SARS April 9 * CMA hosts second teleconference among national health care organizations to discuss SARS developments April 17 * Electronic grand rounds on SARS updated and promoted through cma.ca April 23 * CMA sends email to membership requesting volunteers for the CMA Volunteer Emergency SARS Relief Network April 24 * CMA consults with the American Medical Association regarding the possibility of US physicians volunteering for the relief network April 25 * CMA CEO sends letter to deputy minister of health about the urgent need to create a national ministerial SARS task force April 30-May 1 * CMA participates in Health Canada-sponsored international SARS conference in Toronto May 6 * Health Canada announces the National Advisory Group on SARS and Public Health, headed by Dr. David Naylor May 12 * Opinion editorial by Dr. Dana Hanson, CMA president, on SARS and public health surge capacity published in The Ottawa Citizen; May 28 * CMA organizes a meeting of national health care organizations to discuss lessons learned from SARS June 3 * CMA receives an invitation to submit a brief to the National Advisory Group on SARS and Public Health June 6 * CMA sends e-mail to targeted segment of its membership (community medicine, public health, infectious disease and medical microbiology) requesting volunteers for the CMA Volunteer Emergency SARS Relief Network June 25 * CMA president outlines the CMA’s Public Health Action Plan during a speech at the Canadian Club in Toronto * CMA submission to the National Advisory Committee on SARS and public health APPENDIX 4: CMA’S PROPOSED HEALTH EMERGENCY ALERT SYSTEM [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Health alert may be declared in: Level 1 Level 2 Level 3 Level 4 Level 5 * Any area under federal jurisdiction * Any community or province/territory with a risk of transmission to other provinces/territories or countries * Any community or province/territory with insufficient resources to manage the public health emergency within the capacity of the local public health authorities Definition of the area of concern Voluntary quarantine for individuals or property Increasing surveillance Chief public health officer takes the lead in coordinating the response Regulation or prohibition of travel Facilitating communication Reviewing and updating health emergency procedures Determination of local capacity to lead and respond Coordinating necessary response efforts with national disaster relief agencies, armed forces or law enforcement agencies at the federal–provinical–territorial level Medium to significant limitations of civil rights and freedoms Mandatory surveillance Assessing future resource requirements Deployment of a national response team Medium to significant limitations of civil rights and freedoms Evacuation of persons and the removal of personal property Providing the public with necessary information. Discretionary deployment of the national response team or on request of local authorities Quarantine of individuals and/or property with enforcement by law Implementing interventions, as appropriate, and emergency response actions Regulation of the distribution and availability of essential goods, services and resources Assessing further refinement of actions Restricting access to the area of concern Requisition, use or disposition of property Required consent of governor in council No No Yes Yes Yes Lead response team Municipal or provincial Provincial or national Provincial or national National or international International [TABLE END] REFERENCES 1. Garrett, L. Betrayal of trust: the collapse of global public health. New York: Hyperion; 2000. 2. Health Canada. National consultations, summary report: renewal of the federal health protection legislation. Ottawa: Health Canada; 1999. 3. Federal, Provincial and Territorial Advisory Committee on Population Health. Survey of public health capacity in Canada: highlights. Ottawa: The Committee; 2001. 4. Canadian Institutes for Health Information. National health expenditure trends: 1975–2002. Ottawa: CIHI; 2002. 5. Lévesque M. The economic impact of SARS. TD Economics Topic Paper. TD Bank Financial Group; 6 May 2003. Available: http://www.td.com/economics/topic/ml0503_sars.html (viewed: 20 June 2003). 1 Many countries (e.g., United States, United Kingdom, Norway and the Netherlands) have developed critical masses of public health expertise at the national level. The Centers for Disease Control and Prevention in the United States, which has a critical mass, great depth of scientific expertise and the tools and fiscal resources to fund public health programs at both state and local levels through demonstration projects, is a sterling example of the effectiveness of such a central agency. 2 A review by the Canadian Institute for Health Information recognizes the problem with current expenditure tracking systems and has recommended separating public health from government administrative costs and prepayment administration in future health system cost estimates. 3 On 6 May, the TD Bank released a paper<5> suggesting that the cost of SARS to the Canadian economy may be between $1.5 and $2.1 billion.
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Bill C-12: An Act to prevent the introduction and spread of communicable disease : CMA’s Submission to the House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy1948
Last Reviewed
2012-03-03
Date
2004-11-23
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2004-11-23
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) appreciates the opportunity to appear before the House of Commons Standing Committee on Health to provide our observations concerning Bill C-12, an Act to prevent the introduction and spread of communicable disease, which will repeal and replace the current Quarantine Act. Since our founding in 1867, the CMA has had a long tradition in the field of public health and infectious diseases. For example, in 1885 we worked with the federal government to prevent an outbreak of cholera in Canada, while in 1891 we began a long campaign to encourage governments to deal with tuberculosis. And fast forward to 2003 and SARS, CMA worked along with many levels of government to deal with this public health crisis. While the CMA is particularly interested in how the proposed legislation will impact the practices of our more than 58,000 members across the country, we have reviewed this legislation through the lens of what is in the best interest of patients and the public. 1) Comprehensive Approach to Public Health Our comments call for and are embedded in the broader context of a comprehensive approach to public health. They are also based on previous recommendations CMA has made to the federal government including: a) Response to the Health Protection Legislative Renewal initiative carried out by Health Canada (2004). In this submission, CMA identified the Quarantine Act as a piece of legislation the CMA believed merited urgent updating; b) Review of the World Health Organizations’ draft revised International Health Regulations (IHR), (2004); c) Submission to the Naylor Advisory Committee on SARS and Public Health (2003); d) Submission to the Senate Standing Committee on Social Affairs, Science and Technology during its study of public health issues (2003); and e) Pre-budget submission to the House of Commons Standing Committee on Finance following September 11, 2001. These submissions are all available on request, or at www.cma.ca. The CMA is pleased that Parliament has identified revision of the Quarantine Act as a priority. The Act is more than a century old and the medical community and others have long called for it to be updated. Bill C-12 is an excellent start to modernizing the previous Act; however, we believe the proposed legislation does not go far enough in remedying its deficiencies. In this submission we present eight key recommendations for your consideration, along with questions about particulars in the implementation process, which we suggest Parliament address in subsequent review of the Act and its regulations. 2) Recommendations for Consideration in Review of Bill C-12 Recommendation 1: The Act should be part of a larger, comprehensive Emergency Health Measures Plan. In our brief to the Naylor Advisory Committee, CMA recommended the enactment of a comprehensive Emergency Health Measures Act, administered by the Chief Public Health Officer of Canada. This Act would consolidate and enhance existing legislation, allowing for a more rapid national response to health emergencies, in cooperation with the provinces and territories, based on a graduated, systematic approach. We also recommended that the Emergency Health Measures Act be part of a strong commitment, by all levels of government, to a public health strategy that also included a 5-year capacity enhancement program, development of research and surveillance capability; and funding for a communications initiative to improve technical capacity for real-time communication with front-line health providers during public health emergencies. Recommendation 2: The Chief Public Health Officer of Canada must have authority to enforce the Act The proposed legislation designates the Minister of Health as the person with ultimate responsibility for enforcing the Act; it grants the Minister sweeping powers including the power to overrule a health official’s quarantine. As medical professionals we believe that public health decisions should be made primarily on the basis of the best available medical and scientific evidence, and should be independent to the greatest extent possible of other considerations. Therefore we believe that responsibility for the implementation of the Act should rest with the Public Health Agency of Canada, and with the Chief Public Health Officer of Canada, not with the Minister of Health. In the provinces and territories, Medical Officers of Health do not require approvals from their Ministers to exercise their functions as health professionals; the same should hold true at the federal level. We understand that responsibility has been placed with the Minister of Health due to a lack of existing legislation setting out the mandate, roles, responsibilities and powers of the recently created Public Health Agency of Canada, and the newly appointed Chief Public Health Officer of Canada. We are also aware that enabling legislation is currently being prepared; we urge that this legislation be enacted as soon as possible. On enactment of this enabling legislation, the powers now vested in the Minister should be ceded to the Chief Public Health Officer. Locating responsibility for administration of the Act within the Public Health Agency of Canada will also combine enforcement with other needed functions of surveillance, monitoring and linkage with international monitoring agencies. As we stressed in our previous recommendation, these must all be part of a comprehensive Canadian emergency response strategy. Recommendation 3: The Act must address interprovincial as well as international traffic. We are happy that the provisions of Bill C-12 apply to goods and travellers leaving as well as entering Canada. This was a deficiency identified in the previous Quarantine Act. However, the Act must also expressly address goods and travellers crossing provincial or territorial boundaries. Currently, there is tremendous variation in public health system capacity among provinces and territories and, more particularly, among municipalities and local authorities. Inconsistencies in provincial approaches to public health matters have resulted in significant weaknesses in the “emergency shield” between and across provinces. Unless the potential consequences of these disparities are remedied through federal legislation they must, as a priority, be remedied through federal/provincial/territorial agreements. The role of the Public Health Agency of Canada in facilitating, equalizing and monitoring the management of public health emergencies nationwide must be enshrined in the legislation that establishes the Agency. CMA also hopes that the development of a pan-Canadian Public Health Network, acknowledged in the 2004 Throne Speech, will facilitate the nationwide collaboration essential for adequate and appropriate response to health emergencies. The CMA supports those provisions in Bill C-12 that give the Minister (preferably the Chief Public Health Officer of Canada) the power to establish quarantine centres anywhere in the country. In times of threat to national health security, such bold leadership would be both warranted and expected. Recommendation 4: “Public Health Emergency” must be adequately defined. Bill C-12 contains no definition of “public health emergency” or “public health emergency of international concern.” We believe these should be defined.1 Bill C-12 includes a schedule of specific communicable diseases to which its provisions would apply. We are concerned that this Schedule may limit Canada’s capacity to respond to emergencies. The next public health emergency may be a disease we have not heard of yet; or it may be a bio-terrorist attack, or a chemical or nuclear event. The Act must enable Canada to respond to new and emerging, as well as existing, threats to health. The World Health Organizations’ draft International Health Regulations (IHR) has proposed a set of criteria for assessing emergencies; these include: * Is the event serious? * Is the event unexpected? * Is there a significant risk of international spread? The CMA urges the Canadian government to consider a hybrid approach incorporating both known disease states and criteria such as the ones used by the IHR, for assessing new diseases or other public health emergencies. Recommendation 5: The Act, or its regulations, must clarify the roles, responsibilities and training requirements of emergency response personnel. Some provisions of Bill C-12 have raised questions in our minds about the scope of practice of personnel involved in disease screening, and we would appreciate clarification on these points. For example: Screening officers, the first point of contact for travelers entering or leaving Canada, are customs officers and others designated by the Minister. Their primary role under Section 14 of the Act is to use “non-invasive” screening technology to detect travelers entering and exiting Canada with communicable disease vectors, etc. According to Section 15 (3) screening officers, who are not health professionals, will have the power to “order any reasonable measure to prevent spread of a communicable disease”. Of what might these “reasonable measures” consist? Quarantine officers, by definition in Section 5(2) are medical practitioners or other health professionals or anyone else in this “class of persons”. Since the quarantine officer’s job description includes physical assessment of travellers to determine whether they should be detained – a function that requires the expertise of a health professional - we would appreciate clarification of the phrase “in this class”. Similarly, under Section 26, the quarantine officer has the power to order the traveler “to comply with treatment”. Which officer—screening/quarantine or medical—might actually prescribe the course of treatment? This function must be specifically delegated to medical officers. Bill C-12 gives authorities the powers to restrict personal movement and temporarily impound or seize property. The CMA believes that the government should also provide adequate resources and powers to allow for tracking down apparently well people who cross borders and are subsequently diagnosed with infectious diseases. The Act or its regulations should also address factors that hinder deployment of qualified health professionals, such as portability of licensure and coverage for malpractice and disability insurance. CMA has previously called for the establishment of a Canadian Public Health Emergency Response Service that would maintain a “reserve” of public health professionals who could be deployed to areas of need during times of crisis, and which would co-ordinate the logistics of the issues above mentioned. This would improve the capacity of health professionals to be deployed quickly in times of health emergency, to locations where they are most needed. Finally, CMA suggests that the Act or its regulations provide greater detail on training requirements for screening officers, to guarantee that they are appropriately trained. Recommendation 6: Privacy and confidentiality must be respected and safeguarded. Bill C-12 grants quarantine officers and the Minister some sweeping powers to arrest and detain people without warrants, including people who have refused to comply with testing. Though on rare occasions such measures may be required to protect the public, it is recognized that potential for their abuse may exist. In addition, Bill C-12 raises questions about the degree to which personal health information might be exposed to scrutiny. We note that Section 51 authorizes a quarantine officer to “order any person to provide any information or record…the officer might reasonably require.” This provision could include patient medical records in a doctor’s office, particularly if the Bill guarantees travellers the right to request a “second opinion” which we assume could be obtained from any practicing physician in Canada. Similarly, Sections 55 and 56 appear to give the Minister authority to “collect medical information in order to carry out the purposes of this Act” and to “disclose personal information obtained under the Act” to a host of entities. The CMA believes that the power to obtain and disclose information should be explicitly constrained and circumstances under which this power could be exercised must be outlined in the Act. Recommendation 7: The role of physicians and other health care workers must be respected. The health professional sector is on the front lines of response to health emergencies, as they were during the SARS outbreak. Therefore as a first principle the new Act should recognize the importance of health professionals having the power, subject to appropriate constraints, to make vital decisions in response to health emergencies. This is a legitimate delegation of power, because of the competencies of health professionals. During the SARS outbreak of 2003, physicians and other health care providers were not only partners in containing infection; many became ill or died as well. Since health care workers expose themselves to infection as they respond to health emergencies, protocols should ensure that care and attention is paid to their safety, through measures such as ensuring ready availability of proper masks The Act or regulations should address precautions required to protect quarantine officers and other health care workers from transmission of disease or the effects of becoming ill. For example, it should address compensation for quarantine officers who lose work because they become infected in the course of their duty. We would be remiss in our review of this act if we did not pursue with this Committee the issue of compensation and indemnification programs for physicians and trainees requiring quarantine because of exposure to a communicable disease while providing medical service, or who are required to close their offices for other public health reasons, or who cannot practice in hospitals because of closure of hospitals for public health reasons. Indeed, delegates to our annual general council meeting called on the CMA to do so. A number of these physicians were caught in such situations during the turmoil of the SARS outbreak. Recommendation 8: Decision-making should be evidence-based. At times, public perception and political considerations may widely influence the assessment and management of risk. While this is probably unavoidable, CMA believes that public policy should be founded first and foremost on the highest possible quality of scientific evidence. The Act should provide the requisite mechanisms to ensure that reviews of risk are independent and unbiased. We acknowledge, however, that this principle should not be rigidly applied; “we’re waiting for the evidence” must not be used as an excuse for inaction when action is urgently required. 3) Additional Comments In addition to the above recommendations, additional concerns remain regarding implementation of the Act. In particular we note that many crucial components, such as how physical examinations are to be carried out (section 62(1), medical practitioner’s review process (section 62(d), and the protection of personal information (62(g) are left to regulations. These regulations must be developed as soon as possible. We understand that the current Act constitutes “Phase I” of a longer-term strategy to enhance Canada’s capacity to respond to public health emergencies. Though we believe that the Quarantine Act merits attention at this time, we also believe that it should be looked at with a longer-term view. For instance, as we have already recommended, it should be incorporated into the broader legislative renewal of public health in Canada, with a view to enhancing this country’s ability to respond swiftly and effectively to public health emergencies, locally and nationwide. Above all, Canada must ensure a sustained and substantial commitment of resources to its public health emergency response program. Without this, the best-written laws will be inadequate. The Canadian Medical Association commends the Government of Canada for bringing this bill forward, and looks forward to working with the Government, and the Public Health Agency of Canada, to help keep Canadians safe in the event of a public health emergency. End Notes 1 A public health emergency has been defined by the US Model State Emergency Powers Act (http://www.publichealthlaw.net accessed July 7, 2003) as an occurrence or imminent threat of an illness or health condition of a temporary nature that is believed to be caused by: * the appearance of a novel or previously controlled or eradicated infectious agent or biological toxin; * a bioterrorist event; * a natural disaster * a chemical event or accidental release; or * a nuclear event or accident and that poses a high probability of any of the following harms: * a large number of deaths in the affected population; * a large number of serious or long-term disabilities in the affected population; or * widespread exposure to an infectious or toxic agent that poses a significant risk of substantial future harm to a large number of people in the affected population.
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Canada Pension Plan Disability Program : CMA Presentation to the Sub-Committee on the Status of Persons with Disabilities

https://policybase.cma.ca/en/permalink/policy1965
Last Reviewed
2010-02-27
Date
2003-03-18
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2010-02-27
Date
2003-03-18
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association appreciates the opportunity to once again participate in the deliberations of the Sub-Committee on the Status of Persons with Disabilities. I am accompanied today by Mr. William Tholl, Secretary General and Chief Executive Officer of the Canadian Medical Association. Before I begin my remarks, I want to congratulate this Committee, and particularly the Chair of the Committee, for your efforts in regard to another federal program, the Disability Tax Credit. Your 2002 report on this program, Getting it Right for Canadians, no doubt led to some of the important measures in regard to disabilities undertaken by the government in the recent federal budget. The appointment of the Technical Advisory Committee on eligibility criteria and the $105 million allocated over the next two years to improve assistance for persons with disabilities is, in our view, significant progress. The CMA appreciates this opportunity to discuss issues relating to the Canada Pension Plan (CPP) specifically as the program relates to the disability benefit. I will focus my remarks today in three areas: * Physician experience with federal health programs and forms * The need for common criteria * Recommendations for action While the subject matter before the Subcommittee today is the CPP disability program, we believe a broader focus on the issue of “disability” and federal health programs in general is needed. Issues related to the CPP disability program are issues common to other federal disability assistance programs. THE PHYSICIAN EXPERIENCE I don’t think I need to tell this Committee about the alarming shortages of physicians and other health care providers in Canada. Canada’s physicians have been stretched to the limit and beyond. Therefore, it’s more important than ever that physician’s time be managed in such a way as to maximize our interaction with patients. Unfortunately however, this is not the case. Increasingly physicians are spending more and more of their time filling out forms. Forms for federal health programs such as the CPP or for-private insurance claims, pension benefits, tax credit eligibility, pharmaceutical plans and workers compensation claims to name just a few. To figure out all the various forms and determine eligibility you almost need to be a physician, a lawyer and a tax expert. The result of the proliferation in the number of forms and their increasing complexity has resulted in less time for what physicians are trained to do; treating illness and providing care to patients. If you were to ask the average physician his or her greatest frustration with the health system, the response would be too much time spent administrating the system and not enough time in providing care to patients. In regard to the CPP specifically, we have had in the past a good working relationship with the officials who manage this program. We have worked together well in the past in regard to improving the forms and bring great integrity to the program which has resulted in a reduction of appeals under the program. The CMA believes that in terms of a federal health program, the CPP set the template both in terms of administrative processes and cooperation that should be adopted across all federal programs in this area. That said, there is still considerable room for improvement. I urge the Committee to take into consideration the cumulative impact these various health programs, such as the CPP, have on our health provider workforce. We must look at ways in which to relieve the heavy administrative burden so that physicians can concentrate their efforts on what they do best, patient care. COMMON CRITERIA As with our presentation on the Disability Tax Credit program, the CMA recommends that a standard of fairness and equity be applied across all federal disability benefit programs. Currently, there is virtually a different definition and a different assessment process for each and every program. A common frustration of physicians is that while a patient qualifies as “disabled” under one disability program, that same patient does not under another. When you look at some of the common criteria used to determine the level of a disability, the problem is readily apparent. The CPP criteria define “severe” as preventing an applicant from working regularly at any job and “prolonged” as long term or that which may result in death. However, the DTC program notes that “severe” is to be interpreted to mean markedly restricting any of the basic activities of daily living and that a disability must be “prolonged” over a period of at least 12 months. While daily living includes working regularly at any job it encompasses so much more. Under the CPP criteria the physician is responsible for determining how to define long term; six months or twelve months. Other programs, such as the Veterans benefits that have entirely different criteria, are added to this mixture. This is confusing for physicians, patients and others involved in the application process. If the terms, criteria and the information about the programs are not as clear as possible then we have no doubt that faulty interpretation on the part of physicians when completing the forms can occur. This could then inadvertently disadvantage those who, in fact, qualify for benefits. There needs to be some consistency in definitions across the various government programs. This does not mean that eligibility criteria must be identical. However, there must be a way for a more standardized approach. Inconsistency in the application and administration of the program is likely without a more standardized definition of the program. The reality is that certain individuals with conditions or disabilities may qualify for the CPP disability benefit in one region of the country, while in other regions, an individual with the same condition will be deemed ineligible. There are a number of conditions that society would today view as a “disability,” yet may not fit under the current program. Severe and prolonged is a rigid standard, especially as it is applied to some medical conditions. The reality is that such a standard cannot be applied fairly in all situations. There needs to be greater flexibility and more realistic criteria that takes into account the special nature of some medical conditions that may not meet yesterday’s standards. RECOMMENDATIONS Canada’s physicians offer four specific actions for the Committee to consider: 1. That an emphasis be placed on reducing the administrative burden placed on health care providers under all federal health programs. The CPP program, both in terms of the consultative and administration process, should serve as the template for change. Unlike other federal health programs, the cost of having the eligibility form completed by a physician is subsumed under the program itself. The CMA believes this should be the case for all federal health programs. 2. The establishment of a joint governmental and stakeholder advisory group, similar to the recently announced DTC Advisory Committee, to monitor and appraise the performance of the CPP disability program to ensure it meets its stated purpose and objectives. Representation on this advisory group would include senior program officials; health care providers; various disability organizations; and patient advocacy groups. 3. That there be some consistency in definitions across the various government programs. This would not circumvent the purposes or mandates of the programs. 4. That a comprehensive information package be developed for health care providers and the public 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. CONCLUSION To conclude, the CMA believes that the CPP is a deserving benefit to those Canadians living with a disability. We again congratulate the Committee for the progress it has achieved on behalf of people with disabilities in regard to the recent initiatives announced in the federal budget. The CMA looks forward to working with all concerned to improve the CPP program and all other federal disability health programs. Thank You.
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CMA’s Annual Check-up of Canada’s Health Care System: Presentation to the House of Commons Standing Committee on Finance Pre-Budget Consultations

https://policybase.cma.ca/en/permalink/policy1953
Last Reviewed
2011-03-05
Date
2003-09-25
Topics
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2011-03-05
Date
2003-09-25
Topics
Health systems, system funding and performance
Text
The past year has been an historic one for health and health care in Canada. We applaud the federal government for the reinvestments that were made at the time of the February 2003 Health Accord. However, what we as physicians continue to hear in our offices, clinics and hospitals right across the country is continuing concern from our patients that Canada’s health care system won’t be there for them when they need it. And so while we can understand government’s desire to “turn the page” on health care issues, the temptation must be resisted. It is appropriate and prudent that at least once a year, the federal government take the pulse of the health care system – an annual check-up – to take stock of where we’ve been and identify priorities for the coming year. This year, the Canadian Medical Association’s (CMA’s) submission to the Standing Committee on Finance moves largely away from macro funding issues to focus in on strategic initiatives that are national in scope and promise high returns in terms of value for money. Specifically, we identify three areas that require immediate new investments while reminding committee members of work that remains unfinished from years past. Unfinished Business While the CMA applauds the federal government for its leadership in achieving the 2003 Health Accord, it is now time to follow through on some outstanding promises that were made. In particular, there are two areas that require special mention. At the time of the First Ministers’ Health Accord in February 2003, the federal government agreed to provide up to an additional $2 billion into Canada’s health care system at the end of this fiscal year (2003/04) if a sufficient surplus above the normal Contingency Reserve were available. The federal government must honour their commitment. Health cannot be treated as a residual after other contingencies are addressed. Equally important is moving forward with establishing the Canada Health Council. Suggestions to water down the mandate of the health council to make it more palatable to some jurisdictions are not the answer. Canada needs a robust mechanism that will provide for enhanced evidence and accountability on how Canada’s health care dollars are spent. Canada needs a Health Council that will create a meaningful place at the table for Canadians, health care providers and other stakeholders to provide input on how the system operates and monitor its performance. Protecting Public Health The public health system in Canada lies at the very heart of our community values. It is the quintessential “public good” and is central to the continued good health of our population. It is the view of the CMA that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to emerging crises. On June 25, 2003, the CMA submitted a brief to the National Advisory Committee on SARS and Public Health headed by Dr. David Naylor. In it the CMA called upon the federal government to make a minimum investment of $1.5 billion over five years to achieve legislative reform; capacity enhancement; and enhanced research, surveillance and communications capacities. In particular, the CMA calls for immediate funding of two specific priorities. The first is the same proposal that the CMA brought to the Standing Committee on Finance last year – the REAL (rapid, effective, accessible and linked) Health Communication and Co-ordination Initiative. The purpose of this initiative is to increase the capacity of the public health system to communicate in real time, between multiple agencies and with health care providers. Had CMA’s earlier recommendations been acted upon, perhaps we would have been better prepared to communicate with health care providers when SARS first appeared in Toronto. Improved communications must be a priority this time around – we cannot afford to let this recommendation languish another year. The second short-term priority for public health is to invest in an emergency supply chain for use in times of crisis. SARS showed us that the Greater Toronto Area, an area with one of Canada’s most sophisticated public and acute care health systems, was not able to manage the SARS crisis and maintain its capacity to meet other acute care requirements or important public health services such as suicide prevention programs. The federal government must assure Canadians that plans are in place when the health care system is again tested with another public health emergency. Ensuring Adequate Supply, Distribution and Mix of Canada’s Health Human Resources Health is primarily a people business. Of all of the critical issues facing Canada’s health care system, none is more urgent than the shortages of health providers. Simply put, if people are not available to provide care and treatment to patients everything else is irrelevant. While we were encouraged with the $90 million provided in the 2003-04 to “improve national health human resources planning and co-ordination, including better forecasting of health human resources needs”, details of how these funds will be allocated and for what purposes remain unclear. The CMA has proposals on how this money could be used to support much needed health human resource planning that are ready to be pulled off the shelf and implemented. For example, the CMA believes that an arm’s length Health Institute for Human Resources (HIHuR) should be established to address the human side of health, just as existing institutes address the technological (CCOHTA) and information aspects of health (CIHI). Addressing the Health Status of Canada’s Aboriginal Peoples Particularly alarming is the health status of Canada’s Aboriginal peoples where, despite some improvements over the past few decades, Canada has been largely unable to adequately address the health issues facing this community. At CMA’s annual general meeting in August 2003, Health Minister Anne McLellan noted that despite significant investment Canada’s aboriginal people continue to have poor health outcomes. The CMA recommends that the federal government adopt a comprehensive review to look at how the money being spent on health, health care and related areas of investment for Aboriginal people can result in better health outcomes. The current results are not good enough. We must do better. Conclusion For those involved in the health care community, and indeed for all Canadians, this has truly been a remarkable year for Canada in terms of health and health policy. In many ways, the events of February marked a turn toward significant reinvestment in the health care system. However, with the outbreak of SARS in Ontario and the emergence of other significant public health concerns such as West Nile virus, health continued to be a top-of-mind concern for many Canadians. We also know that despite investments made in the 2003 federal budget, there continue to be areas for targeted, strategic initiatives that promise high payoff in terms of value for money. Public health, health human resources and the health status of Canada’s aboriginal people are the three areas that we have highlighted where additional attention and funding can make a real impact at the national level. When considering these investments, however, we must remember that we cannot afford to rob Peter to pay Paul. Both the public health and the acute care systems must simultaneously benefit from increased investment in order not to download one problem onto the other. To return to the analogy of an annual health check-up, let us conclude with this prognosis. Many actions taken in the past year should help over time address the acute symptoms of the patient. However, we must not be complacent. Long term health requires follow-through on last year’s initiatives, targeted new investments and ongoing vigilance. We look forward to the year ahead. INTRODUCTION When historians look back on 2003, they may very well call it the year of health. Since the Canadian Medical Association’s (CMA’s) presentation to the Standing Committee on Finance on October 22, 2002, several key events have highlighted health and health care issues in the minds of Canadians. Senator Michael Kirby and the Standing Committee on Social Affairs, Science and Technology kicked off the year by releasing its final report of the review of the federal health care system in October 2002. This report was followed closely by the release of the final report of the Commission on the Future of Health Care in Canada (the Romanow Commission) in November. In February 2003, Canada’s First Ministers agreed to their second Health Accord in just over two years. February also brought the federal government’s 2003 federal budget, which featured health as a key element. Emerging threats to the health of Canadians such as SARS and West Nile virus, coupled with ongoing concern that the health care system is not meeting patient needs in a timely way, clearly illustrate the prominence health care has played as an issue over the past year. Indeed, Canadians continue to show unwavering interest in health and the health care system. According to an EKOS Poll, Private Voices, Public Choices, health care was consistently identified as Canadians’ highest priority for the federal government as compared to other significant public policy issues (debt, level of taxation and unemployment) between August 1995 and January 2002.i Despite ongoing consensus on the need to make progress in the area of health, polling done for the CMA by Ipsos Reid found that the public remains unsatisfied with the federal government’s response to the health issue. In the CMA’s recently released Third Annual National Report Card on Health Care, 64% of respondents gave the federal government either a “C” or “F” rating in their performance in dealing with health care in Canada.ii Notwithstanding, the CMA acknowledges that the flurry of activity and the amount of public attention that health and health care has garnered over the past year can lead to policy fatigue. However, practitioners working in the health care system continue to see the concern of Canadians about being able to access health care services when and where they need them. Add to that their heightened sense of vulnerability in the face of new infectious diseases and ongoing reports about the poor state of our public heath care infrastructure, and anxiety regarding health and the health care system over the past year has become almost palpable. Health care is also a huge sector of our economy. At over $112 billion dollars,iii Canada’s health care system represents 9.7% of our Gross Domestic Productiv. At the federal level, major transfers to other levels of government (a large proportion of which goes to support health care in the provinces and territories) represents almost a quarter (22%) of total program spending by the federal government.v And so, while the physicians of Canada can understand the desire to “turn the page” on health care issues, the temptation must be resisted. It is appropriate and prudent that at least once a year, the federal government take the pulse of the health care system – an annual check-up if you like – to take stock of where we’ve been and identify priorities for the coming year. The CMA recognizes that great strides were made last year in terms of reinvestment in Canada’s health care system. As such, this submission to the Standing Committee on Finance will move largely away from macro funding issues to focus in on targeted, initiatives that are national in scope and promise high returns in terms of value for money. Specifically, we have identified three areas that require immediate new investment. 1. Protecting public health; 2. Ensuring adequate supply, distribution and mix of Canada’s health human resources; and 3. Addressing the health status of Canada’s Aboriginal peoples. Will any of these initiatives alone improve the overall health of Canadians and increase their access to health care? The answer is no. But by improving the public health infrastructure; ensuring better supply of health human resources; and addressing the particularly urgent health care needs of Canada’s Aboriginal peoples, the proposed initiatives represent significant steps that can be taken toward eliminating many of the access issues that are top of mind concerns for so many Canadians. However, before discussing these priorities for new investment, there are a couple of areas of unfinished business that need to be brought to the attention of members of the Standing Committee. Unfinished Business – delivering on the health accord promise Federal Reinvestments in Health Care Financing In February 2003, the federal government announced new funding of $24.9 billion over 5 years1 for the provinces and territories. This was a significant investment and we applaud the federal government for making health a priority, while noting that a gap persists between the reinvestments made and the CMA’s recommendations for new funding to shore up Canada’s core health care system. (Appendix A provides further details of this gap in funding). At the time of the First Ministers’ Health Accord in February 2003, the federal government agreed to provide up to an additional $2 billion into Canada’s health care system at the end of this fiscal year (2003/04) if a sufficient surplus above the normal Contingency Reserve were available.vi Over the past summer however reports in the media have suggested that this money may not be forthcoming, a concern that has impacted negatively on the federal/provincial/territorial (F/P/T) relationship and created a barrier for advancing the business of health care reform. It is exactly this unpredictability that fosters provincial/territorial distrust of the federal government’s role in health care. While the CMA firmly believes that the federal government has a critical role to play in supporting health care across the country, it must fulfil this role in a manner that reassures provinces and territories that promises made are promises kept. This must be the modus operandi of federal health investments. Let us state in the strongest words possible that the CMA and Canada’s physicians expect the Government of Canada to ensure its fiscal house is in order so that this commitment can be fulfilled. Canada’s health care system must not be treated as a residual after other contingencies are addressed. Canada Health Transfer The CMA was pleased to see the 2003 budget announce the creation of a separate Canada Health Transfer effective April 1, 2004. It is the CMA’s view that this measure is a significant step toward greater accountability and transparency of funds and we applaud the federal government for this bold initiative. However, in creating the Canada Health Transfer the government has neglected to build-in the key feature of how to ensure the ongoing sustainability of federal support for health care in the provinces and the territories. Without a built-in escalator, claims by the federal government that its investments have introduced sustainability into the system ring hollow. As it stands now, the Canada Health Transfer does not provide for increases in funding to grow in step with increases in health care expenditures or our ability to pay as a country. In the longer term this will result in a return to the imbalance between federal funding of provincial and territorial health expenditures. The CMA reiterates its recommendation made last year to the Standing Committee on Finance and to the Commission on the Future of Health Care in Canada, that a built-in escalator tied to increases in GDP is a fundamental component of the Canada Health Transfer. Canada Health Council One of the biggest piece of unfinished business arising from the February 2003 Health Accord is the continued lack of progress in the area of the Canada Health Council. Canadians are demanding greater accountability for their health care system. Canadians are also fed-up with inter-jurisdictional bickering on health care financing. A Council would provide a forum to allow for non-political assessment of health care issues divorced from the political wrangling that has defined health care in Canada for more than a decade. It would also enhance F/P/T accountability on how health care dollars in Canada are being spent in order to ensure that Canada’s health care dollars are being used wisely. In February, governments promised Canadians that the Health Council would be set up in May. Throughout the summer of 2003, federal government officials indicated that it would be just a matter of time. Most recently, at their Annual Conference on September 4, 2003, F/P/T Ministers of Health agreed to take another seven weeks to “expedite work on the Health Council”.vii Prior to that meeting, the CMA challenged Health Ministers to ratify an implementation plan for a Canada Health Council that would have a council in place no later than November 28, 2003, one year after the release of the final report of the Romanow Commission.viii Suggestions to water down the mandate of the Health Council to make it more palatable to some jurisdictions are not the answer. Canada needs a robust mechanism that will provide for enhanced evidence and accountability on how Canada’s health care dollars are spent. Canadians need an independent, empowered Council. Senator Kirby said it when he called for a National Health Care Council.ix Commissioner Romanow said it when he recommended a Health Council of Canada.x Canadians are demanding greater accountability. Enough is enough. Get on with it. Health Research Another area for continued reinvestment is health research. In our submission to the Romanow Commission, the CMA called for federal government support of health research equal to at least 1% of national health expenditures. For 2002 this would equal approximately $1.1 billion. Actual budgeted expenditure by the federal government for the Canadian Institutes of Health Research for 2002/03 was only $727.2 million.xi Canada must move beyond viewing health care expenditures as a drain on government budgets and start treating them the same as in any other sector – investments. Today’s research provides tomorrow’s treatments. For example, the benefits of increased investment in research extend far beyond the scientist’s lab. Rather, the return on investment is potentially many times the initial investment through increased trade potential, increased innovation and increased productivity. For this reason, the CMA supports, in principle, that idea proposed by Dr. Henry Friesen for the creation of a Health Innovation Council to encourage greater innovation and investment in Canada’s health care system. Key Recommendations Keep your word. Direct the Minister of Finance to honour his promise to put $2 billion back into Canada’s health care system in this fiscal year. Introduce a built-in escalator into the Canada Health Transfer to ensure the federal contribution to the health system keeps pace and remains sustainable. Enough is enough! Establish the Canada Health Council. Identify support for health research equal to at least 1% of national health expenditures. Protecting public health The public health system in Canada lies at the very heart of our community values. It is the quintessential “public good” and is central to the continued good health of our population. It includes the systematic response to infectious disease, but also much more. It ensures access to clean drinking water, good sanitation and the control of pests and other disease vectors. It provides immunization clinics, and programs promoting healthy lifestyles as well as being there to protect Canadians when they face a public health crisis like SARS. Our public health system is the first — and often only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. Most health threats know no boundaries, so our public health armaments must be in a constant state of “battle readiness.” It is the view of the CMA that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to emerging crises. At no time was this more apparent than following the tragic events of September 2001. As a result, the CMA dedicated our 2001 submission to the Standing Committee on Finance to issues related to emergency preparedness in terms of security, health and capacity. In light of SARS and other public health threats those recommendations continue to ring true today.xii It is our contention that had these actions been taken, Canada would have been better prepared to face the recent public health challenges. Unfortunately, the opposite road was taken. Rather than making reinvestments in public health, the federal government has scheduled declines in departmental spending in this area. In fact, according to Government of Canada estimates, by 2005/06 public health expenditures are planned to decrease in current dollars to their lowest level in over a decade (Chart 1). And while we were encouraged by recent investments made in the health care system, we question the lack of investment and forecast reductions in funding for public health. We cannot continue to rob Peter to pay Paul. Both the public health and acute care systems require ongoing investments and attention. On June 25, 2003, the CMA submitted a brief to the National Advisory Committee on SARS and Public Health headed by Dr. David Naylor. In it we identified the need to establish a clearer alignment of authority and accountability in times of extraordinary health emergencies. We also highlighted the need to enhance the system’s capacity to respond to public health threats across the country. To achieve this, we call on the federal government to make a minimum investment of $1.5 billion over five years to achieve legislative reform; capacity enhancement; and enhanced research, surveillance and communications capacities. (For additional detail, please refer to CMA’s submission to the National Advisory Committee on SARS and Public Health, June 2003.xiii A copy of our recommendations and associated costs are attached as Appendix B.) While significant, this level of funding represents only a small investment relative to the massive potential cost of, for example, another SARS crisis. $1.5 billion over five years should be treated as the minimum that could be allocated to these initiatives in order to operationalize each of the recommendations. Estimates do not include existing expenditures on public health that would be reallocated within the public health system. While all of our recommendations for the public health care system are important, there are two components that the CMA believes need immediate action by the federal government. The first refers to the particular urgency to improve communications between health professionals and address immediate shortages in supplies and equipment. Last year we came to the Standing Committee on Finance with a proposal for the REAL (rapid, effective, accessible and linked) Health Communication and Co-ordination Initiative. The purpose of this plan was to increase the capacity of the public health system to communicate in real time, between multiple agencies and with health care providers. (A copy of the REAL proposal is attached as Appendix C.) This followed the call in our 2001 submission for increased communications between public health officials, police, fire and ambulance services, hospitals and other services.xiv The effectiveness of the public health system depends, largely, on its capacity to disseminate authoritative information in a timely way. Information is key to be able to respond to patient needs effectively during times of emergency. Information in real time is also essential for effective day-to-day health care to provide, for example, information on adverse drug reactions. Had the CMA’s 2001 and 2002 recommendations been acted upon, perhaps we would have been better prepared to communicate with health care providers when SARS first appeared in Toronto. As it was, the CMA mobilized its own communication networks to provide physicians with the critical information that they needed to manage SARS. And while this worked to get the word out in a pinch – it also underlined the fact that Canada does not have information systems in place to facilitate real-time communication with health professionals. How many SARS-type events must we have? This must be a priority. With a one-time infusion of $100 million, and an additional $2 million a year, the REAL proposal would provide the technical capacity to communicate with front-line public health providers in real time during health emergencies. We cannot afford to let this recommendation languish another year. The second short-term priority for public health is to invest in emergency supply chain for use in times of crisis. SARS showed us that the Greater Toronto Area, an area with one of Canada’s most sophisticated public and acute care health systems, was not able to manage the SARS crisis and maintain its capacity to meet other acute care requirements or important public health services such as suicide prevention programs. Most hospitals work on a just-in-time inventory basis for the purchase of drugs. Without some sort of plan to quickly re-supply their pharmacies and expand their capacity, patient care suffers. Emergency bed space is also lacking. The federal government must assure Canadians that plans are in place when the health care system is again tested with another public health emergency. That is where the federal government can ensure the health system’s readiness and reassure Canadians that help will be there when they need it. (Additional information is provided in Appendix D.) Key Recommendation Immediately allocate $1.5 billion over 5 years to reinforce Canada’s public health care system in order to respond to public health threats and acute events, such as SARS starting with a Rapid Effective Accessible Linked (REAL) Health Communications and Co-ordination Initiative; and an emergency medical supplies and equipment supply chain. Health human resources Health is primarily a people business. Of all of the critical issues facing Canada’s health care system, none is more urgent than the shortages of health providers. Bluntly put, if the people are not available to provide care and treatment to patients everything else is irrelevant. The CMA has been encouraged by significant movement toward the implementation of the 1999 Canadian Medical Forum recommendations calling for an increase in undergraduate medical training positions and the subsequent 30% increase in the number of first-year, first-time medical students. Despite these efforts, there continues to be growing concern over the shortage of physicians. Statistics Canada figures suggest that the number of Canadians who do not have a family physician is greater than three million. Indeed, in order for Canada to meet the OECD average with respect to physician numbers, Canada must increase the number of physicians by an alarming 38%. Given that Canada continues to average a net loss of approximately 200 physicians per year due to emigration, action must come without delay to address this growing concern. Similarly, research published last year by CNA predicts that Canada will have a shortage of 78,000 registered nurses by 2011 and up to 113,000 by 2016.xv While we were encouraged with the $90 million provided in the 2003-04 to “improve national health human resources planning and co-ordination, including better forecasting of health human resources needs”xvi, details of how these funds will be allocated and for what purposes remain unclear. Indeed, it appears to be somewhat of a shell game with various federal departments vying for funding but no one department coming forward to provide leadership with clear proposals. The CMA has proposals on how this money could be used to support much needed health human resource planning that are ready to be pulled off the shelf and implemented. For example, the CMA believes that an arm’s length Health Institute for Human Resources (HIHuR) should be established to address the human side of health, just as existing institutes address the technological (CCOHTA) and information aspects of health (CIHI). It would be a virtual institute, in the same sense as the Canadian Institutes for Health Research (CIHR). The Institute should promote collaboration and the sharing of research among the well-known university-based centres of excellence (e.g., MCHP and CHSPR) as well as research communities within professional associations and governments. It would enable and focus on needs-based long-term planning. HIHuR would have the ability to embark upon large scale research studies such as needs-based planning that is beyond the purview or financial ability of any single jurisdiction. Standard methodologies could be established for data collection and analysis to estimate health human resource requirements based on the disease-specific health needs and demands of the population (e.g., Aboriginal peoples, the elderly, etc.). The institute would work in close collaboration with primary data providers such as Statistics Canada and CIHI. It would complement the work of the new Canada Health Council. Possible deliverables of the model could include such cross-disciplinary issues as measuring effective supply, functional specialization, regulatory restrictions, and assessing new and existing models of delivery. The institute could build on and maintain the initiatives of the various health sector studies. The institute would advise on medium and long-term research agendas that could be adopted and implemented by such funding bodies as CHSRF and CIHR. The CMA recommends that base funding be provided by the federal government (with other members also financially supporting the HIHuR) and that the annual budget for the institute be $2.5 million with an initial institute development grant from the federal government of $1 million. (Further details of the HIHuR funding proposal are attached in Appendix E). High tuition fees also have the potential to have a serious, negative impact on the supply, mix and distribution of health human resources. The CMA is very concerned that high tuition fees in undergraduate programs in medicine are creating barriers to access to a medical education and threatening the diversity of future physicians who later serve the needs of Canadians. High tuition fees have made a medical education unaffordable to many Canadians and may create an imbalance in admissions to medical school by favouring those who represent the affluent segment of society and not the variety of groups reflected in the Canadian population. High student debt loads, as a consequence of high tuition fees and insufficient financial support, can also influence students’ decisions about practice specialty and practice location. Ultimately, these factors could threaten the availability of services provided to Canadians, particularly in rural and remote communities. For these reasons, the CMA is an active participant on the National Professional Association Coalition on Tuition (NPACT) and supports its recommendations concerning professional tuition and access to post-secondary education. Key Recommendation Instruct federal departments to work together on key health human resource initiatives and fund a new Health Institute for Human Resources (HIHuR). Health status of Aboriginal peoples Throughout the 1980s, Canada either just maintained or lost ground in the international rankings on key health indicators with other leading industrialized countries. In 1990, Canada ranked fifth on the United Nations Human Development Index measuring average achievement on three basic dimensions of human development – a long and healthy life; knowledge; and a decent standard of living. In 1991, Canada moved to second place behind Japan and in 1992 Canada topped the list. In 2001, however, Canada dropped back to third place as a result of new figures for life expectancy and educational enrolment.xvii Since the 1980s, Canada has continued to improve in key indicators such as infant mortality and life expectancy. However, other industrialized countries have also made improvements either equalling and in many cases, quite dramatically surpassing gains made in Canada. As a result, Canada’s ranking has either stayed the same or dropped. For example, although Canada’s infant mortality rate dropped by 22% between 1990 and 1999, its rank dropped from 5th to 17th among the 31 industrialized countries included in the Organization for Economic Cooperation and Development (OECD). Similarly, Canada’s ranking for life expectancy at birth decreased over the same period from 3rd to 5th. (Additional information on how Canada compares to other countries in terms of health status indicators is attached as Appendix F.) Particularly alarming is the health status of Canada’s Aboriginal peoples where, despite some improvements over the past few decades, Canada has been largely unable to adequately address the health issues facing this community. The facts speak for themselves: * The incidence and prevalence of chronic and degenerative diseases (diabetes, cardiovascular disease, cancer and arthritis) is higher among Aboriginal Canadians than for the rest of the population (e.g., the rate of Type II diabetes among First Nations is three to five times that of Canadians in general and is considered a growing problem); * Certain infectious diseases are more prevalent among Aboriginal Canadians (e.g., the incidence of hepatitis and tuberculosis are five and ten times higher, respectively, than for other Canadians); and * Manifestations of mental health problems such as violence, suicide and sexual abuse are widespread (e.g., the rate of death from suicide is four times higher among the Inuit than Canadians in general.) These problems are compounded by the remoteness of many Aboriginal communities, which makes access to health services and infrastructure costly and difficult. Other issues include the distinct health needs of different Aboriginal communities (First Nations, Metis, Inuit and urban Natives) and jurisdictional problems such as the separation of health and social services and conflicting or overlapping F/P/T areas of responsibility. As well, it is broadly accepted that the health status of Canada’s Aboriginal peoples is a result of a broad range of factors and is unlikely to be improved significantly by merely increasing the quantity of health services. Instead, inequities within a wide range of social and economic factors must also be addressed, for example: income and education; environmental hazards, water quality, housing quality and infrastructure; and maintenance of cultural identity. At CMA’s annual general meeting in August 2003, Health Minister Anne McLellan noted that despite significant investment Canada’s aboriginal people continue to have poor health outcomes. Simply put, these results are unacceptable. The CMA recommends that the federal government adopt a comprehensive review to look at how the money being spent on health, health care and related areas of investment for Aboriginal people can result in better health outcomes. The current results are not good enough. We must do better. Key Recommendation The federal government should adopt a comprehensive review to look at how the money being spent on health, health care and related areas of investment can result in better health outcomes. CONCLUSION For those involved in the health care community, and indeed for all Canadians, this has truly been a remarkable year for Canada in terms of health and health policy. In many ways, the events of February marked a turn toward significant reinvestment in the health care system. However, with the outbreak of SARS in Ontario and the emergence of other significant public health concerns such as West Nile virus, health continued to be a top-of-mind concern for many Canadians. We also know that despite investments made in the 2003 federal budget, there continue to be areas for targeted, strategic initiatives that promise high payoff in terms of value for money. Public health, health human resources and the health status of Canada’s aboriginal people are the three areas that we have highlighted where additional attention and funding can make a real impact at the national level. When considering these investments, however, we must remember that we cannot afford to rob Peter to pay Paul. Both the public health and the acute care systems must simultaneously benefit from increased investment in order not to download one problem onto the other. Finally, promises made must be promises kept. The federal government must ensure that the fiscal environment is such so that it can fulfill its commitment to provide an additional $2 billion in this fiscal year. As well, the CMA intends to hold the federal government and the provinces and territories to their promise to implement a Canada Health Council. Governments must open the political black box of health decision making and let others in. To exclude physicians and other health stakeholders would seriously undermine the Health Council and deprive it of the benefits of first-hand insight into how care is actually delivered. Governments must take advantage of this opportunity to introduce a mechanism that will provide evidence to Canadians that they are getting a good return on their investment in health care. To return to the analogy of an annual health check-up, let us conclude with this prognosis. Many actions taken in the past year should help over time address the acute symptoms of the patient. However, we must not be complacent. Long term health requires follow through on last year’s initiatives, targeted new investments and ongoing vigilance. We look forward to the year ahead. Appendix A: Federal Reinvestments in Health Care Financing In the January 2003 document, From Debate to Actionxviii, the Canadian Medical Association challenged Canada’s First Ministers to put the health of Canadians first. With respect to health care financing, we underlined the need for a financial commitment to health care that is adequate, stable, predictable, transparent and sustainable. In February 2003, the federal government announced new funding to the provinces and territories of $24.9 billion over 5 years.2 The CMA and others suggested that these reinvestments were good but insufficient to address the challenges facing Canada’s health care system.xix Specifically, we had called for a minimum commitment by the federal government to “fund 50% of the core health care system with at least half of the federal government’s contribution in cash”.xx. (Core defined to include non-targeted and targeted investments in infrastructure such as health human resources, information technology, capital infrastructure, and rural and remote access.) Altogether, we called for a minimum cash investment of $31.5 billion over 5 years to renew the health care system. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Gap Between 2003 Health Accord and CMA Recommended Re-Investments in Canada’s Health Care System ($ billions) 2003?2004 2004?2005 2005?2006 2006?07 2007?2008 Total Core Funding 3.5 3.9 4.4 4.6 4.9 $21.3 Targeted Core 0.5 0.5 0.5 0.5 0.5 $2.5 Targeted New Programs 1.1 2.1 2.2 2.3 $7.7 Total 4.0 5.5 7.0 7.3 7.7 $31.5 Federal Reinvestments 4.8 3.3 4.9 5.2 6.7 $24.9 Remaining Gap in Funding (0.8) 2.2 2.1 2.1 1.0 $ 6.7 [TABLE END] There remains a significant gap of almost $ 7 billion over 5 years between our estimate of the minimum requirement needed for the renewal of the health care system and the new resources dedicated by the federal government. In light of this, the CMA calls upon the federal government to finish its unfinished business and allocate an additional $7 billion over 5 years in its next budget for the Canada Health Transfer to shore up Canada’s health care system. Appendix B: Recommendations to the National Advisory Committee on SARS and Public Health Legislative reform ($20 million / 5 years*) 1. The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. 2. The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government. 3. The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan. Capacity enhancement ( $1.2 billion / 5 years*) 4. The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals. 5. The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies. 6. Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the proposed Canadian Office for Disease Surveillance and Control. 7. Federal government funding in the amount of $1 Billion over 5 years to build adequate and consistent surge capacity across Canada and improve co-ordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions. Research, surveillance and communications ($310 million / 5 years*) 8. An immediate, sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. 9. The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and intervention. 10. The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Co-ordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies. Appendix B: Estimated Cost of Implementing the Recommendations [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] RECOMMENDATION ESTIMATED COST OVER 5 YEARS Legislative and Institutional Reform 1. Canada Emergency Health Measures Act N/A 2. Canadian Office for Disease Surveillance and Control (CODSC) ? $20 million 3. Chief Public Health Officer of Canada Capacity Enhancement 4. Canadian Centre of Excellence for Public Health $100 million 5. Canadian Public Health Emergency Response Service $35 million 6. Canadian Institute for Health Information and Statistics Canada $35 milliona 7. Surge capacity $1 billionb Research, surveillance and communications 8. Canadian Institutes of Health Research $200 millionc 9. Mandatory reporting Included under 2 and 3 above 10. Enhanced communications $110 million TOTAL $1.5 billion [TABLE END] a. Work is currently underway to break out public health from the current category of “public health and administration.” b. This is an incremental investment in addition to funding currently available under Health Canada’s Health Promotion and Prevention Strategic Outcome area. c. Funding must be sequestered specifically for new initiatives related to public health. Additional money could also be acquired through funding from the Canadian Foundation for Innovation, which received an additional $500 million in 2002–2003 (announced in the 2003 federal budget) to enhance the Foundation’s support of public health infrastructure. Appendix C: REAL (Rapid, Effective, Accessible , Linked) Health Communication and Co-ordination Initiative The effectiveness of the public health system is dependent, in large part, on its capacity to communicate authoritative information in a timely way. A two-way flow of information between experts and the practising community is necessary at all times. It becomes essential during emergency situations. Information, including health advice and alerts, needs to move out to front line health care providers from public health bodies. Information, such as data for surveillance and analysis purposes, needs to move in from these front line providers to the public health authorities. To detect new emerging diseases or health threats and effectively care for their patients, front-line health professionals must have accurate and timely information. Conversely public health specialists depend on information coming in from the front lines to track disease and institute appropriate public health interventions. Despite the tremendous developments in information management, there has been scant attention paid to this issue within public health. The SARS outbreak highlighted various weaknesses in our current communication capacity. Gaps in the basic IT infrastructure prevented public health agencies and acute care institutions from communicating with each other in real-time. There are a number of anecdotal reports of public health units stationing personnel inside hospitals to retrieve information and then telephone it into their units. Case investigators used paper-based files to manage the hundreds of cases reported to public health units, and to investigate and follow up of thousands of contacts. Identification of clusters and links between cases literally depended upon pencil and paper and brainpower. Toronto Public Health did create a database for its SARS cases and could send it electronically to the province. However the province had a different database which raised concerns about the transfer of data files from one system to another. The deficiency in IT capacity hindered exchanges between public health staff, private clinicians and other sources of information. The potential for a disconnect in communications between different jurisdictions (international, national, provincial/territorial, municipal) and sectors (environment, health, transportation) that are affected by a health emergency is a further challenge to the public health system. The importance of communicating essential health advice and public health management protocols to front line practitioners and institutions cannot be overstated. During the SARS experience it became evident that government did not have information systems in place to communicate rapidly with physicians across the country. In response to requests from Health Canada the CMA was able to mobilize its communication networks to get information to physicians in real-time. It is interesting to note that in local areas the problem often was not one of not enough information, but of too much information, which was often confusing, conflicting or impractical for a practice setting. Consistent messaging disseminated in a coordinated fashion is essential for a consistent and coordinated response to a health crisis. The CMA believes that the federal government must take a leadership role to ensure that the communication tools and information technology necessary for a modern efficient public health system, with the capacity to mount a rapid and informed response to public health emergencies, are in place in all regions of the country. The CMA brought this to the attention of the House of Commons Standing Committee on Finance in October 2001, and again in October 2002 with our recommendation for a REAL (rapid, effective, accessible, linked) Health Communication and Co-ordination Initiative. We called for a one-time infusion of $100 million, and an additional $2 million a year, to improve technical capacity to communicate with front-line public health providers in real-time during health emergencies. This initiative would facilitate seamless communication between local, provincial and federal levels of the public health system and rapid, real-time communication between the public health sector and other components of the health care system. It must also ensure a two-way flow of information between front-line health care providers and public health professionals at the local public health unit, the provincial public health department and the proposed Canadian Office for Disease Surveillance and Control. The REAL Health Communication and Co-ordination Initiative would improve the ability of the public health system to communicate in a rapid fashion by: * Providing a focal point for inter-jurisdictional communication and co-ordination in order to improve preparedness in times of emergency; * Developing a seamless communication system leveraging formal and informal networks and * Researching the best way to disseminate emergency information and health alerts to targeted health professionals and public health officials in a rapid, effective and accessible fashion. As well as funding research and demonstration projects, funding should also be allocated to provinces/territories and municipalities to build their connectivity infrastructure. The initiative should build on communication systems currently in place, filling gaps and enhancing capacity. Communicating with Health Professionals. One of the key lessons the CMA has drawn from the experience of SARS is that physicians take up information in different ways. Some want it by e-mail, others by fax and still others by mail. Even those with e-mail have expressed a desire to get emergency information in a different format. Other health care associations have also employed various ways to communicate with their membership. During the SARS crisis, the existing communication networks between health professionals were an important, if informal, avenue to disseminate and in some cases explain public health interventions and information. In fact ten national health care associations3 met via teleconference and in person during the crisis to share information and ensure a consistency of message to health professionals. This sector can play a critical role in bridging the gap between clinicians and the public, as well as in the delivery of credible public education and training to both professionals and the public. The importance of communicating timely and relevant information directly to those in leadership positions (Chief of Staff, Hospital CEO) should not be overlooked. These individuals can make the information relevant for their particular setting, and ensure that it is widely disseminated within their community. The uptake of new information is influenced by many qualitative factors and research is needed to determine how best to communicate with individual physicians and other health care providers in emergency situations. Any new communication processes should be based on sound research and build on existing communication networks. The REAL Health Communication and Co-ordination Initiative would be led by the Canadian Office for Disease Surveillance and Control and would undertake work in three phases. 1. Research Phase For example: * Evaluation of communications during the SARS crisis * Quantitative research on how health professionals want to receive information * Catalogue of existing communication networks 2. Pilot projects in areas such as risk communications and information management in public health. 3. Evaluation and dissemination of best practices in communications and information management. Appendix D: Emergency Medical Supplies and Equipment Supply Chain In the aftermath of the September 11, 2001 terrorist attacks in the United States, the CMA, in its October 2001 pre-budget submission to the Standing Committee on Finance, stressed the fact that in the event of a significant attack on our population among the first points of contact with the health system will be doctors’ offices and the emergency rooms of our hospitals. The SARS outbreak has proven that this point is just as valid when faced with a public health emergency. SARS showed us that the Greater Toronto Area, an area with one of Canada’s most sophisticated public and acute care health systems, was not able to manage the SARS crisis and maintain its capacity to meet other acute care requirements or important public heath services such as suicide prevention programs. Most hospitals work on a just-in-time inventory basis for the purchase of drugs. Without some sort of plan to quickly re-supply their pharmacies and expand their capacity, patient care suffers. Emergency bed space is also lacking. The federal government must assure Canadians that plans are in place when the health care system is again tested with another public health emergency. That is where the federal government can ensure the health system’s readiness and reassure Canadians that help will be there when they need it. We have also witnessed in recent years the enormous strain these facilities can be placed under when even something quite routine like influenza strikes a community hard. The acute care occupancy rates of Ontario public hospitals across the Ontario Hospital Association regions in 1999-00 illustrate this point. In three of the five regions (Eastern Ontario, Central and South West) the occupancy rate ranged from 94% to 97%.xxi The highest rate was found in the very heavily populated Central region. A British Medical Journal study suggests that an occupancy rate over 90% indicates that the hospital system is in a regular bed crisis.xxii This problem is not unique to Ontario: “the decrease in the number of acute care beds across Canada over the past decade, coupled with an aging population and our extraordinary success in extending the survival of patients with significant chronic illness, has eliminated any cushion in bed occupancy in the hospital system.”xxiii With this in mind, picture the impact of another public health crisis such as an influenza pandemic when hundreds of thousands of individuals could be affected. The public health system and medical diagnostic and treatment systems in the community and hospitals would become overwhelmed very quickly without the ability to absorb the extra caseload. We need no further demonstration of the need to enable hospitals to open beds, purchase more supplies, and bring in the health care professionals it requires to meet the need. Currently the National Emergency Stockpile System can supply up to 40,000 cots, as well as medical supplies and relatively rudimentary hospital equipment. Reports indicate, however, that much of the equipment is decades old, and that protocols for logistical management (e.g., transport and rapid deployment) are outdated. There is an urgent need to reassess and reaffirm capacity in this context. The SARS experience also brought to our attention the critical lack of equipment. The Canadian Association of Emergency Physicians (CAEP) has noted that many emergency departments across the country are not adequately equipped for 21st century infection control challenges. They do not have negative pressure rooms with contained toilets, often have only one resuscitation suite for critically ill patients and do not have a safe place to segregate accompanying persons. Nor do they have protective hoods like the PARR device that is needed to safely intubate SARS patients. CAEP concluded that most emergency departments are not physically designed to cope with infection control problems. The federal government must assure Canadians that municipal and provincial plans are in place with an overarching national plan to support these jurisdictions if their service capacities are overwhelmed. But the government should help further by making available an emergency fund that would enable hospitals to plan and organize their surge capacity. The purpose of having such elaborate response plans and stockpiles of supplies and equipment is to be ready for the possibility that, in spite of all efforts to prevent a catastrophe from occurring, it nevertheless happens. That is where the federal government can facilitate the health system’s readiness and reassure Canadians that help will be there when they need it. Appendix E: Health Institute for Human Resources (HIHuR) While the need for more health human resources is apparent, resource planning is difficult and fraught with complexity. Answers must balance affordability, reflect population health needs and consider issues pertaining to the supply, mix and distribution of physicians. Over the last decade, a number of stakeholders including government, associations, and researchers have invested significant resources in health human resource planning.xxiv However, these groups do not systematically communicate with each other and do not always buy into each other’s products. The result is silo-based planning, lack of progress on key areas of database development, and an overall failure to address important issues such as professional burnout. 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. At the same time, 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 that take into account the mobility of health care providers nationally and internationally. Identification of the need for more coordinated research in the area of health human resources has come from many sources. In the Listening for Directions report of 2001xxv, the partner organizations indicated health human resources as the number one priority theme for research funding over the next two to five years. A joint report in 1995 by national organizations representing occupational therapists, physiotherapists, dieticians and nurses established an integrated health human resources development framework with three main components of planning, education and training, and management.xxvi Similarly, the Canadian Policy Research Networks Inc. (CPRN) commissioned by Mr. Romanow to investigate and summarize health human resource issues, recommended the creation of a national health human resources coordinating agency to provide focus and expertise for health human resource planning. Senator Kirby also identified the need for such a planning body in his final report. He recommended that the federal government work with other concerned parties to create a permanent National Coordinating Committee for Health Human Resources, to be composed of representatives of key stakeholder groups and of the different levels of government.xxvii Finally, the final report of the Commission of the Future of Health Care in Canada called for a substantial improvement in the base of information on Canada’s health workforce and the need to establish a comprehensive plan for addressing supply, distribution, and education issues.xxviii The CMA believes that an arm’s length Health Institute for Human Resources (HIHuR) should be established to address the human side of health, just as existing institutes address the technology (CCOHTA) and information aspects of health (CIHI). It would be a virtual institute, in the same sense as the Canadian Institute for Health Research. The Institute should promote collaboration and the sharing of research among the well-known university based centres of excellence (e.g., MCHP and CHSPR) as well as research communities within professional associations and governments. It would enable/focus on needs-based long term planning. HIHuR should have the ability to embark upon large scale research studies such as needs-based planning that is beyond the purview or financial ability of any single jurisdiction. Standard methodologies could be established for data collection and analysis to estimate health human resource requirements based on the disease-specific health needs and/or demands of the population (e.g., Aboriginal peoples, the elderly, etc.). The institute would work in close collaboration with primary data providers such as Statistics Canada and CIHI. It would complement the work of the new Canada Health Council. Possible deliverables of the model could include such cross-disciplinary issues as measuring effective supply, functional specialization, regulatory restrictions, and assessing new and existing models of delivery. The institute could build on, and maintain, the initiatives of the various health sector studies. The institute would advise on medium and long-term research agendas that could be adopted and implemented by such funding bodies as CHSRF and CIHR. It is recommended that base funding be provided by the federal government (with other members also financially supporting the HIHuR). It is proposed that the annual budget for the institute would be $2.5 million with an initial institute development grant from the federal government of $1 million. Appendix F : Straight facts about health…Is Canada getting left behind? Straight facts about health... Is Canada getting left behind? Through the 1980s, Canada has either remained the same or lost ground in the international rankings on key health indicators with other leading industrialized countries surpassing our progress. This worrisome turn of events, the Canadian Medical Association believes, needs attention. United Nations Human Development Index In 1990, the United Nations Development Programme (UNDP) began publishing an annual Human Development Report (www.undp.org/hdr). The Human Development Index (HDI) is one of the key indicators in this report. It is a composite index that measures average achievement in three basic dimensions of human development: a long and healthy life; knowledge and a decent standard of living. How has Canada fared? In 1990, Canada ranked fifth. Canada moved to 2nd place behind Japan in 1991 and into 1st place in 1992. It again dropped behind first-place Japan in 1993. Canada then led the world on the HDI between 1994 and 2000. In 2001, Canada dropped back to 3rd place. As the UNDP reported in 2001, “Norway is now ranked first in the world and Australia second. Both moved narrowly ahead of Canada, the leader for the previous six years, as a result of new figures for life expectancy and educational enrolment. Canada fell in the rankings even though its per capita income rose by 3.75 percent.” Canada remained in 3rd place in 2002. World Health Organization health system performance indicators The World Health Organization (WHO) (www.who.int/whr) ranked the health system performance of 191 member countries for the first time in its 2000 World Health Report. The ranks are based on the measurement of population health in relation to what might be expected given the level of input to the production of health. WHO presented two rankings. The first, performance on health level, considers health status in disability-adjusted life expectancy relative to a country’s resource use and human capital. Canada ranked 35th among 191 countries with respect to this indicator in 2000. The second indicator is a measurement of overall performance. This assesses health system attainment relative to what might be expected for five goals of the health system, including health status, health inequality, level and distribution of responsiveness and fairness in financing. In 2000, Canada ranked 30th on the index of overall performance. France led the world on this indicator in 2000. International health indicators Since the 1980s, Canada has continued to record improvements on key health indicators such as infant mortality and life expectancy. However, other industrialized countries have also recorded improvements that have either equaled or, in some cases, quite dramatically surpassed the gains made in Canada. As a result, Canada’s ranking has either stayed the same or dropped. Infant Mortality — Although Canada’s infant mortality rate dropped by 22% between 1990 and 1999, its rank dropped from 5th to 17th among the 31 industrialized coun-tries included in the Organization for Economic Cooperation and Development (OECD). Other countries have recorded even greater gains; for example, Sweden and Austria both recorded a drop of 43% in infant mortality over the same time period. Among others, Spain, Italy and the Czech Republic now rank ahead of Canada. However, the United Kingdom, United States and Australia rank behind Canada. Perinatal Mortality — Between 1990 and 1999, Canada’s perinatal mortality rate declined by 18% while its international ranking remained essentially the same — moving from 10th in 1990 to 11th in 1999. In comparison, the perinatal mortality rate for 1st-ranked Japan dropped by 31% during the same period. Life Expectancy — In 1999, Canada ranked 5th in life expectancy at birth, down from 3rd in 1990. During the 1990–1999 period, total life expectancy increased by 1.8% in Canada, compared to 2.0% in 1st-ranked Japan. Healthy Life Expectancy (HALE) — Healthy life expectancy is based on life expectancy but includes an adjustment for time spent in poor health. In its 2002 World Health Report, WHO presented HALE esti-mates for 191 countries during 2001. Among these countries, Canada ranked 20th in 2001, tying with the Netherlands at 69.9 years at birth. Japan and Switzerland headed the list at 73.6 and 72.8 years respectively in 2001. Health human resources per capita Canada continues to lag behind other industrialized countries with respect to physicians per 1000 population. The OECD average of 2.8 per 1000 population is one-third higher than Canada’s rate of 2.1 (including post-graduate residents), placing us 23rd out of 27th for this indicator. In a comparison of G-8 countries (excluding Russia) between 1990 and 1999, Canada was the only country that did not show any improvement in the physician-to-population ratio. The situation for nurses is equally distressing. Canada placed only 12th in 1999 and experienced a 7% drop in the ratio between 1990 and 1999 from 8.1 per 1000 population to 7.5. This puts Canada in the middle of the G-8 group. Public sector as percent of total health spending Among the industrialized (OECD) countries, Canada has consistently reported one of the lower public shares of total health spending since the 1980s. In 1985, Canada’s public spending on health represented 75.6% of total health spending — placing Canada at 14th among the 22 countries reporting. In 2000, with public spending rep-resenting 72% of total health spending, Canada ranked 16th among 26 countries reporting. Canada’s 2000 level of public spending was down almost four percentage points from 1985. Note: The UNDP contains 173 countries, WHO contains 191 countries and the OECD contains 31 countries. Life expectancy figures represent years at birth. Infant mortality represents the number of deaths of babies less than one year of age that occurred during a year per 1000 live births during the same year expressed as a rate. Perinatal mortality represents the number of deaths under 7 days (early neonatal deaths) plus fetal deaths of 28 weeks of gesta-tion or more per 1000 total live births (live and stillbirths). Health indicators data are from OECD Health Data, 2002, 4th ed. www.oecd.org/healthdata. WHO performance indicators for 2002 are based as estimates for 1997. ENDNOTES 1 $24.9 billion includes all new federal transfers to the provinces and territories (targeted and non-targeted) announced at the time of the First Ministers’ meeting on February 4/5, 2003 and confirmed in the February 18, 2003 Federal Budget. It includes the $2 billion in funding to be made available at the end of fiscal year 2002/03. It does not include previously announced CHST funding, nor investments in federal health programs. 2 $24.9 billion includes all new federal transfers to the provinces and territories (targeted and non-targeted) announced at the time of the First Ministers’ meeting on February 4/5, 2003 and confirmed in the February 18, 2003 Federal Budget. It includes the $2 billion in funding to be made available at the end of fiscal year 2002/03. It does not include previously announced CHST funding, nor investments in federal health programs. 3 Canadian Association of Emergency Physicians, Canadian Council on Health Services Accreditation, Canadian Dental Association, Canadian Healthcare Association, Canadian Medical Association, Canadian Infectious Disease Society, Canadian Nurses Association, Canadian Pharmacists Association, Canadian Public Health Association, Association of Canadian Academic Healthcare Organizations i Ekos Research Associates. Presentation to the Charles E. Frosst Foundation for Health Care. Private Voices, Public Choices. November 7, 2002. ii Canadian Medical Association. Third Annual National Report Card on Health Care. August, 2003. (Conducted by Ipsos Reid). p. 17. iii Canadian Institute of Health Information. National Health Exenditure Trends, 1975-2002. December 2002. iv Organization for Economic Cooperation and Development (OECD), Health Data 2003. v Government of Canada. The Budget Plan, 2003. February 18, 2003. p. 211. vi Government of Canada. The Budget Plan, 2003. February 18, 2003. p. 69. vii News Release, Annual Conference of Federal-Provincial-Territorial Ministers of Health, Halifax, Nova Scotia, September 4, 2003. viii Canadian Medical Association. Press Release, “CMA Calls for Council by November 28 – Further Delay Unacceptable”. September 3, 2003. ix Standing Senate Committee on Social Affairs, Science and Technology. Final Report on the State of the Health Care System in Canada: The Health of Canadians – The Federal Role Volume Six: Recommendations for Reform. October 2002. p. 17 - 20. x Commission on the Future of Health Care in Canada. Building on Values: The Future of Health Care in Canada – Final Report. November 2002. p. 52. xi Canadian Institutes of Health Research. Report on Plans and Priorities for the Fiscal Year, 2003-2004. p. 29. xii For more information, please refer to CMA’s 2001 report to the Standing Committee on Finance, Security Our Future … Balancing Urgent Health Care Needs of Today with the Important Challenges of Tomorrow. November 1, 2001. xiii Canadian Medical Association. Submission to the National Advisory Committee on SARS and Public Health. Answering the Wake-up Call: CMA’s Public Health Action Plan. June 2003. xiv Canadian Medical Association. Presentation to the Standing Committee on Finance Pre-Budget Consultations. Securing our Future … Balancing Urgent Health Care Needs of Today With the Important Challenges of Tomorrow. November 1, 2001. xv Canadian Nurses Association. Canada’s Nurses See Latest Data as a Warning: Action Needed to Address Nursing Shortage. Press Release, September 17, 2003. xvi Government of Canada. The Budget Plan, 2003. February 18, 2003. p. 78. xvii United Nations Human Development Project. Human Development Report 2001. Press Release, July 10, 2001, Mexico City (www.undp.org/hdro). xviii Canadian Medical Association. From debate to action. Message to First Ministers … It’s time to put the health of Canadians first. January 2003. xix Other organizations that reiterated the need for additional investment in health care included the Canadian Healthcare Association (Press Release, February 18, 2003 (www.cha.ca) and the Association of Canadian Academic Healthcare Organizations (Press Release, February 19, 2003 (www.ACAHO.org). xx Canadian Medical Association. From debate to action. Message to First Ministers … It’s time to put the health of Canadians first. January 2003. p. 8. xxi Ontario Hospital Reporting System, 2001. Acute Care Occupancy Rates, Ontario Public Hospitals by OHA region, 1999/00. Ontario Ministry of Health and Long Term Care. xxii Bagust A, Place M, Posnett J. Dynamics of bed use in accommodating emergency admissions: stochastic simulation model. BMJ; 319: 155-158 July 17, 1999. xxiii Nicolle L. Viruses without borders. Can J Infect Dis Vol. 11, Issue 3, May/June 2000 (Downloaded from Web: October 23, 2001: www.pulsus.com/Infdis/11_03/nico_ed.htm) xxiv At the national level there are a number of bodies that, in some cases, have been involved in health human resource planning issues for literally decades. The long standing Advisory Committee on Health Human Resources reported to the Conference of Deputy Ministers on health human resource issues but it functioned without outside expertise from the provider community and found it difficult to implement an integrated approach to planning. The National Coordinating Committee on Postgraduate Medical Training did include membership from both the medical profession and the government but its mandate was narrow (postgraduate training of physicians) and the committee was de facto sunsetted a couple of years ago. xxv Canadian Health Services Research Foundation. Listening for Direction: A National Consultation on Health Services and Policy Issues. June 2001. xxvi Canadian Association of Occupational Therapists, Canadian Dietetic Association, Canadian Nurses Association, Canadian Physiotherapy Association, Integrated Health Human Resources Development – Pragmatism or Pie in the Sky, August 1995. xxvii Standing Senate Committee on Social Affairs, Science and Technology, The Health of Canadians – The Federal Role, Final Report, October 2002. xxviii Commission on the Future of Health Care in Canada. Building on Values: The Future of Health Care in Canada – Final Report. November 2002. p. 108.
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CMA Submission on infrastructure and governance of the public health system in Canada: Presentation to the Senate Standing Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy1954
Last Reviewed
2011-03-05
Date
2003-10-08
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2011-03-05
Date
2003-10-08
Topics
Health systems, system funding and performance
Text
The Canadian Medical Association (CMA) has prepared this submission for the Standing Senate Committee on Social Affairs, Science and Technology study on the governance and infrastructure of the public health system in Canada and its response during public health emergencies. We applaud this initiative and welcome the opportunity to present the views of Canada’s medical community. Introduction Canada has a distinguished history as one of the best countries in the world in which to live, ranking number one on the UN’s Human Development Report from 1994 to 2000. Our health care system was a major contributor to the country’s top position but in the past few years Canada has lost ground in international rankings on key health indicators. For example, although Canada’s infant mortality rate dropped by 22% between 1990 and 1999, other countries recorded greater declines in infant mortality over the same time period. As a result, Canada’s rank dropped from 5th to 17th among the 31 industrialized countries included in the Organization for Economic Cooperation and Development (OECD). In 1999, Canada ranked 5th in life expectancy at birth, down from 3rd in 1990. During the 1990-1999 period, total life expectancy increased by 1.8% in Canada but other countries made larger gains. The CMA believes that this worrisome turn of events needs attention. Delegates to its 2003 General Assembly called on the federal government to commit to the goal of establishing Canada as the top country worldwide, regarding the health status of its citizens, within ten years. To achieve this Canada will need a national strategy that defines national health goals and can seriously address the health inequalities that continue to exist in Canada. Improvement to health status in Canada will not be possible without a strong, effective and well-resourced public health system. Unfortunately we do not have that today. For years the CMA has been warning that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to new and emerging health threats. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. For example, the CMA’s submission to the House of Commons Standing Committee on Finance’s pre-budget consultations on October 22, 2001 called for substantial investments in public health and emergency response as a first step to improve the public health system infrastructure and surge capacity. It also drew attention to the need for improved co-ordination and communication between jurisdictions. In February 2003, before the World Health Organization (WHO) issued a global alert about Severe Acute Respiratory Syndrome (SARS), the CMA again raised concerns about the capacity of Canada’s health system to handle emerging infectious diseases without being overwhelmed. This warning came in the CMA’s submission to the House of Commons Standing Committee on Health hearings on West Nile Virus. Most recently, in our submission to the National Advisory Committee on SARS & Public Health, Answering the Wake-Up Call: CMA’s Public Health Action Plan, the CMA called for a clearer alignment of authority and accountability in times of extraordinary health emergencies. The submission also recommended enhancement of the system’s capacity to respond to public health threats across the country. The Public Health Action Plan and accompanying technical backgrounders have previously been circulated to the Committee and are attached as Appendix 1. In this submission we will expand on the recommendations contained in Answering the Wake-Up Call: CMA’s Public Health Action Plan to focus on the federal government’s role in public health. Particular emphasis will be placed on legislative reform, human resource capacity enhancement, and surveillance and communications. Public Health in Canada Public health is the science and art of protecting and promoting health, and preventing disease and injury. It complements the health care system, which focuses primarily on treatment and rehabilitation, sharing the same goal of maximizing the health of Canadians. However, the public health system is distinct from other parts of the health system in two key respects: its primary emphasis is on preventing disease and disability and its focus is on the health needs of populations rather than those of specific individuals. It is interesting to note that Canada’s current public health legislation was enacted more than a half century before our health care legislation. Public health is about ensuring access to clean drinking water, good sanitation and the control of pests and other disease vectors. Further, it is immunization clinics and programs promoting healthy lifestyles and healthy environments. It is also the systematic response to infectious diseases, there to protect Canadians when they face a public health threat like SARS. When the public health system is fully prepared to carry out essential services, communities across the country are better protected from acute health events. Unfortunately it is only when something goes terribly wrong, as in the Walkerton tragedy when 7 people died and 1,346 were affected by E. coli contamination of a community well, that the important role and contribution of public health is highlighted. Today’s reality is that Canada does not have a strong, integrated, consistently and equitably resourced public health system. In 2001, a working group of the Federal, Provincial and Territorial Advisory Committee on Population Health assessed the capacity of the public health system through a series of key informant interviews and literature reviews. The consistent finding was that public health had experienced a loss of resources. There was also concern for the resiliency of the system’s infrastructure and its ability to respond consistently and proactively to the demands placed on it. Significant disparities were observed between “have” and “have-not” provinces and regions in their capacity to address public health issues. The report’s findings are consistent with previous assessments by the Krever Commission and the Auditor General of Canada. In 1999, the Auditor General said that Health Canada was unprepared to fulfil its responsibilities in public health: communication between multiple agencies was poor; and weaknesses in the key surveillance system impeded effective monitoring of injuries and communicable and non-communicable diseases. In 1997, Justice Horace Krever reported that the “public health departments in many parts of Canada do not have sufficient resources to carry out their duties.” Public health systems across Canada are fragmented. It is less a system and more a patchwork quilt of programs, services and resources across the county. In truth, it is a group of multiple systems with varying roles, strengths and linkages. Each province has its own public health legislation. Most legislation focuses on the control of communicable diseases. Public health services are funded through a variable mix of provincial and municipal funding formulae, with inconsistent overall strategies and results, and with virtually no meaningful input from health professionals via organizations such as the CMA, or its divisions and affiliates, in terms of strategic direction or resources. Federal legislation is limited to the blunt instrument of the Quarantine Act and a variety of health protection-related acts like the Food and Drugs Act, Hazardous Products Act, Controlled Drugs and Substances Act, Radiation Emitting Devices Act. Some of the laws, such as the Quarantine Act, date back to the late 19th century. Taken as a whole, the legislation does not clearly identify the public health mandate, or the respective roles and responsibilities of the different levels of government. In many cases, the assignment of authorities and accountabilities is anachronistic. The existing Emergencies Act gives the federal government the power to become involved in public welfare emergencies when regions of the country are faced with “an emergency that is caused by a real or imminent….disease in human beings .. that results or may result in a danger to life or property … so serious as to be a national emergency.”1 However, in order to use this power, the federal government must declare a “public welfare emergency” which itself has political and economic implications, particularly from an international perspective, that mitigate against its use. CMA believes that this all-or-nothing approach is not in the public’s best interest and that the concept of national emergency in the context of public health requires a different and differentiated response from governments in the future. In its submission to the National Advisory Committee on SARS and Public Health the CMA called for the enhancement of the federal government’s “command and control” powers in times of national health emergencies through the enactment of a Canada Emergency Health Measures Act. The Act would give the federal government specific authority to act for a pre-determined, temporary period of time, during a declared extraordinary health emergency. It would also provide the authority for development of a graduated health alert system with corresponding public health interventions to enable a rapid co-ordinated response as a public health threat emerges. The declaration of a health alert would imply that financial, scientific and human resources from the federal government would be available as required to address the crisis. An incremental level of federal assistance should be associated with each of the five levels of health alert to help meet the basic costs of response and recovery when such expenditures exceed what an individual province or territory could reasonably be expected to bear on its own. For example at level three a 50/50 cost sharing arrangement could be envisioned with this increasing to 90/10 at level 5. At health alert levels 1 and 2 the financial contribution should be considered to be within the operational funds of the proposed Canadian Office for Disease Surveillance and Control. Financial assistance that may be required during health alert levels 3 to 5 should be submitted to and approved by the Governor in Council during the authorization for declaration of the health alert. The level of health alert and affected area would be reviewed regularly and modified as needed. The graduated system of health alerts proposed by CMA will ensure a more appropriate and effective response to public health emergencies than currently exists.2 The CMA has also brought the issue of emergency response forward on the international stage through its membership in the World Medical Association (WMA). At the WMA General Assembly in September 2003, delegates from over 50 countries supported a motion put forward by the CMA urging the WHO to enhance its emergency response protocol to deal with world epidemics such as SARS. (See Appendix ll.) The WMA agreed to establish a working group, headed by the CMA, to develop a public health risk alert plan. The report of the National Advisory Committee on SARS and Public Health has now been submitted to the federal health minister. The federal government must not let this report languish on the shelf. It must develop a plan to respond to its recommendations in order to create a strong and well-resourced public health system with adequate surge capacity and sufficient highly qualified public health professionals. The CMA has determined that a very targeted incremental investment of $1.5 billion over five years is needed to address the legislative reform and capacity enhancement required to bring our public health system into the 21st century. Simply re-allocating funds within existing health budgets is not sufficient and would only negatively impact efforts to shore the core of current health care services. Recommendation One The federal government rapidly move to enact a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation. This new Act would allow for a more rapid national response, in co-operation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. Recommendation Two The federal government invest in the country’s public health system with an immediate commitment of $ 1.5 Billion over five years to rebuild the public health infrastructure. An Action Plan for the Federal Government National leadership is critical to articulate the key issues and challenges facing public health today and to implement comprehensive strategies to address the deficiencies in the system’s infrastructure. The CMA has called for a renewed and enhanced national commitment to public health anchored in new federal legislation. Legislative Reform Canada’s response to SARS brought into stark relief the urgent need for national leadership and coordination of public health activity across the country, especially during such a serious health crisis. It was a wake-up call that highlighted the need for comprehensive legislative reform to clarify the roles of governments and public health officials with respect to the management of public health threats. The development of a national public health system ought not to occur by the instalment plan, provoked by SARS-like events. It must be carefully planned and evaluated. This, in turn, requires clear identification of key issues and mobilization of resources. A sustainable public health system also requires a critical mass of technical expertise to support essential public health functions3. The CMA believes that the federal government has a critical role to play in the development of a strong, co-ordinated pan-Canadian public health system. In both the United Kingdom and the United States, national leadership has been instrumental in clearly defining health goals for the population and stating the role of the public health system, its key infrastructure elements and the development of strategies to attain them. Canada does not have a formal national leadership position comparable to England’s Chief Medical Officer or the Surgeon General in the US. There is currently no single credible public health authority vested, through legislation or federal-provincial-territorial agreement, with the overall responsibility for pan-Canadian public health issues. The CMA has recommended the appointment of a Chief Public Health Officer of Canada with decision-making powers in areas of federal jurisdiction. Currently there is tremendous inequity in the public health system capacity among different provinces and territories. Considering the breadth of public health issues, the relative population sizes and differences in wealth, it will never be feasible to have comprehensive centres of public health expertise for each province and territory. Even if one achieved this, there would increasingly be issues of economies of scale and unnecessary duplication among centres. This issue is not unique to Canada.4 The CMA has proposed the establishment of a Canadian Office for Disease Surveillance and Control (CODSC) as a key component of its public health action plan. A comprehensive centre of public health expertise allows for a strategic pan-Canadian approach to public health planning and services while developing a critical mass of scientific and public health expertise and resources that can be deployed to any region in the country when necessary. A first priority of the CODSC must be to facilitate pan-Canadian agreement on the definition of the core functions of the public health system as it will not be possible to assess and develop system infrastructure if these are not defined. (As noted earlier in this paper the Federal-Provinical-Territorial Advisory Committee on Public Health has suggested five core functions.) A follow-up step to the development of core functions for public health is to identify national health goals to improve health status and address health inequities within populations across the country. The impact of inequality in health on health status can be seen within the aboriginal population. The degree of ill health within their communities is one of Canada’s major unresolved challenges. Although there have been significant improvements over the past few decades, the overall health status of Aboriginal peoples falls well below that of others living in Canada. Mortality and morbidity records indicate that life expectancy, while varying among communities, remains significantly less than that of the average Canadian. And the incidence and prevalence of chronic and degenerative diseases (Type II diabetes mellitus, cardiovascular disease, cancer and arthritis) is increasing. The CODSC would be a key player in establishing health goals and supporting Aboriginal peoples with public health expertise and resources. The CODSC and the Chief Public Health Officer of Canada will also have a central role in providing public health services to those areas falling under federal jurisdiction where local and provincial Chief Medical Officers of Health do not have access or authority. Airports, railways, military bases, aboriginal peoples living on reserve, federal meat packing plants and national parks are examples of areas under federal jurisdiction. The delivery of public health in these jurisdictions has been especially compromised by the lack of comprehensive coordination between provincial and federal systems. The CODSC must address this issue. Under the CMA’s plan, CODSC would become the lead national agency on public health matters with a broad mandate to co-ordinate all aspects of planning for national public health emergencies. It would also provide ongoing national health surveillance and work closely with provinces/territories to reinforce other essential public health functions. The Chief Public Health Officer of Canada would head the CODSC and act as the lead scientific voice for public health in Canada. To effectively carry out its mandate the CODSC’s structure must respect five guiding principles. It must be: * Independent – At arm’s length from government, insulated from day-to-day vagaries of political pressures while remaining accountable to Canadians. * Science-based – Adherence to the highest standards of risk assessment and decision-making with a view to safeguarding the health of Canadians. * Transparent – Open to public scrutiny and encouraging public participation in its activities. * Responsive – Characterized by a nimble decision-making process and a capability of deploying resources and expertise quickly and efficiently to any part of the country. * Collaborative – Partnership-oriented, fostering collaboration with other federal, provincial and non-governmental partners. There are three main options for the governance structure of the CODSC. Canadian and international precedents exist for each of the options. 1. Federal departmental entity Under this option, the CODSC would be created under federal legislation as a departmental branch or agency with the minister of health having general authority for its management and direction. The chief public health officer would be answerable to the minister and to the Prime Minister for the quality of management and advice provided by the office and for any actions taken by agency officials. This would not be very different from what already exists at Health Canada. The critical difference is that the CODSC would be a separate entity reporting to the minister of health, as opposed to the current structure where the Population and Public Health Branch is an entity within the department. Canadian examples: Canadian Food Inspection Agency, Pest Management Regulatory Agency International example: U.S. Centres for Disease Control and Prevention 2. National arm’s length agency This option consists of incorporating the office as a not-for-profit entity under the Canada Corporations Act (Part II), with the federal and provincial governments as members/shareholders. The CODSC would be structured on a corporate model with a board, and the chief public health officer acting as CEO. However, instead of direct accountability to Parliament, the office would be accountable to the Conference of F-P-T Ministers of Health. This option would signal a more radical departure from current arrangements and would make CODSC more of a joint venture with the provinces and territories. While the concept is intriguing, this model might place the management of national public health concerns too far from the ambit of governmental accountability. Canadian examples: Canadian Blood Services, Canadian Institute for Health Information, Canada Health Infoway, Canadian Coordinating Office for Health Technology Assessment 3. Federal arm’s length agency This middle option would consist of creating a more independent entity within the purview of the federal government. Under this approach, CODSC would be structured on a corporate model in which decision-making powers are vested in a board. The board, in turn, would be accountable to Parliament and the public for the exercise of these powers. The chief public health officer would be CEO and would oversee the day-to-day operation of the office. CODSC would be created through new federal legislation but would remain under the health portfolio, with accountability to Parliament through the health minister. Canadian examples: Canadian Institutes for Health Research, Canadian Centre for Substance Abuse, Hazardous Materials Information Review Commission International example: U.K. Health Protection Agency While each of the options discussed has strengths and weakness, a federal arm’s length agency would be the best fit with the CMA’s vision for the CODSC. It would mark a departure from the status quo in that the level of professional autonomy would increase and the level of ministerial involvement in professional issues would be reduced. This would contribute to making the CODSC more credible as a science-based organization. The board governance structure would encourage participation from the broader public health community and could therefore be more effective in creating partnerships with other key players. Illustration of a federal arm’s length agency CMA is very encouraged with the strong support for a Canadian public health agency shown by federal Health Minister Anne McLellan and her provincial /territorial counterparts following their most recent meeting. We also welcome their recognition of the need for significant resources to deliver the kind of integrated, collaborative national public health infrastructure needed to protect the health and safety of Canadians. 5 We have estimated the incremental cost of establishing and operating the CODSC to initially be $20 million over five years, over and above existing funding for programs that could be transferred to the new office such as emergency preparedness and response, and surveillance co-ordination. In its recent brief to the House of Commons Standing Committee on Finance 2003 pre-budget hearings, CMA asked that these monies be allocated immediately to allow for the creation of the CODSC within the next fiscal year. Recommendation Three That the federal government create a Canadian Office for Disease Surveillance and Control led by a Chief Public Health Officer of Canada to be the lead Canadian agency in public health, operating at arm’s length from government. Recommendation Four That the federal government allocate at least $20 million / 5 years with appropriate ongoing funding, over and above the funding for existing national public health programs, for the creation and operating expenses of the Canadian Office for Disease Surveillance and Control. Health Human Resource Capacity Enhancement The CMA has been speaking out on the impact of the shortage of physicians and other health care professionals on the acute care system for the last five years. In prior submissions to this Committee, to the House of Commons Committee on Finance and to the Royal Commission on the Future of Health Care in Canada, the CMA called for increased funding for the recruitment, education and on going training of physicians to address the current crisis in the acute care workforce. The SARS outbreak has clearly demonstrated that Canada’s public health workforce is especially thin. The shortage of community medicine and infectious disease specialists, nurses and laboratory technicians affects our capacity to respond to health threats. For the essential functions of the public health system to be realized, public health agencies need a workforce with appropriate and constantly updated skills. As the first line of defence against threats to the health of Canadians, the public health system must be able to respond quickly to an emergency with a skilled and trained workforce with sufficient numbers to meet the demands of the crisis. While Health Canada has made some limited progress to help address ongoing education needs of public health practitioners, there are virtually no resources currently dedicated to address public health emergency response skills or the essential cross-training that is critical during a public health crisis. Effective cross-training boosts surge capacity by equipping public health practitioners with knowledge and skills that can be called upon in times of public health emergency while allowing them to fulfil essential public health services at other times. CMA’s submission to the National Advisory Committee on SARS and Public Health has called for investment in multidisciplinary training programs in public health and the dissemination of best practices to public health professionals.6 But our country’s response to SARS also confirmed the co-dependent nature of the public health and acute care systems. The scarcity of hospital-based infection control practitioners, emergency physicians, nurses and technologists in the clinical and laboratory arenas within the acute care system were particularly striking during the SARS outbreak. This clearly demonstrated the need for a pre-planned approach to support and augment the public health and acute care workforce during a crisis. With essentially no plan in place to systematically shift human resources within the public health and acute care systems, we were ill prepared to move health professionals from other jurisdictions to respond to the crisis. Consequently Toronto public health and acute care professionals were stretched to their physical and mental limits. Recruitment of health care professionals to assist in the Greater Toronto Area depended, to a large degree, on volunteerism rather than co-ordinated efforts. Therefore, the CMA has proposed the establishment of a Canadian Public Health Emergency Response Service to work in collaboration with non-governmental health organizations like the CMA and the Canadian Public Health Association and function under the auspices of the Canadian Office for Disease Surveillance and Control.7 The Canadian Public Health Emergency Response Service would be made up of a core group of highly trained and mobile public health professionals, employed by the CODSC, able to carry out emergency response interventions as directed by the Chief Public Health Officer of Canada. But what SARS also clearly demonstrated was the need to be able to support and provide respite to the physicians and nurses overwhelmed by the influx of patients to acute care facilities and the accompanying institutional infection control measures. The CMA believes that the federal government must have access to a predetermined cadre of health care professionals willing to be deployed to provide acute care “locum” services during health emergencies. The CMA is well positioned to play an important part in recruiting physicians for an Emergency Relief Network. CMA’s MedConnexions online job matching service for health professionals, developed in partnership with Industry Canada, is a tool that could be used to disseminate information on the Network and collect contact information from physicians interested in volunteering to be deployed to provide local services. Volunteers would be asked to provide services that they normally provide, (for example, emergency medicine, intensive care, respirology, infection control) or other general services in affected areas to provide relief to staff that are stretched to the limit. Training in outbreak investigation would allow these individuals to also supplement the public health workforce in times of crisis. CMA would maintain control of the volunteer list and establish procedures to ensure that the information on the list is accurate and current. CMA would also undertake to determine that issues such as compensation (payment services and lost time [e.g., because of quarantine]), licensing, liability, disability coverage, logistics (travel and accommodation) are covered. CMA would contact members of the list in response to a request from the federal government through the CODSC. Recommendation Five That the federal government invests $250,000/ year on an ongoing basis to establish, in partnership with the profession, an Emergency Relief Network of physicians able to provide “locum” services during health emergencies. Recommendation Six That the federal government under the auspices of the Canadian Office for Disease Surveillance and Control provide funding for the training of physician volunteers in outbreak investigation. Surveillance and Communications The effectiveness of the public health system is also dependent, in large part, on its capacity to communicate authoritative information in a timely manner. A two-way flow of information between experts and the practising community is necessary at all times but becomes especially crucial during emergency situations. A well-functioning public health system will allow for this two-way communication — disease information to a central body that can analyze the aggregate data, and a capability to share aggressively and in real time the resulting analytical assessment with front line workers. A pan-Canadian surveillance system must be a fundamental component of the public health system. One of the keys to building a strong surveillance system is a robust connectivity with all points of health care. This would ensure real time notification through a pan Canadian health surveillance system of the occurrence of reportable diseases by front line health care workers throughout the country. All jurisdictions have embarked on information technology strategies that will build the connectivity to points of care over time. It is estimated that this work will take up to 10 years to complete and will require a $4 billion investment. Provinces and territories are at different stages of advancing this agenda and Ontario probably has the most progressive initiative. (It has committed to spending approximately $1 billion to put in place the pipelines that provide the connectivity and will cover the costs to carry the information traffic.) It is also important to note that Canada, as a World Health Organization member state, has international obligations in public health surveillance under the International Health Regulations (IHR). The IHR, introduced in 1969 to help monitor and control four serious diseases which had significant potential to spread between countries, involve: i. Notification of cases: * WHO Member States are obliged to notify WHO for a single case of cholera, plague or yellow fever, occurring in humans in their territories, and give further notification when an area is free from infection. * These notifications are reported in WHO's Weekly Epidemiological Record. ii. Health-related rules for international trade and travel. iii. Health organization: Measures for deratting, disinfecting, and disinsecting international conveyances (ships, aircraft, etc.) are to be implemented at points of arrival and departure (ports, airports and frontier posts). The health measures called for are the maximum measures that a state may apply for the protection of its territory against cholera, plague and yellow fever. iv. Health documents required: Requirements are included for health and vaccination certificates for travellers from infected to non-infected areas; deratting/deratting exemption certificates; health declarations- Maritime Declaration of Health; Aircraft General Declaration. 8 The IHR are currently under revision to include mandatory reporting of “public health emergencies of international concern”. 9 The health consequences of new infectious diseases are magnified because these public health threats cross local, provincial/territorial and national borders. Decisions made by one government have a direct impact upon the activities of adjacent governments. Canadian jurisdictions must co-ordinate their approaches to public health challenges to ensure they are effectively managed. Canada must ensure that our surveillance networks and public health infrastructure are up to the challenge in order to meet our international obligations to recognize and deal with emerging infectious diseases. In our submission to the National Advisory Committee on SARS & Public Health the CMA argued for a $1 billion infusion to rebuild the capacity of the public health system. Part of this investment is to help with the communication dimension of the connectivity problem. SARS highlighted the fact that Canada does not have information systems in place to facilitate real time communication with front line health professionals. Gaps in the basic communication infrastructure prevented public health agencies from interacting with each other in a timely manner. They also hindered exchanges between public health staff, private clinicians and other allied health workers about the latest information on the management of the disease. In addition, contact information, when it was there, was found to be seriously out of date and communications methods were not appropriately targeted to the end users. CMA learned some valuable lessons about how to provide real time communications to physicians. The health crisis resulted in the CMA mobilizing our communication networks to provide physicians with critical information about the public health management of SARS. Over 50,000 physicians received pertinent information on SARS over a 24-48 hour period of time. In addition, over 1500 health care facilities received critical authoritative information on SARS via the Canadian Council on Health Services Accreditation. For the first time in Canadian history an e-grand rounds initiative was launched to provide on line advice to physicians across this country in a format that they are familiar with. While the CMA succeeded in getting the information to physicians virtually in real time it was clear that the current infrastructure was inadequate. The CMA had to jury-rig a system that tied together disparate information lists and communications channels to move the information out to physicians. There was no guarantee the approach would work and there was no guarantee it would be timely. Luck was on our side. But we cannot continue to rely on luck; we must rely on sound management and planning. A stronger and more complete communications capacity to move information to physicians needs to be in place as soon as possible. This system has to ensure that the information is shared in a manner that respects the confidentiality and modality of how physicians would like to receive time sensitive information. One of the key lessons drawn from this latest emergency is that information is taken up by physicians in different ways. Some like to receive it by e-mail, others by fax and still others by mail. Even those with e-mail have expressed a desire to get emergency information in a different format. Iterative research will provide the information necessary to construct a solution that best maps how physicians work. There is a critical need to invest in data management infrastructure to maintain physician contact information (over 20% changes yearly) and build the correct modality channel to forward emergency information. This is a labour intensive process without which the assurance of reaching the majority of physicians would be compromised. The CMA has carried out an internal assessment on how it can best mobilize its own outreach capabilities coupled with those of its 12 divisions and has determined that with a one time investment of $250,000 for research, development and implementation of internal IT systems and ongoing operational funding of $100,000 a more robust, timely and assured connectivity with physicians will result. It is estimated that this connectivity could be built within the next twelve months. Recommendation Seven That the federal government partner with the CMA and the Canadian Council on Health Services Accreditation to ensure the capacity to communicate with physicians in real time during health emergencies. Recommendation Eight That the federal government invest in communication between professionals within the health care system through immediate funding for dedicated internet connectivity for all physicians in Canada. Conclusion SARS brought out the best in Canada and Canadians’ commitment to one another. It also turned a bright, sometimes uncomfortable spotlight on the ability of this country’s health care system to respond to a crisis, be it an emerging disease, a terrorist attack, a natural disaster or a large-scale accident. We must learn from the SARS experience and quickly move to build the infrastructure of a strong public health system. Different parts of the country have developed particular public health strengths and we can build on these strengths. With national leadership, commitment and resources, Canadians can have a well-functioning pan-Canadian public health system. The CMA believes that the federal government has a critical responsibility to ensure that the infrastructure for a strong public health system to serve all Canadians is in place. Summary of Recommendations 1. That the federal government rapidly move to enact a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in co-operation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. 2. The federal government invest in the country’s public health system with an immediate commitment of $ 1.5 Billion over five years to rebuild the public health infrastructure. 3. That the federal government create a Canadian Office for Disease Surveillance and Control led by a Chief Public Health Officer of Canada to be the lead Canadian agency in public health, operating at arm’s length from government. 4. That the federal government allocate $20 million / 5 years with appropriate ongoing funding, over and above the funding for existing national public health programs, for the creation and operating expenses of a Canadian Office for Disease Surveillance and Control. 5. That the federal government invest $ 250,000/ year on an ongoing basis to establish, in partnership with the profession, an Emergency Relief Network of physicians able to provide “locum” services during health emergencies. 6. That the federal government under the auspices of the Canadian Office for Disease Surveillance and Control provide funding for the training of physician volunteers in outbreak investigation. 7. That the federal government partner with the CMA and the Canadian Council on Health Services Accreditation to ensure the capacity to communicate with physicians in real time during health emergencies. 8. That the federal government invest in communication between professionals within the health care system through immediate funding for dedicated internet connectivity for all physicians in Canada. Appendix l (These documents available on the CMA website, under Submissions to Government) Answering the Wake-Up Call: CMA’s Public Health Action Plan, June 2003 Technical Backgrounders, July 21, 2003 Appendix ll WORLD MEDICAL ASSOCIATION Latest releases: 15 September 2003 Action Urged to Improve Response to World Health Epidemics The World Health Organisation has been urged by physicians of the World Medical Association to enhance its emergency response protocol to deal with world epidemics such as Sars. Meeting in Helsinki for their General Assembly, WMA delegates from almost 50 countries were critical of the way in which the Sars epidemic was handled earlier this year and in particular the failure of WHO to involve physicians early enough. The WMA Assembly called on the WHO to provide for the "early, ongoing and meaningful engagement and involvement of the medical community globally, including initiating immediate discussion on the establishment of an effective and real time means of communicating reliable, evidence-based information to front line workers and the establishment of reliable sources of products and materials needed to safeguard the health of front line workers and their patients". The WMA has also agreed to develop a public health risk alert plan covering areas of communications, preventive measures for physicians and patients, best practice in terms of diagnostic and therapeutic methods and evidence-based travel advice for the public. The plan is to be drawn up by a working group headed by the Canadian Medical Association, which, at the height of the Sars epidemic in Canada, managed to contact 26,000 physicians via e mail and the internet. The CMA described the World Medical Association's new resolution as "a wake up call to the world". The WMA has now invited all national medical associations to share the lessons learned during the Sars epidemic by providing details of measures taken in their countries to strengthen the responsiveness of their public health systems. Printed from: http://www.wma.net/e/press/2003_20.htm 1 Emergencies Act, R.S.C. 1985, c.22 (4th Supp), s. 5. “National emergency” is defined in section 3 as “an urgent and critical situation of a temporary nature that (a) seriously endangers the lives, health or safety of Canadians and is of such proportions or nature as to exceed the capacity or authority of a province to deal with it, or (b) seriously threatens the ability of the Government of Canada to preserve the sovereignty, security and territorial integrity of Canada, and that cannot be effectively dealt with under any other law of Canada.” (Emergencies Act, R.S.C. 1985, c.22 (4th Supp) section 3). 2 See Appendix 1: Technical Backgrounders to Answering the Wake-Up Call: CMA’s Public Health Action Plan for details on the Emergency Health Alert System. 3 The FPT Advisory Committee on Population Health recommended the following as essential functions of the public health system: population health assessment; health surveillance; health promotion; disease and injury prevention; health protection. 4 Many countries (e.g., United States, United Kingdom, Norway and the Netherlands) have developed a critical mass of public health expertise at the national level. The Centers for Disease Control and Prevention in the United States, which has a critical mass, great depth of scientific expertise and the tools and fiscal resources to fund public health programs at both state and local levels through demonstration projects, is a sterling example of the effectiveness of such a central agency. 5 McLellan promises health cash injection, A4, The National Post, 04-09-2003 6 Recommendation 4 of Answering the Wake-Up Call: CMA’s Public Health Action Plan: The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals. 7 Recommendation Five of Answering the Wake-Up Call: CMA’s Public Health Action Plan: The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies. 8 http://www.who.int/csr/ihr/current/en/print.html accessed September 15, 2003 9 (http://www.who.int/csr/ihr/revision/en/print.html) accessed July 4, 2003
Documents
Less detail

Health Protection and a Canadian Public Health Strategy: A Comprehensive Approach To Public Health: Submission to Health Canada

https://policybase.cma.ca/en/permalink/policy1958
Last Reviewed
2011-03-05
Date
2004-04-12
Topics
Population health/ health equity/ public health
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2011-03-05
Date
2004-04-12
Topics
Population health/ health equity/ public health
Text
This submission is the response of the Canadian Medical Association to Health Canada's request for feedback on its detailed "Health Protection Legislative Renewal" legislative proposal released in June 2003. Our submission calls for and is embedded in the broader context of a comprehensive approach to public health. The Canadian Medical Association is committed to working with others to realize the vision of a comprehensive, robust public health strategy as a vital component of Canada's health care system. This strategy should rest upon three pillars: * Emergency Response Empowering rapid and effective response to health emergencies, e.g. communicable disease outbreaks, water contamination, bio-terrorist attacks. * Health Protection: Ensuring that Canadians are protected from health risks in their daily environment; for example, risks associated with the use of health or consumer products, or with the potential spread of infectious disease. * Health Promotion and Disease Prevention Instituting programs to encourage healthy behaviour and advocating for public policy and fiscal policy that supports health. Though these three pillars have different foci and different legislative instruments, they must all be part of a strategy to enhance public health and public health service delivery in Canada. With specific reference to health protection, CMA believes that legislation should rest on the following principles: a) Commitment to the primacy of health and safety. b) Commitment to evidence-based decision making. c) A thorough risk-analysis procedure based on the relative risk of products or services. d) Support for informed patient decision-making. e) Accountability vested in the Government of Canada. f) A comprehensive, effective post-marketing surveillance system. g) Enforcement through effective, meaningful penalties for noncompliance. h) Flexibility to quickly and efficiently accommodate new technologies. i) Openness and transparency. j) Encouragement of collaboration and co-operation with other stakeholders, while respecting existing jurisdictions and legislative mechanisms. Recommendations A Canadian Public Health Strategy 1) That the federal government ensure that legislative and administrative measures related to public health complement one another in function and are connected through communications and co-ordination mechanisms. The Drug Review Process 2) That the federal government implement a timely and efficient drug review process to reduce review times to the fastest level consistent with ensuring improved health outcomes and the safety of the drug supply. 3) That the federal government consider co-operative agreements for drug review with comparable agencies in Europe, the United States and Australia, while retaining final authority as to whether a new product should be allowed on the Canadian market. 4) That the drug review and approval process be open and transparent, providing updates on review status and the opportunity for stakeholder input. 5) That Health Canada apply a priority review process to "breakthrough" drugs, i.e. those that demonstrate a substantial improvement over products already on the market. Patient Safety and Post-Marketing Surveillance 6) That Health Canada work in partnership with stakeholders including CMA and other national medical and health professional associations, to develop a rigourous post-marketing surveillance system to monitor the ongoing safety of marketed drugs. 7) That government accelerate activities to establish the Patient Safety Institute using a systems approach to support a culture of safety. 8) That all stakeholders join in supporting and encouraging outcome-based research to ascertain best practices in prescribing. 9) That the federal government invest in measures such as electronic communications networks, to increase physicians' capacity to report medication incidents and to improve the timeliness of adverse event reporting. Drug Information and Advertising 10) That all stakeholders work to ensure that Canadians have ready access to a source of comprehensive, reliable information on health products and their uses, and that governments fund development and dissemination of validated information to physicians and to the public. 11) That the legislation define "promotion" and "advertising" so as to clearly distinguish them from unbiased health information, and from counselling by health professionals. 12) That the current safeguards against deception be strengthened in order to * Forbid fraudulent or misleading health claims in advertisements, on labels or in any other promotional or descriptive material pertaining to the product; * ensure pre-clearance and ongoing review of all health claims by an objective agency; * provide meaningful penalties for infraction. 13) That Health Canada maintain the current ban on advertising health products for treatment, prevention and cure of conditions or disease states to be identified in a regulatory schedule or administrative list; the inclusion of conditions in this list should be determined through a set of criteria that are written into the Act or regulations. 14) That the existing ban on direct to consumer advertising of prescription drugs be maintained and enforced to the full extent of the law, and that the loophole that currently permits advertising the name, price and quantity of a prescription drug be closed. 15) That all stakeholders, including medical associations and industry groups, work together toward effective regulation of drug promotion to health practitioners. Safeguarding the Privacy of Health Information 16) That the Health Protection Act respect the provisions of the Charter of Rights and Freedoms, the Federal Privacy Act and the Personal Information Protection and Electronic Documents Act (PIPEDA). 17) That the privacy provisions in the Health Protection Act meet the legislative test outlined in Section 3.6 of CMA's Health Information Privacy Code. Other Issues 18) That the Health Protection Act give Health Canada a clear mandate to develop guidance documents to address health and safety issues raised by new technologies. 19) That Natural Health Products be regulated on a strict framework that ensures their safety, quality and efficacy as well as the provision of complete and unbiased information to the public. 20) That the Act provide Health Canada with a clear mandate to collaborate with provincial/territorial and local governments across Canada in reviewing legislation governing all aspects of drinking water from source to consumption to ensure that comprehensive programs are in place and being properly implemented. 21) That Health Canada urgently review the Quarantine Act and modernize its provisions. 1. Introduction This submission is the response of the Canadian Medical Association (CMA) to Health Canada's request for feedback on its detailed "Health Protection Legislative Renewal" legislative proposal released in June 2003. Our submission calls for and is embedded in the broader context of a comprehensive approach to public health. It also includes recommendations dealing with selected specific issues raised in the proposal, particularly those that have a potential major impact on physicians and other health professionals, and on the practice of medicine. The Canadian Medical Association supports the government's efforts to update and revitalize health protection legislation. Physicians are committed to working with others to realize the vision of a comprehensive, robust public health strategy as a vital component of Canada's health care system, in order to realize Canada's potential as a healthy nation. Recent headlines illustrate the diversity of public health challenges facing Canadians: * The spread of avian flu across Asia, and the reappearance of SARS in China; * Reports linking the use of Selective Serotonin Reutake Inhibitor antidepressants to increased suicide and other behavioural disorders in children and adolescents, which led to a public warning against their use in this population; * The rapidly rising rates of obesity in Canada and other developed countries. To deal with these problems and others, a comprehensive public health strategy is required. This strategy should rest upon three pillars: emergency response, health protection and health promotion (Figure 1). Each of these pillars is discussed in greater detail in the following section. 2. Three Pillars of a Canadian Public Health Strategy a) Pillar #1: Emergency Response The 2003 SARS outbreak shone a merciless light on the difficulties that Canada's stretched public health system can encounter when it needs to respond to health emergencies. The 21st century has brought a disturbing array of new public health risks (such as avian flu) and old risks revisited (such as contamination of water supplies). A comprehensive public health strategy should be able address these risks by: * Empowering rapid and effective response to health emergencies, e.g. communicable disease outbreaks, water contamination, bio-terrorist attacks. * Supporting health surveillance, screening and research, to identify potential health risks. [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Figure 1. The Three Pillars of Public Health [FIGURE END] CMA Position: CMA's 2003 submission to the National Advisory Committee on SARS and Public Health (the Executive Summary is attached as Appendix I) recommended a number of measures to strengthen Canada's capacity to respond to health emergencies. These included: * The enactment of a Canada Emergency Health Measures Act to allow for a more rapid national response to emergencies that pose an acute and imminent threat to human health and safety in Canada. * The creation of an independent Canada Public Health Agency, headed by a Chief Public Health Officer of Canada who would work with provinces and territories to develop and implement a pan-Canadian public health action plan. * Enhancements to the current system of disease surveillance and response, so that it remains privacy sensitive and ensures a two-way flow of information between public health experts and front-line clinicians. In 2004 CMA reiterated these recommendations to the Honourable Carolyn Bennett, Minister of State for Public Health, in response to her request for consultation on a Canada Public Health Agency. b) Pillar #2: Health Protection The Health Protection function ensures that Canadians are protected from health risks in their daily environment; for example, risks associated with the use of health or consumer products, or with the potential spread of infectious disease. Specific health protection functions include: * Ensuring that Canadians have access to the right pharmaceutical drugs, which have been proven safe and efficacious, at the right times, for the right prices. Our policy in this area is further discussed in our 2003 submission to the House Standing Committee on Health's review of prescription drugs, an executive summary of which is attached (Appendix II). * Monitoring Canada's pharmaceutical drug supply to ensure its safety, effectiveness and continued availability. * Ensuring the safety of natural health products, medical devices, hazardous products and other consumer products. This should include the regulation of toxic substances, including tobacco. * Regulating health claims for consumer products. * Monitoring the advertising and promotion of health products to the public. * Administering quarantine procedures. * Developing regulatory frameworks to ensure the safety and effectiveness of new technologies such as gene therapy and genetically modified foods. CMA Position: The principles that CMA believes should guide review of health protection legislation are discussed in Section 3. c) Pillar #3: Health Promotion and Disease Prevention For more than 30 years the federal government has incorporated the promotion of health, as well as the treatment of disease, into its mandate. Activities undertaken in pursuit of this function include: * Programs to encourage healthy behaviours, e.g. physical activity strategies. * Advocating for or implementing public policy that supports health e.g. bans on tobacco advertising and sponsorship, and fiscal policies, such as high tobacco taxes. * Research strategies to increase our understanding of the determinants of health. CMA Position: The CMA has called on the federal government to commit to the goal of establishing Canada as the top country in the world with regard to the health status of its citizens. Canada remains one of the few countries in the industrialized world without a clear statement of national health goals, targets and strategies. All levels of government should enable the Health Council of Canada to monitor and report on defined health goals and priorities. In addition, the CMA has developed policies and statements urging action on specific health promotion issues including: obesity control; injury prevention; physical activity; tobacco control; mental health; and many others. Though these three pillars have different foci and different legislative instruments, they must all be part of a comprehensive legislative agenda and strategy to renew and enhance public health and public health service delivery in Canada. Addressing issues under one pillar without reference to the other pillars or to a comprehensive public health framework and strategy fails to address the overall public health needs of Canadians. Recommendation 1. That the federal government ensure that legislative and administrative measures related to public health complement one another in function and are connected through communications and co-ordination mechanisms. 3. A Policy Framework for Health Protection Legislation This submission is a response to a legislative proposal regarding health protection; consequently the rest of this document will focus on the second of the three pillars described above, the "health protection" pillar. This section discusses the overall policy framework that the CMA believes should govern health protection in Canada. The CMA holds that health protection legislation should rest on the following principles: i) Primacy of Health and Safety. Legislation should commit to protection of public health and safety as its primary objective. ii) Core Values. Legislation should recognize the core values of Canadians, such as privacy of health and personal information, freedom of choice, and protection of vulnerable citizens, and be sensitive to cultural, gender, socio-economic and other factors where relevant. Where there is a conflict between Principle (i) and other values, this conflict and the grounds on which to resolve it should be explicitly stated. iii) Evidence-based Decision Making. Legislation should reflect a commitment to scientific, evidence-based decision making. It should provide for the requisite mechanisms to ensure that reviews of risk are independent and unbiased. iv) The Risk Assessment Process. Legislation should reflect a thorough risk-analysis procedure including risk assessment and evaluation. The pre-approval scrutiny to which a product1 is subjected should be based on its relative risk: regulatory requirements should be greater for products with greater risk and lower for those with less risk. Risk assessment should take into account risk to the community as well as to individuals. While the risk assessment process should be science-based, it should also recognize that public perception might influence the management and communication of risk. In areas of risk uncertainty, application of the precautionary principle could be considered on a case-by-case basis. v) General Safety Requirement. The CMA supports the proposal to include in the legislation a General Safety Requirement that would make it illegal for anyone to manufacture, promote or market a product that may present an undue risk to health, under reasonably foreseeable conditions of use. However, this overall requirement should not be used as a substitute for enacting regulations to cover specific products if evidence indicates that such regulations are necessary to protect public health. Nor should it be used as a rationale for relaxing regulatory regimes currently in place. vi) Support for Informed Patient Decision-Making. Legislation should ensure that Canadians have access to reliable, evidence-based information to support them in making decisions regarding their own health, and should ensure that the information they receive is not misleading or deceptive. vii) Accountability. Legislation should ensure that there is clear accountability for decision-making, and that this is vested in the Government of Canada. viii) Surveillance. Legislation should ensure comprehensive, effective post-marketing surveillance of drugs and other health products. This should be co-coordinated with surveillance and research programs governed by related public health acts such as the proposed Canada Emergency Health Measures Act. ix) Enforcement. Legislation should provide and enforce effective, meaningful penalties for noncompliance. x) Flexibility. Legislation should allow for flexibility in product approval, consistent with Principle i, in order to quickly and efficiently accommodate emerging issues (such as new technologies) developed in Canada and internationally. xi) Openness and Transparency. Legislation should operate transparently, incorporating ongoing, two-way communication with stakeholders, including health professionals and the public. xii) Working with Others. Legislation should encourage collaboration and co-operation with other federal departments, with provinces and territories, and with non-governmental and international organizations. At the same time it should respect existing jurisdictions and existing legislative and administrative mechanisms. 4. Impact of Health Protection Legislation on Medical Practice Physicians, along with other health professionals, play an important role in maintaining high health standards and communicating appropriate health information to Canadians. Some of the proposals included in the legislative proposal could have a significant positive or negative impact on medical practice. These include: a) The Drug Review Process Stakeholders have repeatedly drawn attention to the slowness and secrecy of Canada's drug approval process. Between 1996 and 1998 Canadian approval times (median 518 days) were significantly longer than Sweden (median 371 days), the UK (median 308 days) and the United States (median 369 days). These have not improved significantly even after Health Canada implemented a cost-recovery approach to funding drug reviews. In addition, the review process may not distinguish genuinely new and innovative "breakthrough" drugs from imitations of products already on the market. The legislative proposal discusses possible means of modernizing the drug review process, including co-operative agreements with comparable drug review agencies in other jurisdictions, and establishment of a mechanism for public comments. The CMA approves both these suggestions. To ensure that Canadians have access to the right drugs for their conditions as quickly as is consistent with safety, the CMA recommends: Recommendations 2. That the federal government implement a timely and efficient drug review process to reduce review times to the fastest level consistent with ensuring improved health outcomes and the safety of the drug supply. 3. That the federal government consider co-operative agreements for drug review with comparable agencies in Europe, the United States and Australia, while retaining final authority as to whether a new product should be allowed on the Canadian market. 4. That the drug review and approval process be open and transparent, providing updates on review status and the opportunity for stakeholder input. 5. That Health Canada apply a priority review process to "breakthrough" drugs, i.e. those that demonstrate a substantial improvement over products already on the market. b) Patient Safety and Post-marketing surveillance Recent reports have drawn public attention to the need for a rigourous, well-resourced post-marketing surveillance system to monitor the ongoing safety of marketed drugs and other health products in Canada. CMA strongly recommends that Health Canada work in partnership with stakeholders to develop such a system. The system should be non-punitive, supporting a "culture of safety" rather than one of blame, and should respect the privacy of patients and physicians. In this context the CMA supports the establishment of the Patient Safety Institute. In developing its post-marketing surveillance capacity, Health Canada should ensure that sufficient resources are in place to enable the system to: * Facilitate the reporting of adverse reactions by health professionals and others. The CMA supports activities that encourage the voluntary reporting of adverse reactions by physicians and others. For example, to facilitate timely and comprehensive reporting, forms should be easily accessible and the reporting process should be computerized, simple and transparent. * Collect and analyze data and produce information that health care professionals and policy makers can use in decision-making at the population level. With appropriate privacy safeguards, this information could also be used for a number of research purposes, e.g. monitoring the importation and use of drugs not yet licensed in Canada; ascertaining best practices in prescribing. * Communicate this information back to the provider in real time. The importance of real-time two-way communication with front-line practitioners and institutions cannot be overstated. The CMA has repeatedly called for sustained and substantial investment in a Health Communications and Coordination Initiative to improve the technical capacity of front-line health providers to communicate in real time with one another and with the rest of the health care system. This is a critical endeavour and should be undertaken immediately, using funds established for health surveillance in the March 2004 Federal Budget, and implemented within the next 6 months. This network could form the cornerstone of an adverse drug reaction reporting system. Recommendations: 6. That Health Canada work in partnership with stakeholders including CMA and other national medical and other health professional associations, to develop a rigourous post-marketing surveillance system to monitor the ongoing safety of marketed drugs. 7. That government accelerate activities to establish the Patient Safety Institute using a systems approach to support a culture of safety. 8. That all stakeholders join in supporting and encouraging outcome-based research to ascertain best practices in prescribing. 9. That the federal government invest in measures such as electronic communications networks, to increase physicians' capacity to report medication incidents and improve the timeliness of adverse event reporting. c) Drug Information and Advertising CMA believes that the public has a right to unbiased, accurate information on drugs and other therapeutic products. This information should be provided in accordance with CMA's "Principles for Providing Information about Prescription Drugs to Consumers" (Appendix III). Brand-specific product advertising is a less than optimal way of providing this information, and should be carefully monitored to discourage fraudulent or misleading claims. In particular, direct to consumer advertising of prescription drugs should not be permitted in Canada. Physicians and their associations are willing to work with Health Canada and other stakeholders in developing and disseminating accurate, unbiased information to the public and to health professionals about drugs and other health products. Recommendations: 10. That all stakeholders work to ensure that Canadians have ready access to a source of comprehensive, reliable information on health products and their uses, and that governments fund development and dissemination of validated information to physicians and to the public. 11. That the legislation define "promotion" and "advertising" so as to clearly distinguish them from unbiased health information, and from counselling by health professionals. 12. That the current safeguards against deception in advertising be strengthened in order to * Forbid fraudulent or misleading health claims in advertisements, on labels or in any other promotional or descriptive material pertaining to the product; * Ensure pre-clearance and ongoing review of all health claims by an objective agency; * Provide meaningful penalties for infraction. 13. That Health Canada maintain the current ban on advertising health products for treatment, prevention and cure of conditions or disease states to be identified in a regulatory schedule or administrative list; the inclusion of conditions in this list should be determined through a set of criteria that are written into the Act or regulations. 14. That the existing ban on direct to consumer advertising of prescription drugs be maintained and enforced to the full extent of the law, and that the loophole that currently permits advertising the name, price and quantity of a prescription drug be closed. 15. That all stakeholders, including medical associations and industry groups, work together toward effective regulation of drug promotion to health practitioners. d) Safeguarding the privacy of health information Patients must be able to feel assured that anything they tell their physicians will remain confidential, imparted to others only to the extent necessary to ensure optimal care. Accordingly, the privacy and confidentiality of patient-specific and physician-specific information should be safeguarded to the fullest extent possible. New technologies, e.g. electronic health records, have made the transfer of information simpler and more efficient. They have also made it more vulnerable to infringements on a patient's right to privacy. Several important pieces of legislation to safeguard privacy have already been enacted. In addition, the CMA has developed a Privacy Code (Appendix IV) that discusses confidentiality issues specific to health information. Section 3.6 of this Code contains a legislative test to which all proposed legislation, including the Health Protection Act, should be submitted. Recommendations 16. That the Health Protection Act respect the provisions of the Charter of Rights and Freedoms, the Federal Privacy Act and the Personal Information Protection and Electronic Documents Act (PIPEDA). 17. That the privacy provisions in the Health Protection Act meet the legislative test outlined in Section 3.6 of CMA's Health Information Privacy Code. e) Other Issues The legislative proposal discusses giving Health Canada the power to develop guidelines or regulatory frameworks for specific circumstances, e.g. for new products and technologies such as genetically modified foods; or for situations in which the health of the public may otherwise be at risk, such as contamination of drinking water. In addition, the proposal discusses the possibility of modernizing existing laws that have become outdated. The CMA supports the direction of these proposals. The Quarantine Act, for example, is a piece of legislation the CMA believe merits urgent updating; new legislation should incorporate quarantine provisions for possible vectors leaving as well as entering Canada, and for inter-provincial as well as international traffic. With regard to specific issues not addressed elsewhere in this submission, the CMA recommends: Recommendations 18. That the Health Protection Act give Health Canada a clear mandate to develop guidance documents to address health and safety issues raised by new technologies. 19. That Natural Health Products be regulated on a strict framework that ensures their safety, quality and efficacy as well as the provision of complete and unbiased information to the public. 20. That the Act provide Health Canada with a clear mandate to collaborate with provincial/ territorial and local governments across Canada in reviewing legislation governing all aspects of drinking water from source to consumption to ensure that comprehensive programs are in place and being properly implemented. 21. That Health Canada urgently review the Quarantine Act and modernize its provisions. 5. Conclusion Health protection is one of three pillars of an effective public health system, along with rapid and effective emergency response, and programs and policies to maintain health and prevent disease. The CMA is pleased to have been able to advise governments on all of these pillars, in order to establish the health of Canadians on a strong foundation. We look forward to continued consultation with Health Canada on the proposed Health Protection Act, both on its overall framework and on specific issues of concern to the medical profession. We trust that the result will be strong legislation, founded on fair and enduring principles, to safeguard the health and security of Canadians. APPENDIX I Answering the Wake-up Call: CMA's Public Health Action Plan CMA Submission to Naylor Advisory Committee on SARS and Public Health (Executive Summary) The public health system in Canada lies at the heart of our community values. It is the quintessential "public good" and is central to the continued good health of our population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong - like the Walkerton tragedy or when we are faced with a new threat like SARS - is the integral, ongoing role of public health really recognized. The Canadian Medical Association (CMA) has been warning that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to the latest crises. Canada's physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. Our public health system is the first - and often the only - line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health armaments must be in a constant state of "battle readiness." In today's climate of SARS, West Nile Virus, mad cow disease and monkey pox, even the thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians. Physicians have always been an integral part of the public health system serving as medical officers of health, community health specialists and other related roles. Indeed public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians. In this submission, we reflect on the lessons to be learned from our recent experience with SARS and reflect on the longer-term needs of the public health system as a whole. The objectives of the pan-Canadian Public Health Action Plan proposed by the CMA are, first to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies; and, second, to enhance the system's capacity to respond to public health threats across the country (see recommendations, below). To achieve these twin objectives, three broad strategies are presented for immediate attention. They are legislative reform; capacity enhancement; and research, surveillance and communications. Legislative reform (see recommendations 1-3) The country's response to SARS has brought into stark relief the urgent need for national leadership and coordination of public health activity across the country, especially during a health crisis. The apparent reluctance to act quickly to institute screening at airports, the delay in unifying the practice community for a concerted response and the appalling communications confusion worked against optimum handling of the outbreak - despite the best efforts of health care professionals. This is a wake-up call that highlights the need for comprehensive legislative reform to clarify the roles of governments with respect to the management of public health threats. A renewed and enhanced national commitment to public health should be anchored in new federal legislation to be negotiated with the provinces and territories. Specifically, the CMA recommends an Emergency Health Measures Act, to deal with emergent situations in tandem with the creation of a Canadian public health agency headed by a Chief Public Health Officer of Canada. Capacity enhancement (see recommendations 4-7) The SARS crisis has demonstrated the diminished capacity within the public health system. The Greater Toronto Area (GTA), with one of Canada's most sophisticated public and acute health systems, has not been able to manage the SARS crisis adequately and carry on other health programs. The acute care system virtually ground to a halt in dealing with SARS. There was little or no surge capacity in Canada's largest city. We should be grateful that SARS did not first strike a smaller centre in a far less-advantaged region of Canada. A critical element of the public health system is its workforce and the health professionals within the acute care system, such as hospital-based infectious disease specialists and emergency physicians who are the front-line interface. Let there be no doubt that the ongoing efforts of the GTA front-line providers are nothing short of heroic. However, the lack of coordinated contingency planning of hospital and community-based disease control efforts was striking. The overall shortage of critical care professionals and the inability of governments to quickly deploy the required professionals to areas of need contributed to the enormous strain on the public and health care system. Considering the importance of the public health system and its clearly limited capacity to protect and promote the health of Canadians, it is incomprehensible that we do not know how much is actually spent on the system. It is imperative that public health expenditures and capacity, in terms of both physical and human resources, be tracked and reported publicly. The CMA recommends a $1-billion, 5-year capacity-enhancement program to be coordinated with and through the new Canadian public health agency. Research, surveillance and communications (see recommendations 8-10) Canada's ability to respond to public health threats and acute events, such as SARS, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications. A concerted pan-Canadian effort is required to take full advantage of our capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. New-millennium challenges require moving beyond old-millennium responses. Enhanced surveillance is an overdue and integral part of public health, performing an essential function in early detection and response to threats of infectious diseases. Mandatory national reporting of identified diseases by all provinces and territories is critical for national and international surveillance. During times of crisis, rapid communication to the public, public health staff and front-line clinicians is of critical importance, but in many jurisdictions impossible. We tested our systems during the SARS outbreak and they came up short. The CMA recommends a one-time federal investment to enhance technical capacity to allow for real-time communication. Conclusion The CMA believes that its proposed three-pronged strategy, as set out in the attached recommendations, will go a long way toward addressing shortfalls of the Canadian public health system. Action now will help to ensure that Canadians can once again be confident that they are protected from any future threat of new infectious diseases. Action now will help Canada regain its position as a leader in public health. We wish the advisory committee well in its deliberations and offer the CMA's assistance at any time in clarifying the strategies set out in our submission. Recommendations to the National Advisory Committee on SARS and Public Health Legislative reform ($20 million / 5 years*) 1. The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. 2. The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm's length from government. 3. The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan. Capacity enhancement ( $1.2 billion / 5 years*) 4. The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals. 5. The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies. 6. Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the proposed Canadian Office for Disease Surveillance and Control. 7. Federal government funding in the amount of $1 Billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions. Research, surveillance and communications ($310 million / 5 years*) 8. An immediate, sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. 9. The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and intervention. 10. The one-time infusion of $100 million, with an additional $2 million a year, for a "REAL" (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies. APPENDIX II The Right Drugs, at the Right Times, for the Right Prices: Toward a Prescription Drug Policy for Canada CMA Submission to House of Commons Standing Committee on Health Every year, three hundred million prescriptions - about 10 for every man, woman and child - are filled in Canada. Prescription drugs have benefited both the health of Canadians, and the health care system itself; they have meant dramatically improved quality of life for many Canadians, and have saved the country a great deal in hospitalization, social benefits and other expenses. However, it could be questioned whether all of Canada's prescription drug use is appropriate; patients may be receiving too few medications, too many medications or suboptimal medications for their conditions. In addition, prescription drugs carry a price tag of their own. Since 1975, expenditures on prescription medication have risen faster than any other category in the health sector in Canada, and more is now spent on prescription drugs than on physician services. Governments, health care providers, drug manufacturers and the public must constantly strive to ensure that Canadians receive optimal and appropriate prescription drug therapy: the right drugs, at the right times, for the right prices. A considered, coherent, comprehensive, "made in Canada" approach to prescription drug policy should: * Put the health of the patient first; * Promote and enhance quality prescribing; * Respect, sustain and enhance the therapeutic relationship between patients and health professionals; * Promote patient compliance with drug therapy; * Respect the principles of patient confidentiality and the privacy of patient and prescriber information. Prescription drug policy in Canada should address: Access: to * efficacious new drugs within an appropriate time; * coverage for medically necessary drugs for catastrophic care; * generic drugs at reasonable prices; * a patient/physician consultation as part of the prescribing process; * continued research and development capacity in Canada. Information for health care providers and the public that is balanced and accurate. Safety: through mechanisms for the systematic monitoring of prescription drugs and their effects. Canada's doctors are committed to working with others to ensure that Canadians receive the right drugs, at the right times, for the right prices. Summary of CMA Recommendations: 1. That the federal government implement a timely and efficient drug review process to reduce review times to a level at or better than that in other OECD countries. 2. That the pharmaceutical industry give priority to research and development on drugs and delivery mechanisms that demonstrate a substantial improvement over products already on the market. 3. That Health Canada apply a priority review process to all drugs that demonstrate a substantial improvement over products already on the market. 4. That governments and insurance providers conduct research to identify the current gaps in prescription drug coverage for all Canadians, and develop policy options for providing this coverage, including consideration of the roles of public and private payers. 5. That the federal government monitor and, if necessary, regulate the export of prescription medications to ensure their continued availability to Canadians. 6. That prescribing of medication be done within the context of the therapeutic relationship which exists between the patient and the physician. 7. That brand-specific direct to consumer prescription drug advertising (DTCA) not be permitted in Canada, 8. That the federal government enforce the existing restrictions on DTCA found in the Food and Drug Act to the full extent of the law. 9. That the federal government develop and fund a comprehensive program to provide accurate, unbiased prescription drug information to patients. 10. That all stakeholders join in supporting and encouraging outcome-based research to ascertain best practices in prescribing. 11. That government accelerate activities to establish the Patient Safety Institute using a systems approach to support a culture of safety. 12. That a post-marketing surveillance system be implemented to monitor the ongoing safety of marketed drugs. APPENDIX III CMA POLICY Principles for Providing Information about Prescription Drugs to Consumers Approved by the CMA Board of Directors, March 2003 Since the late 1990's expenditures on direct to consumer advertising (DTCA) of prescription drugs in the United States have increased many-fold. Though U.S.-style DTCA is not legal in Canada 2 , it reaches Canadians through cross-border transmission of print and broadcast media, and through the Internet. It is believed to have affected drug sales and patient behaviour in Canada. Other therapeutic products, such as vaccines and diagnostic tests, are also being marketed directly to the public. Proponents of DTCA argue that they are providing consumers with much-needed information on drugs and the conditions they treat. Others argue that the underlying intent of such advertising is to increase revenue or market share, and that it therefore cannot be interpreted as unbiased information. The CMA believes that consumers have a right to accurate information on prescription medications and other therapeutic interventions, to enable them to make informed decisions about their own health. This information is especially necessary as more and more Canadians live with chronic conditions, and as we anticipate the availability of new products that may accompany the "biological revolution", e.g. gene therapies. The CMA recommends a review of current mechanisms, including mass media communications, for providing this information to the public. CMA believes that consumer information on prescription drugs should be provided according to the following principles. 3 Principle #1: The Goal is Good Health The ultimate measure of the effectiveness of consumer drug information should be its impact on the health and well-being of Canadians and the quality of health care. Principle #2: Ready Access Canadians should have ready access to credible, high-quality information about prescription drugs. The primary purpose of this information should be education; sales of drugs must not be a concern to the originator. Principle #3: Patient Involvement Consumer drug information should help Canadians make informed decisions regarding management of their health, and facilitate informed discussion with their physicians and other health professionals. CMA encourages Canadians to become educated about their own health and health care, and to appraise health information critically. Principle #4: Evidence-Based Content Consumer drug information should be evidence based, using generally accepted prescribing guidelines as a source where available. Principle #5: Appropriate Information Consumer drug information should be based as much as possible on drug classes and use of generic names; if discussing brand-name drugs the discussion should not be limited to a single specific brand, and brand names should always be preceded by generic names. It should provide information on the following: * indications for use of the drug * contraindications * side effects * relative cost. In addition, consumer drug information should discuss the drug in the context of overall management of the condition for which it is indicated (for example, information about other therapies, lifestyle management and coping strategies). Principle #6: Objectivity of Information Sources Consumer drug information should be provided in such a way as to minimize the impact of vested commercial interests on the information content. Possible sources include health care providers, or independent research agencies. Pharmaceutical manufacturers and patient or consumer groups can be valuable partners in this process but must not be the sole providers of information. Federal and provincial/territorial governments should provide appropriate sustaining support for the development and maintenance of up-to-date consumer drug information. Principle #7: Endorsement/ Accreditation Consumer drug information should be endorsed or accredited by a reputable and unbiased body. Information that is provided to the public through mass media channels should be pre-cleared by an independent board. Principle #8: Monitoring and Revision Consumer drug information should be continually monitored to ensure that it correctly reflects current evidence, and updated when research findings dictate. Principle #9: Physicians as Partners Consumer drug information should support and encourage open patient-physician communication, so that the resulting plan of care, including drug therapy, is mutually satisfactory. Physicians play a vital role in working with patients and other health-care providers to achieve optimal drug therapy, not only through writing prescriptions but through discussing proposed drugs and their use in the context of the overall management of the patient's condition. In addition, physicians and other health care providers, and their associations, can play a valuable part in disseminating drug and other health information to the public. Principle #10: Research and Evaluation Ongoing research should be conducted into the impact of drug information and DTCA on the health care system, with particular emphasis on its effect on appropriateness of prescribing, and on health outcomes. APPENDIX VI CMA POLICY HEALTH INFORMATION PRIVACY CODE This Code articulates principles for protecting the privacy of patients, the confidentiality and security of their health information and the trust and integrity of the therapeutic relationship. Its provisions are more exacting than those currently in place in the Canadian health care system. Although a patchwork of laws across Canada permit or require health information collection, use, disclosure and access without patient consent, or even knowledge, this Code would require that all of these laws and any proposed laws be reviewed for consistency with its provisions. Moreover, existing practices and initiatives concerning health information collection, use, disclosure and access, including health information systems or networks, may be contrary to patient expectations and the physician's duty of confidentiality. These practices and initiatives must also be reviewed for consistency with this Code. Many laws, practices and initiatives may not withstand the kind of scrutiny deemed necessary and reasonable for the protection of privacy and the trust and integrity of the therapeutic relationship. CMA issues this Code in recognition that its implementation raises numerous issues and challenges, and that the changes it envisions will require time and the expenditure of resources. CMA appreciates that, given the complexity of the health care system, agreement and cooperation among a wide range of users and collectors of health information will be essential to the successful implementation of this Code. In view of these challenges, CMA issues this Code to the Canadian health care community at this time as an ideal to strive for, to guide and coordinate the efforts that need to be made to protect the privacy of patients, the confidentiality and security of their health information and the trust and integrity of the therapeutic relationship. Moreover, this Code is issued in the understanding that those to whom it applies will not be able to achieve full compliance with its provisions until such time as numerous implementation issues have been clarified and resolved through cooperation and the coordinated efforts of many different stakeholders. Consequently, companion implementation documents are being developed that provide for a gradual implementation of the Code's provisions over a five-year span and outline work that needs to be done to achieve the ideal it envisions. Section A: Scope This Health Information Privacy Code ("Code") has been produced by physicians to protect the privacy of their patients, the confidentiality and security of their health information and the trust and integrity of the therapeutic relationship. This Code is based on the Canadian Standards Association's Model Code for the Protection of Personal Information ("CSA Code") as a sectoral code of the CSA Code. This Code provides instruction and guidance respecting health information collection, use, disclosure and access. 1. This Code describes the minimum requirements to protect the privacy of patients and the security and confidentiality of their health information. 2. This Code has been developed by physicians in their capacity as clinicians and in recognition of their principal obligation to patients. 3. This Code recognizes the potential benefits of the use of health information for secondary purposes, including teaching, research and system planning, and contains provisions to permit such use under clearly defined terms and conditions. 4. This Code has been developed as a sectoral code of the Canadian Standards Association's Model Code for the Protection of Personal Information and consequently adopts the minimum standards contained in the CSA Code and augments them to meet the special circumstances of health information. 5. The development of this Code has been inspired by the report of the House of Commons Standing Committee on Human Rights and the Status of Persons with Disabilities, entitled Privacy: Where Do We Draw The Line? 6. The Code applies to all health information and to all individuals, groups or organizations that collect, use, disclose or access such information. Its objective is to instruct in the development and implementation of policies, practices, health information systems or networks and legislation. 7. The principles that make up this Code are interrelated. Health information custodians adopting this Code shall adhere to these principles as a whole. 8. Health information custodians must subscribe to the principles contained in this Code and agree to uphold them, but may tailor this Code by modifying or adding principles provided the changes afford no less protection to the privacy of patients and the confidentiality and security of their health information. 9. Statements containing "shall" or "must" indicate requirements that must be met by any health information custodian who wishes to adopt this Code and be recognized for having done so. The use of "should" indicates a recommendation or aspiration. Section B: Definitions The following definitions apply in this Code: "Access" means the ability to acquire or possess health information in any information format. "Accountability" means having clearly defined and understood responsibilities in connection with health information, agreeing to accept those responsibilities and being subject to appropriate sanctions for failing to fulfil accepted responsibilities. "Authorized" means that which occurs with patient consent or within the provisions of this Code and applies to purposes, collection, use and disclosure of, or access to, health information. "Authorized user" is someone permitted to collect, use, disclose or access health information under the provisions of this Code, who is properly instructed on his or her limits and responsibilities, and who can be held accountable for his or her compliance. "Collection" means the act of accessing, receiving, compiling, gathering, acquiring or obtaining health information from any source, including third parties, and by any means. It includes information collected from the patient, as well as secondary collection of this information in whole or in part by another provider or user. "Confide" and "confided" mean the revelation of information by a patient within the therapeutic context. "Confidentiality" and "confidential" mean that health information that is confided by a patient is to be kept secret and not disclosed or made accessible to others unless authorized by patient consent. A breach of confidentiality occurs whenever a health professional discloses or makes health information available to others without or inconsistent with the patient's consent. "Consent" means a patient's informed and voluntary agreement to confide or permit access to or the collection, use or disclosure of his or her health information for specific purposes. Express consent is given explicitly, either orally or in writing. Express consent is unequivocal and does not require any inference on the part of the provider seeking consent. Implied consent arises where agreement may reasonably be inferred from the action or inaction of the individual and there is good reason to believe that the patient has knowledge relevant to this agreement and would give express consent were it sought. "Disclosure" means the provision of health information to a third party for any reason, or making health information available for a third party to collect. It includes any transfer or migration of health information from one provider or user to another. "Duty of confidentiality" means the duty of physicians and other health professionals in a fiduciary relationship with patients to ensure that health information is kept secret and not disclosed or made accessible to others unless authorized by patient consent. "Emergency situations" mean those instances when health care must be provided to preserve life or prevent severe harm to a patient who is unable, owing to the circumstances, to be cognizant of the context and whose surrogate is not immediately available to make decisions on the patient's behalf. "Fiduciary duty" means the obligation to act with the utmost good faith for the benefit of another. "Health information" means any information about a patient that is confided or collected in the therapeutic context, including information created or generated from this information and information that is not directly or indirectly linked to the provision of health care. It includes all information formats. "Health information custodian" means any organization or institution that has custody, care or control of health information, and includes hospitals, regional boards, governments, corporations and solo or group medical practices. "Information format" means any form containing or recording health information, including: (a) a form that identifies or could identify a specific patient, either directly or indirectly; (b) a form that removes the link between the patient and information about him or her and which could, either directly or indirectly, be manipulated to reconnect the link between the patient and information about him or her ("deidentified-relinkable"); (c) a form that removes the link between the patient and information about him or her with the intent of preventing any reconnection of the link between the patient and information about him or her in accordance with recognized standards ("anonymous"); or (d) the composite form produced when health information is linked to any information about the patient from any other source, whether or not it is also health information. "Integrity of health information" means the preservation of its content throughout storage, use, transfer and retrieval so that there is confidence that the information has not been tampered with or modified other than as authorized. "Health professional" is any person having a fiduciary duty to patients who is registered and entitled by provincial or territorial law to practise or provide health care in that province or territory. "Knowledge" means the patient's awareness of what can or must happen with the health information he or she confides or permits to be collected. "Linkage" is the joining together of health information with information from any other source or database, in whatever form. When health information is linked to any other information, the composite is also health information. "Nonconsensual" collection, use, disclosure or access, whether justified or not, occurs without a patient's consent and contravenes the patient's right of privacy. "Patient" means the person about whom health information is collected and, for the purposes of this Code, may also mean a surrogate or guardian acting on behalf of this person. "Physician" means a person who is registered and entitled under the laws of a province or territory to practise medicine in that province or territory. "Primary" means that which occurs for the therapeutic benefit of a particular patient. Secondary means not directly related to the therapeutic benefit of the particular patient from whom the information has originated. "Purpose" means an end or aim for which health information is collected, used, disclosed or accessed. A description of purpose can be general enough to incorporate a range of like information uses provided that the generic description is sufficiently narrow and limited so as to communicate to the ordinary person a clear understanding of the potential information uses that could reasonably be expected to be relevant to their consent. The primary therapeutic purpose is the delivery of health care to a particular patient with respect to a particular and immediate health need or problem. It encompasses consultation with and referral to other providers on a need-to-know basis. A primary longitudinal purpose concerns developing composite health information about a particular patient, such as a detailed medical history, beyond direct application to any particular and immediate health need or problem, in order to enhance ongoing care to that person. Secondary legislated purposes have been subjected to the legislative test specified in this Code and have subsequently been written in law. Secondary nonlegislated purposes are any other purposes, such as education or research not governed by legislation, that meet the provisions of this Code and the secondary nonlegislative test provided by this Code. "Provider" means a health professional or institution that delivers health care services or products in the therapeutic context. "Right of privacy" includes a patient's right to determine with whom he or she will share information and to know of and exercise control over use, disclosure and access concerning any information collected about him or her; it entails the right of consent. Nonconsensual collection, use, disclosure or access violates the right of privacy, even if it is justified. "Security" means reasonable precautions, including physical and technical protocols, to protect health information from unauthorized collection, use, disclosure and access, and to ensure that the integrity of the information is properly safeguarded. A breach of security occurs whenever health information is collected, used, disclosed or accessed other than as authorized, or its integrity compromised. "Sensitivity" of health information refers to the patient's interest in keeping the information secret. It varies according to the nature of the information, its form, and the potential negative repercussions of its collection, use or disclosure on the patient's interests. "Therapeutic context" means a setting in which information is confided by or collected from, about or on behalf of a patient who: (a) is in a therapeutic relationship with or under the care of a physician or health professional; (b) is resident in or seeking health care within a facility or institution whose principal purpose is the provision of health care, including physicians' offices, hospitals and other health care facilities; (c) confides information within a fiduciary relationship to a health care professional and with the belief that the health care professional will maintain its confidentiality, subject to very limited exceptions; or (d) confides information in the belief that it is necessary for the safe, timely and effective delivery of health care. "Transparency and openness" are the characteristics of policies, procedures and practices that seek to ensure that patients know what can or must happen with the health information they confide or permit to be collected, used, accessed or disclosed. "Use of health information" means any processing of health information including storage, retention, retrieval, manipulation, connection or linkage to other sources of information in any format. Section C: Principles Principle 1: The Right of Privacy The right of privacy is fundamental in a free and democratic society. It includes a patient's right to determine with whom he or she will share information and to know of and exercise control over use, disclosure and access concerning any information collected about him or her. The right of privacy and consent are essential to the trust and integrity of the patient-physician relationship. Nonconsensual collection, use, access or disclosure violates the patient's right of privacy. The right of privacy is important and worthy of protection, not just for the good of individuals in society but also for the good of society as a whole. 1.1 Canadians are entitled to expect and enjoy fundamental privacy rights and guarantees, which include: (a) physical, bodily and psychological integrity and privacy; (b) privacy of personal information; (c) freedom from surveillance; (d) privacy of personal communications; and (e) privacy of personal space. 1.2 The basic duties owed to others to ensure that their privacy rights are adequately respected include: (a) the duty to ensure consent; (b) the duty to take all the steps necessary to respect adequately others' privacy rights or, if their rights must be infringed, to interfere with privacy as little as possible; (c) the duty to be accountable; (d) the duty to be transparent; and (e) the duty to build privacy protection features into technological systems and designs. 1.3 The specific duties related to the protection of the patient's right of privacy in health information include: (a) the duty to hold health care information in trust; (b) the duty to limit information collection to what is necessary and justifiable for the benefit of the patient; (c) the duty to ensure that patients are informed by reasonable means about purposes for collection, use, disclosure or access at or before the time of collection, including the potential for such to occur nonconsensually; (d) the duty to ensure that the information is accurately recorded; (e) the duty to ensure consent by reasonable means, except in limited circumstances where the right of privacy and of consent are justifiably infringed by some compelling right, good or duty; (f) the duty to ensure that the right of privacy and the right to consent are infringed no more than is necessary by the compelling right, good or duty; (g) the duty to use and disclose health information only as consistent with the purposes identified at or before the time it was collected; (h) the duty to keep health information only for as long as necessary to fulfil identified purposes; (i) the duty not to disadvantage people because they elect to exercise their right of privacy; and (j) the duty of physicians and other health professionals to hold information in confidence. 1.4 Although the patient's interests and concerns about health information may vary depending on the sensitivity of the information, the right of privacy extends to all health information in whatever format. Principle 2: Special Nature of Health Information Governing principles and rules for health information must recognize the patient's right of privacy in health information, its highly sensitive nature, the circumstances of vulnerability and trust under which it is confided or collected, and the fiduciary duties of health professionals in relation to this information. The patient-physician relationship as defined by trust and a professional promise of confidentiality is a societal good worthy of protection. 2.1 Principles and rules governing health information must recognize: (a) its high level of sensitivity and protect the patient's right of privacy accordingly; (b) that the principal purpose for confiding and collecting this information is to benefit the patient; (c) that in the therapeutic context patients may be vulnerable and under duress, and must not be subjected to manipulation, coercion or exploitation; (d) that patients confide information to physicians and other health professionals under a very special trust, and that physicians and other health professionals have fiduciary duties to patients, including a duty to hold information in confidence. 2.2 Principles and rules governing health information must ensure that physicians and other health professionals can discharge their fiduciary duties and therefore shall take into account that: (a) patients may be in a situation of vulnerability owing to infirmity or incapacity, urgent need, lack of knowledge and power, or simply because they have needs and have to rely or depend upon providers to meet those needs; (b) patients confide information that is ordinarily considered by them to be private because they have certain needs that require the care of a provider and believe the information is required by the provider to help meet those needs; (c) were it not for those needs, and the expectation that the provider can help patients meet them, the occasion for the collection of the health information would not exist and the information would remain private; (d) were it not for the reputation of health professionals for trustworthiness and the expectation that information disclosed to them will be held in confidence, patients would be less willing to confide health information fully and truthfully in the therapeutic context; and (e) to the extent that provisions for health information inhibit patients from confiding health information fully and truthfully, their health care will be adversely affected. Principle 3: Constraints on Purposes and Limitation on Collection, Use, Disclosure and Access The principal purpose for the collection of health information is to benefit the patient who confides or permits information to be collected for a therapeutic purpose. Secondary purposes for the use of the information shall not be pursued if they inhibit patients from confiding information for the primary purpose, exploit patients' vulnerability, compromise the ability of physicians to discharge their fiduciary duties to patients or borrow on the trust patients invest in physicians for the primary therapeutic purpose. Collection, use, disclosure or access for secondary purposes shall be restricted to what is necessary for those purposes and shall not impede the confiding or collection of information for primary purposes. Nonconsensual access to and collection, use or disclosure of health information is a violation of a patient's right of privacy, compromises the physician's duty of confidentiality and is potentially disruptive of the trust and integrity of the therapeutic relationship. Therefore, it must only occur in very limited circumstances - namely emergency situations, in accordance with legislation that meets the requirements of this Code, or in response to a court decision or order. Even consensual collection, use, disclosure or access may erode the right of privacy and the trust and integrity of the therapeutic relationship. Therefore, it must only occur with due consideration of possible negative impacts and with measures designed to maximize privacy protection. 3.1 Provided that the principles contained in this Code are adhered to, and in particular that the principles related to patient consent are rigorously applied, health information may be collected, used, disclosed or accessed for the following purposes: (a) Primary purposes: (i) Primary therapeutic purpose is the initial reason for a patient seeking or receiving care in the therapeutic context, and pertains to the delivery of health care to a particular patient with respect to the presenting health need or problem. It encompasses consultation with and referral to other providers on a need-to-know basis. (ii) Primary longitudinal purpose concerns developing composite health information about a particular patient, such as a detailed medical history, beyond direct application to the presenting health need or problem, in order to enhance ongoing care to that person. (b) Secondary purposes: (i) Secondary legislated purpose refers to health information collection, use, disclosure or access required or permitted by legislation or regulation that meets the provisions of this Code and the legislative test provided by this Code. (ii) Secondary nonlegislated purpose is any other purpose, such as education or research not governed by legislation, that meets the provisions of this Code and the secondary nonlegislative test provided by this Code. 3.2 Health information collection, use, disclosure or access for the primary therapeutic and longitudinal purposes may be as extensive as necessary to fulfil these purposes and reflect the high level of trustworthiness and accountability of health professionals in the therapeutic context. 3.3 Health information collection, use, disclosure or access for any secondary purposes shall be as minimal as necessary in recognition of the need to protect the patient's right of privacy in the therapeutic context. 3.4 Health information collection, use, disclosure or access without patient consent shall only occur in the limited circumstances provided by this clause. Nonconsensual health information collection, use, disclosure or access, including the conversion of health information from one information format to another, is a violation of a patient's right of privacy, may compromise the physician's duty of confidentiality, and is potentially disruptive of the trust and integrity of the therapeutic relationship. Therefore, it must only occur under strict conditions and in these very limited circumstances: (a) when permitted or required by legislation or regulation that meets the requirements of this Code; or (b) when ordered or decided by a court of law. 3.5 Any existing or proposed secondary purpose for health information collection, use, disclosure or access, including health information systems or networks, shall be subjected to a patient privacy impact analysis that shall include an evaluation of: (a) the likely impact of the proposed measures on the right of privacy of patients; (b) the likely impact of the proposed measures on the relationship between patients and their physicians, and in particular on the duty of confidentiality and the trust within this relationship; (c) the likely impact of the proposed measures on the willingness of patients to disclose health information; (d) the likely impact of the proposed measures on the ability of patients to receive health care; and (e) compelling evidence to demonstrate broad public support for the proposed measures. 3.6 Any proposed or existing legislation or regulation made under legislative authority that permits or requires health information collection, use, disclosure or access shall be subjected to the following legislative test: (a) There must be demonstration that: (i) a patient privacy impact assessment has been conducted, the analysis has been made public and has been duly considered prior to the introduction of legislation; (ii) collection, use, disclosure and access will be limited to the greatest degree possible to ensure that - the collection of health information by persons external to the therapeutic context will neither trade on nor compromise the trust of the patient-physician relationship; - patients are not likely to be inhibited from confiding information for primary purposes; - the ability of physicians to discharge their fiduciary duties to patients will not be compromised; and - patient vulnerability will not be exploited; (iii) collection, use, disclosure and access will be restricted to what is necessary for the identified purpose(s) and will not impede the confiding or collection of information for primary purposes; (iv) provisions exist for ensuring that patients are provided with knowledge about the purpose(s) and that, subject to 3.6(b), patient consent is clearly voluntary; (v) the means used are proportionate and the collection will be limited to purposes consented to or made known to the patient; (vi) the patient's privacy will be intruded upon to the most limited degree possible in light of the purpose(s) consented to or made known to the patient; (vii) linkage of the health information will be limited; and (viii) unless clear and compelling reasons exist, - all reasonable steps will be taken to make health information anonymous; and - if it has been demonstrated that making health information anonymous would render it inadequate for legitimate uses, the information will be collected and stored in a deidentified-relinkable format. (b) When nonconsensual collection, use, disclosure or access is permitted or required by legislation or regulation that meets the requirements of this Code, the following conditions must also be met: (i) the right of privacy has to be violated because the purpose(s) could not be met adequately if patient consent is required; and (ii) the importance of the purpose(s) must be demonstrated to justify the infringement of the patient's right of privacy in a free and democratic society. (c) Any legislative provision or regulation that permits or requires health information collection, use, disclosure or access nonconsensually shall not, without compelling reasons, be applied retroactively to existing health information. 3.7 Any proposed or existing secondary nonlegislated purpose shall be subjected to the following nonlegislative test: (a) Before a health information custodian uses health information in its custody for secondary nonlegislated purposes, or before it releases or makes health information accessible to an external third party for secondary nonlegislated purposes, it must demonstrate or require the third party to demonstrate that: (i) a patient privacy impact assessment has been conducted, the analysis has been made public, the results have been duly considered and uses for that purpose will not be pursued if there is an adverse effect on privacy; (ii) collection of health information by persons beyond the therapeutic context will not exploit or compromise the trust of the patient-physician relationship; (iii) patients are not likely to be inhibited from confiding information for primary purposes; (iv) the ability of physicians to discharge their fiduciary duties to patients will not be compromised; (v) patient vulnerability will not be exploited; (vi) collection will be restricted to what is necessary for the identified purpose(s) and will not intrude upon primary purposes; (vii) patients will be fully informed of the purpose(s) and patient consent will be clearly voluntary; (viii) patient privacy will be intruded upon to the most limited degree possible in light of the purpose(s) consented to; (ix) linkage of health information will be restricted and consented to by the patient; (x) unless clear and compelling reasons exist, - all reasonable steps will be taken to make health information anonymous; - if it has been demonstrated that making health information anonymous will render it inadequate for legitimate uses, then the information will be collected and stored in a deidentified-relinkable format; (xi) any third party to whom health information is released has adopted this Code or has equivalent provisions in place; and (xii) the purpose(s) will not be applied retroactively to existing health information unless patient consent is given. 3.8 Health information shall not be collected by means that are unlawful, unfair or exploit the patient's vulnerability, nor shall any of the patient's beliefs or potentially false expectations about subsequent collection, use, disclosure or access be exploited. 3.9 Courts of law should respect the provisions of this Code when issuing orders or decisions. 3.10 Health information shall be retained only as long as it is necessary to fulfil authorized purposes. Once the authorized purposes are fulfilled it shall be securely destroyed, unless some issue or decision related to the patient and pertinent to the patient's health information is pending. Principle 4: Knowledge and Specification of Purpose, Collection, Use, Disclosure and Access In the therapeutic context, health information is confided by or collected from patients under the patient's presumption that it is necessary to meet his or her therapeutic needs. The potential that health information, in whole or in part, may be subsequently collected, used, disclosed or accessed for other purposes without their consent, and what those purposes might be, must be made known to the patient by reasonable means before it is confided or collected for primary purposes. It is not acceptable to withhold such knowledge from patients deliberately out of concern that knowledge could inhibit them from confiding important information fully and truthfully. 4.1 A health information custodian must have documentation that lists all purposes for which it uses or discloses the health information it collects, including to whom it permits access to what information, in what format and whether consent is required. 4.2 Within the therapeutic context health information is confided or provided by patients in the knowledge or with the belief that it is necessary to achieve therapeutic purposes. Patients must be explicitly informed about any other purposes. 4.3 Health information must not be used for purposes not identified to the patient at or before the time it is confided or collected, unless patient consent is subsequently sought and obtained. 4.4 Patients must either have or be provided by reasonable means with knowledge about what can or must happen with their health information. The degree of detail or specificity of this knowledge is what could be presumed germane to the decision of a reasonable person in the circumstances of the patient. 4.5. Unless a particular patient has given indication to the contrary, the conveyance of generic information is a reasonable means of providing knowledge. When the preferences of a particular patient for being informed are known or can be reasonably inferred given his or her circumstances, the provision of knowledge should as much as possible be tailored to these known preferences. 4.6 The goal of providing knowledge to patients is to ensure that before they confide information or permit information to be collected they actually understand what can or must subsequently happen with their information, particularly without their consent. Principle 5: Consent The patient's ability to decide with whom he or she will share information is crucial for the protection of the right of privacy and for the preservation of trust in the therapeutic context. Only the patient's consent to health information collection, use, disclosure and access for the primary therapeutic purpose can be inferred. Except for the very limited nonconsensual purposes addressed in this Code, any other collection, use, disclosure or access requires express consent. Nonconsensual collection, use, disclosure or access infringes the right of privacy and compromises the trust of the fiduciary relationship. To satisfy the requirement that consent be informed, the patient must have, or by reasonable means be provided with, knowledge about the potential for subsequent nonconsensual collection, use, disclosure or access before he or she confides any information. 5.1 Except for the very limited conditions set out in 3.4 concerning nonconsensual collection, use, disclosure or access, consent is required for health information collection, use, disclosure or access for any purpose. 5.2 For the purposes of this Code, consent for health information collection, use, disclosure or access in emergency situations is deemed to have been given to the extent necessary to allay the emergency as consistent with legal principles governing emergency medical care. The protection accorded this information shall be consistent with the provisions of this Code. 5.3 Consent to health information collection, use, disclosure and access for the primary therapeutic purpose may be inferred. Consent to subsequent collection, use, disclosure and access on a need-to-know basis by or to other physicians or health providers for this purpose, and for this purpose alone, may be inferred, as long as there is no evidence that the patient would not give express consent to share the information. 5.4 Interpretation of "need-to-know" shall be guided by consideration of what the reasonable person in similar circumstances would expect, or otherwise authorize by his or her consent. If expectations are unclear or ambiguous, care should be taken to ascertain those expectations and to make the flow of information among providers in the therapeutic context consistent with those expectations. 5.5 Consent to collection, use, disclosure and access for longitudinal primary purposes must be express unless the provider has good reason to infer consent. 5.6 For the purposes of this Code, disclosure of health information to the patient's relatives or significant others is recognized as assisting in primary purposes. Consent to this disclosure must be express unless the provider has good reason to imply patient consent. 5.7 Consent can only be inferred in the case of primary purposes, and for primary purposes alone; collection, use, disclosure or access thus authorized must be limited either to the known expectations of a particular patient or to what the reasonable person in similar circumstances would likely believe necessary to receive health care. 5.8 Implied consent does not deprive the patient of the right to refuse consent or the right to challenge the provider's finding of implied consent. 5.9 Patient consent for secondary nonlegislated purposes shall be express, voluntary and fully informed. 5.10 Where express consent is required, patients must be informed of their right to refuse consent. It is not acceptable to compromise care deliberately as a consequence of the patient's refusal to provide express consent or to exploit any fear the patient might have that this could occur. 5.11 Consent shall not be obtained by coercion, deception or manipulation. Failure to inform the patient by reasonable means of relevant information pertinent to consent invalidates this consent. 5.12 Although all health information is sensitive and should be treated as such, the more sensitive the health information is likely to be, given what is known about the circumstances or preferences of the patient, the more important it is to ensure that consent is voluntary and informed. Principle 6: Individual Access Patients have the right of access to their health information. In rare and limited circumstances, health information may be withheld from a patient if there is a significant likelihood of a substantial adverse effect on the physical, mental or emotional health of the patient or substantial harm to a third party. The onus lies on the provider to justify a denial of access. 6.1 The patient is entitled to know about, and subject to 6.5 to have access to, any information about himself or herself under the custody of the health information custodian. 6.2 Patients should be informed that they have the right to access their health information, to read it and to have copies of it. 6.3 Patients who wish to access their information should be given the opportunity to do so with explanation from a health professional who is knowledgeable about this information and capable of interpreting it for the patient. 6.4 Patients must be able to receive copies of their health information at a reasonable cost that does not exceed the cost of providing the information. 6.5 Providers may, in rare and limited circumstances, withhold health information from a patient if there is a significant likelihood of a substantial adverse effect on the physical, mental or emotional health of the patient or substantial harm to a third party. The onus is on the provider to justify a denial of access. 6.6 Patients are entitled to know who has gained access to their health information and for what purposes. Principle 7: Accurate Recording of Information Accurate recording is important to protect the patient's right of privacy and to meet the purposes for its collection, use, disclosure or access. 7.1 Health information shall be recorded as accurately as possible, and shall be as complete and current as necessary for authorized purposes. 7.2. The recording of statements of fact, clinical judgements and determinations or assessments should reflect as nearly as possible what has been confided by the patient and what has been ascertained, hypothesized or determined to be true using professional judgement. 7.3 Patients who have reviewed their information and believe it to be inaccurately recorded or false have the right to suggest amendments and to have their amendments appended to the health information. 7.4 Whenever possible, health information should be recorded in a form that allows for authorized secondary purposes consented to by the patient. Any standardization of recording requirements relevant to subsequent secondary purposes shall not impede recording of information for primary purposes. Principle 8: Security Security safeguards must be in place to ensure that only authorized collection, use, disclosure or access occurs. Such safeguards must also assure the integrity of the available information. 8.1 Health information, regardless of the information format, shall be protected by security safeguards to ensure compliance with the provisions of this Code. 8.2 The development of security safeguards with respect to levels of access for various users shall recognize the differences in the sensitivity of health information and permit access accordingly. 8.3 Security safeguards shall impede as little as possible health information collection, use, access and disclosure for primary purposes. 8.4 A health information custodian shall ensure that persons are able to collect, use, disclose or access health information in its control only as authorized. Persons thus authorized must have a clear understanding of the authority, parameters, purposes and responsibilities of their access, and of the consequences of failing to fulfil their responsibilities. 8.5 An authorized person's access to health information, including persons or groups external to the health information custodian, shall be limited to only the information needed for the authorized purpose(s), in the least intrusive format. 8.6 Security safeguards shall include both physical and human resource safeguards to prevent unauthorized health information collection, use, disclosure and access. Physical security measures include such safeguards as locked filing cabinets, restricted access to certain offices or areas, and the use of passwords, encryption and lock-boxes. Human resource security measures include security clearances, sanctions, training and contracts. 8.7. Health information custodians must protect health information in their custody so as to ensure its integrity and have assurance that the integrity of information received from other health information custodians has been similarly safeguarded. 8.8 Security safeguards should incorporate identification, authentication, information integrity/availability and non-repudiation, as appropriate. Principle 9: Accountability Accountability is owed first and foremost to the patient. Health information custodians must have in place policies and procedures that recognize this principal accountability and health professionals' duty of confidentiality to the patient. Anyone a health information custodian authorizes to have access to health information must be capable of being held accountable for his or her actions. In addition, health information custodians must designate a qualified person responsible and accountable for monitoring and ensuring internal compliance with this Code. 9.1 Health information custodians are responsible for the security of health information they collect, use, disclose or permit access to. 9.2 Health information custodians must ensure that persons, including administrative and technical support staff, receive authorization to access health information only as necessary to fulfil authorized purposes. 9.3 A health information custodian must ensure that anyone permitted to have access to health information has clearly defined and understood responsibilities in connection with health information, agrees to accept those responsibilities, and is subject to appropriate sanctions for failing to fulfil the accepted responsibilities. 9.4 Health information custodians must designate a qualified person responsible and accountable for monitoring and ensuring internal compliance with this Code. The designated accountable person shall have the autonomy, authority, and resources necessary to ensure the health information custodian's adherence to the Code. In the case of small private practices, practitioners may designate themselves. 9.5 Policies and procedures to ensure compliance with this Code must consider the special, direct accountability of health professionals to their patients. The high level of trust vested in health professionals is crucial to the initial confiding of health information for the therapeutic purpose. 9.6 Health information custodians must ensure that third parties privy to health information have adopted this Code or are bound by equivalent provisions. Provided that this has been determined before health information is disclosed or made accessible, health information custodians are not accountable for the actions of third parties or for what subsequently happens to the information. 9.7 Although it is the responsibility of the health information custodian to ensure that patients are appropriately informed, secondary users whose information requirements impose a burden upon the health information custodian are responsible for covering their share of any related costs or resource requirements (e.g., preparation of brochures). Health information custodians may reasonably require secondary users to cover their own costs as a condition of making health information available to them as authorized. Principle 10: Transparency and Openness Policies, procedures and practices relating to health information must be transparent so that patients can clearly understand the extent and circumstances of health information collection, use, disclosure and access. They must be explicit enough that patients are adequately informed and able to acquire knowledge germane to their confiding of information, and must be open to scrutiny and challenge. 10.1 Health information custodians must have transparent, explicit and open policies, procedures and practices, tailored to their practice setting, that seek to ensure that patients are provided with information about what can or must happen with their health information without their consent. 10.2 Policies, procedures and practices shall be as explicit as necessary to ensure that patients are aware of any considerations that could be relevant to deciding what information they elect to freely confide or consent to be collected, used, disclosed or accessed. Nothing must be left implicit that, if made explicit, could reasonably be expected to alter a patient's decision to freely confide information. Information about nonconsensual collection, use, disclosure and access must be made explicit. 10.3 Patients should be able to discuss the health information custodian's policies, procedures and practices concerning health information with a knowledgeable person and have specific questions about their own health information answered in a timely fashion. 10.4 A health information custodian's policies, procedures and practices shall ensure that patients can understand what might, can or must happen to their health information, that consent is sought as required by this Code and that nothing is left implicit or unknown to patients that if known or made explicit could reasonably be expected to alter a patient's decision to freely confide information. 10.5 Patients shall be able to challenge the health information custodian's compliance with the provisions of this Code by addressing their concerns to the designated accountable person. 10.6 Procedures shall be in place to receive and respond to complaints or inquiries about policies, procedures and practices relating to health information collection, use, disclosure and access. The complaint process must be easily accessible and simple to use. 10.7 Patients who make inquiries or lodge complaints shall be informed of the existence of relevant complaint mechanisms. 10.8 All complaints shall be investigated. If a complaint is found to be justified, appropriate remedial measures shall be taken such as amending policies, procedures or practices. Section D: Health Information Policies Health information custodians must have in place and implement policies, procedures and practices that give effect to the principles of this Code. 1.1 Health information policies, procedures and practices should be tailored to the specific health care setting of the custodian and shall address and provide for: (a) complying with and giving effect to the principles of this Code; (b) protecting the security of health information; (c) ensuring the accurate recording and integrity of health information; (d) documentation of all purposes for which the health information custodian uses or discloses the health information it collects, including to whom it permits access to what information, in what format and whether consent is required; (e) documentation of what health information may be linked to other pieces of information; (f) documentation of what health information is made available to third parties; (g) allowing access only to authorized users in the appropriate format and for the limited purposes for which they are authorized; (h) identification of the person who is accountable for the policies, procedures and practices and to whom complaints or inquiries can be made; (i) receiving and responding to complaints and inquiries; (j) ensuring that persons who collect, use, disclose or access health information can be held accountable and are under an enforceable duty to keep information secure; (k) ensuring that persons who work for or in the health institution know and receive sufficient training about this Code and related institutional policies, procedures and practices to ensure accountability; (l) the means of gaining access to one's own health information held by the health institution; (m) making available information that a particular patient specifically requests or reasonably can be presumed to wish to know; (n) ensuring that patients have, or by reasonable means are provided with, knowledge about their health information and that consent is sought and obtained as appropriate; and (o) specification of minimum and maximum retention periods and rules for the succession, transfer and destruction of health information. 1.2 The health information custodian's policies must be readily available to patients and should include information about practices and procedures. 1 Though this submission uses the word "product" in this context, it is understood that services, e.g. therapeutic procedures, may also be covered by the Health Protection Act. 2 DTCA is not legal in Canada, except for notification of price, quantity and the name of the drug. However, "information-seeking" advertisements for prescription drugs, which may provide the name of the drug without mentioning its indications, or announce that treatments are available for specific indications without mentioning drugs by name, have appeared in Canadian mass media. 3 Though the paper applies primarily to prescription drug information, its principles are also applicable to health information in general.
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Joint Submission to the Subcommittee on Sport-Related Concussions in Canada House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy14080
Date
2019-01-29
Topics
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Date
2019-01-29
Topics
Health care and patient safety
Text
Based on a well-established collaboration addressing concussion, the Canadian Academy of Sport and Exercise Medicine (CASEM) the College of Family Physicians of Canada (CFPC), and the Canadian Medical Association (CMA) are pleased to submit this brief to the Subcommittee on Sport-Related Concussions (SCSC) of the House of Commons Standing Committee on Health. About the Canadian Academy of Sport and Exercise Medicine (CASEM) CASEM is a physician member-based organization comprised of 850 medical doctors from many specialties who have specialized training and skills in sport and exercise related injuries/illnesses for active patients of all ages and abilities, including concussion care. CASEM physicians hold national and international leadership roles in concussion care. Namely, at the national level, CASEM chairs the Canadian Concussion Collaborative (CCC) and at the international level, several CASEM members played leadership roles in the development of the International Consensus Statements on Concussion in Sport which is the key document that establishes concussion management recommendation every 4 years. About the College of Family Physicians of Canada (CFPC) The CFPC is the professional organization that represents more than 38,000 family physician members across the country. The College establishes the standards for, and accredits, postgraduate family medicine training for Canada’s 17 medical schools. It reviews and certifies continuing professional development programs, and materials, that enable family physicians to meet certification and licensing requirements. The CFPC provides high-quality services, supports family medicine teaching and research, and advocates on behalf of family physicians and the specialty of family medicine. About the Canadian Medical Association (CMA) The Canadian Medical Association unites 85,000 physicians on national health and medical matters. Formed in Quebec City in 1867, the CMA’s rich history of advocacy led to some of Canada’s most important health policy changes. As we look to the future, the CMA will focus on advocating for a healthy population and a vibrant profession. Along with CASEM, the CMA is a co-founding member of the CCC. 3 KEY KEY THEMESTHEMES AND RECOMMENDATIONSAND RECOMMENDATIONS: In this brief, CASEM, CFPC, and the CMA submit a series of recommendations under two key themes. Taken as a whole, we believe these will help inform the Subcommittee’s study on how to improve concussion awareness, prevention and treatment for all Canadians. Background information regarding the groups and initiatives mentioned in the key themes and recommendations, is provided in the subsequent part of this document. KEY THEME #1: The impacts of concussion and the benefits of awareness efforts are slowly becoming better known at the higher levels of sport participation that received support for the implementation of proper concussion management strategies (namely through the Canadian Concussion Protocol Harmonization Project). Further efforts and government funding should address the issue at all levels of sport participation. This must include school-based sport programs, and concussion occurring in other contexts (e.g. leisure, occupation, etc.). RECOMMENDATIONS related to key theme #1: #1.1 The federal government should commission and fund the development and evaluation of additional efforts to improve awareness and proper management of concussion at all levels of sport participation and contexts where concussions occur in Canada. #1.2 Since “key aspects of concussion prevention, detection and management occur prior to, as well as after, the initial medical intervention”1, “public health strategies should be developed and implemented to address the issue of concussions.”1 #1.3 Given their competencies and expertise in this area, “family physicians2 and sport and exercise medicine (SEM) physicians should play a central role in the design and implementation of strategies that work in conjunction with families, schools, sports organizations, employers and governments to educate, support and empower the implementation of proper concussion prevention, detection and management protocols.”1 #1.4 Any future effort to improve concussion awareness and management should, whenever possible, be evidenced-informed, and aim for synergy with ongoing Canadian initiatives. #1.5 Innovative dissemination strategies that have the potential to reach all levels of sport participation and contexts where concussions occur should be considered and evaluated (e.g. massive open online course or MOOC 3). 1 The Role of Family Physicians and physicians with Added Competencies in Sport and Exercise Medicine in a Public Health Approach to Concussions. A joint position statement of CASEM, CFPC, and the CMA. 2017 https://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=4319&langType=4105 2 This is not meant to exclude the possible role of other health care disciplines, such as nurse practitioners, that can be involved in the diagnosis and medical management of concussions in some Canadian jurisdictions. 3 https://www.ulaval.ca/les-etudes/mooc-formation-en-ligne-ouverte-a-tous/commotion-cerebrale-prevention-detection-et-gestion-dans-mon-milieu.html 4 KEY THEME #2: For the majority of Canadians affected by a concussion, family physicians play a central role in concussion identification and management through the recovery process. However, where persistent concussion symptoms arise, family physicians and their patients require timely access to SEM physicians, and multidisciplinary care for the development and implementation of individualized treatment plans. As it presently stands, access to such expert medical and multidisciplinary resources for concussion is very limited (especially in rural and remote regions). To complicate matters, Canadians affected by a concussion are all too often uncertain how best to navigate a health care system that isn’t well organized to address their unique needs. RECOMMENDATIONS related to key theme #2: #2.1 Medical schools and organizations should maintain continuous efforts aiming for the rapid integration of the most current clinical practice recommendations about concussion. #2.2 Initial care for Canadians affected by a concussion should be coordinated by the patient’s family physician. #2.3 To work in collaboration with their family physicians, patients affected by persistent symptoms following a concussion should have timely access to medical experts on concussion and allied professionals with expertise in concussion management. #2.4 The potential of telemedicine strategies or other virtual network to improve access to concussion experts for support in the management of concussion should be considered and evaluated. BACKGROUNDBACKGROUND:: The challenging dynamics of concussion: Sport-related concussion seriously impacts the health and well-being of Canadians across the country; to say nothing of the costs to the health care system and concussed individuals. Canadian statistics show that among children and youth (10-18 years) who visit an emergency department for a sports-related head injury, 39% were diagnosed with concussions, while a further 24% were possible concussions.4 Between 2003 and 2013 in Ontario, a 4.4-fold increase of pediatric concussion-related consultations has been observed, with a sharp increase between 2010 and 2013 and nearly 35000 visits in 2013.5 Although, the precise reasons for this increased incidence of concussion are unknown, the study suggests that “…concussion education and awareness, improved diagnosis of 4 https://www.canada.ca/en/canadian-heritage/services/concussions.html 5 Zemek et al. J Pediatr 2017; 181: 222-8 (https://doi.org/10.1016/j.jpeds.2016.10.067) 5 concussion, and revised concussion guidelines advocating stricter follow-up…” played an important role. The body of knowledge regarding concussion is rapidly and constantly changing; a dynamic that is unlikely to change for the foreseeable future. One important limitation of our knowledge about concussion is the lack of information on the true burden of concussion in Canada. A significant proportion of all concussions are not captured by traditional health-related databases, or clinical research, because individuals often do not consult a physician. One positive and recent development that will help better understand the true burden of sport related concussion in youth occurred in November 2018 when a group of more than 30 Canadian researchers including CASEM and CFPC leaders on concussion received $12 million from the National Football League “Play Smart, Play Safe” initiative.6 This 3-year longitudinal cohort study will evaluate diagnostic tools, prognostic indicators, prevention strategies, and treatment strategies. This study will characterize the true incidence rate and recovery characteristics of concussion in high school-based sport settings. Psychological and social factors must also be considered. Attitudes and awareness towards injury are complicating factors that highlight the need for improved concussion prevention and awareness. These include injury minimization, the lack of a visible injury, and a general lack of both pre and post-injury awareness. Those closely associated with a concussed individual (coaches, co-workers, employers, or an injured individual themselves) may have an incentive, or experience pressure, to hide/downplay injury or avoid medical assessment due to stigma.7 The natural human predilection towards downplaying the nature of injury is another important factor to consider, especially where, post-injury, the effects aren’t clearly visible. A concussed individual may lack the mental acuity to be able to understand that their symptoms require medical attention. Another area to consider is the availability of qualified health care resources. Family physicians, whether in primary care settings or emergency departments, and SEM physicians, are generally the first medical professionals seen by a person who has sustained a concussion during a sport, leisure or occupational activity. They are the first point of contact for proper management, advice, and education regarding that person’s gradual return to cognitive (e.g. school and work) and physical activities (e.g. sport, exercise or work).8 Gaps in medical training, and the fast-paced evolution of concussion best practices, means that clinicians sometimes struggle to maintain up-to-date knowledge regarding the detection and treatment of concussions. These factors are further complicated by ambiguous scopes of practice across the multidisciplinary professions involved 6 https://www.ucalgary.ca/utoday/issue/2018-11-16/nfl-gives-significant-funding-help-youth-shred-burden-concussion 7 Delaney J, Caron J, Correa J, et al. Why Professional Football Players Choose not to Reveal their Concussion Symptoms During a Practice or Game. Clin J Sport Med, 2018, 28(1): 1-12. 8 College of Family Physicians of Canada & Canadian Academy of Sport and Exercise. Joint Position Statement - The Role of Family Physicians and Physicians with Added Competencies in Sport and Exercise Medicine in a Public Health Approach to Concussions. 2017. 6 with concussion management. Finally, there is general lack of available medical experts on concussion to whom family physicians can refer patients that present persistent symptoms. Our recommendations also take into consideration the following factors:
The simple principles of initial concussion management6-8 are within the scope of practice of family physicians.
In the vast majority (80-90%) of cases, once simple principles of initial management have been implemented, concussion is a condition that will evolve favorably within 7-10 days.8
Even with proper initial management, some concussion patients will present with persistent symptoms that require a multidisciplinary team approach.
“Persistent symptoms” has been defined as more than 4 weeks in youth and more than 2 weeks in adults.9
Access to physicians with added competencies in concussion care (e.g. SEM Physicians, Physiatrists, Neurologists), and allied health professionals with experience in treating specific presentations of concussions is limited, especially in Canada’s rural and remote areas. CASEM & CFPC’s concussion efforts to date: Since 2012, CASEM has played a key role in the evolution of concussion care in Canada by leading the work of the CCC10. The CCC is composed of 18 health organizations concerned with concussions that aim “to improve education about concussions, and the implementation of best practices for the prevention and management of concussions”. The CFPC has been involved with the CCC from the start. In 2015, the CCC published 2 key recommendations in a document entitled “Recommendations for policy development regarding sport-related concussion prevention and management in Canada”11 that state:
Organizations responsible for operating, regulating or planning sport and sporting events with a risk of concussion should be required to develop/adapt and implement a concussion management protocol, based on current best practices, that is customized for their context and available resources.
In situations where timely and sufficient availability of medical resources qualified for concussion management is lacking, multidisciplinary collaborative approaches should be used to improve concussion management outcomes while facilitating access to medical resources where appropriate. Since 2015, the CCC has contributed a multidisciplinary health care perspective to key concussion-related initiatives in Canada. The first of these initiatives was initiated in January 2015 by Sport Canada and led to the creation of a Federal-Provincial-Territorial working group (FTP-WG) on 9 McCrory et al. Consensus statement on concussion in sport. (2017) https://bjsm.bmj.com/content/51/11/838 10 https://casem-acmse.org/resources/canadian-concussion-collaborative/ 11 https://bjsm.bmj.com/content/49/2/88 7 concussion that brings together sport, education, government and health stakeholders. Later in 2015, the mandate letters from Prime Minister Trudeau asked the Minister of Health and the Minister of Sport and Persons with Disabilities to collaborate on a national strategy on concussion. The Federal government budgeted $1.4 million to allow the Public Health Agency of Canada to work with provinces and territories to develop harmonized concussion management guidelines across Canada.12 Most of that work has been accomplished by funding to Parachute for the development of the Canadian guideline on concussion in sport.13 Members of the CCC and concussion leaders from the CFPC and CASEM were closely involved. Since 2016, one of the CASEM and CFPC leaders on concussion developed a Massive Open Online Course (MOOC) to develop general awareness on concussion and facilitate the implementation of proper concussion management protocols in specific settings. After 4 iterations of that French language MOOC, over 8000 participants have accessed it. Presently an English version is being developed in collaboration between Laval University and the University of Calgary. In August 2017, CASEM and CFPC, published a joint position statement entitled “The role of family physicians and physicians with added competencies in sport and exercise medicine in a public health approach to concussions”14 that is directly related to the recommendations presented in this brief. Finally, since mid-2018, CASEM and CFPC have partnered with the Canadian Medical Association (CMA) to completely revamp the CMA’s policy on Head Injury in Sport. To foster high-level advocacy, cultural sensitivity, and awareness messaging on concussion, it has been redeveloped for a host of target audiences from all relevant perspectives. It is set for release in early 2019. CONCLUSIONCONCLUSION: Concussion is a pressing public health issue in Canada. The members of the SCSC should keep in mind that concussions are not limited to higher level organized sport. It’s a sudden, and unwanted challenge that hundreds of unsuspecting and unprepared Canadians face each day. These concussions occur in a range of situations, inside and outside of sports settings, and often go untreated; with a potential for tragic consequences. To truly address the issue and make progress towards the objectives expressed by Prime Minister Trudeau in the mandate letters, the Government of Canada must provide significant investments. To make progress across the spectrum of sports, leisure and other context where concussions 12 https://www.budget.gc.ca/2016/docs/plan/ch5-en.html 13 The Canadian guideline on concussion in sport was part of the Parachute-led Concussion Protocol Harmonization Project. 14 https://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=4319&langType=4105 8 occur, the Government funding should minimally represent a 10-fold increase from the initial $1.4M budgeted in 2016. With their respective membership, tools and resources, CASEM and the CFPC can play an important role in addressing the burden that concussions place on Canadians. With this brief, we are expressing the willingness of our organizations to collaborate with the government in the design and implementation of strategies to systemically address concussion from all causes as a public health issue. To be successful this must occur across all levels of sport participation and include: leisure, school-based sports, occupational activities and address the rural and remote areas of the country. On behalf of CASEM, and the CFPC, we would welcome the opportunity, and privilege, to present and discuss these recommendations with your Committee. Respectfully submitted, Dr. Paul Watson CASEM President Dr. Pierre Fremont Chair of the CFPC’s SEM Committee and Past President of CASEM Dr.Tatiana Jevremovic Past President of CASEM Dr. Gigi Osler CMA President Contacts: Dawn Haworth, Executive Director, CASEM dhaworth@casem-acmse.org 613 748 5851 – ext 1 Artem Safarov, Director of Health Policy and Government Relations, CFPC asafarov@cfpc.ca 905-629-0900 x 249
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Letter to the Honourable Pierre Pettigrew on mandatory retirement

https://policybase.cma.ca/en/permalink/policy11701
Last Reviewed
2017-03-04
Date
2004-03-24
Topics
Health human resources
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2017-03-04
Date
2004-03-24
Topics
Health human resources
Text
Dear Minister: On behalf of the Canadian Medical Association, I am writing to highlight the concerns of our members regarding the issue of mandatory retirement for physicians practicing medicine in Canada. The sustained interest in this subject follows as a result of a resolution adopted by the CMA General Council on August 20, 2003. This resolution reads "that CMA, its divisions and affiliates advocate for the enactment of regulations and/or legislation that will prevent mandatory retirement of physicians based on age." Your predecessor, the Honourable Anne McLellan, requested further information from the CMA with regard to the aforementioned legislation, for the purposes of further discussion with provincial counterparts. Currently, rules governing mandatory retirement of physicians are complex and vary across jurisdictions. Nationally, the Canadian Human Rights Act governs mandatory retirement only insofar as physicians are considered employees of a federally regulated sector. The Act states that mandatory retirement is not discriminatory when a person has "reached the normal age of retirement for employees performing similar types of work." Provincially/territorially, human rights legislation varies from jurisdiction to jurisdiction. In general, employers are not allowed to discriminate on the basis of age, although some provinces and territories only protect employees to the age of 65. Most physicians however, operate as self-employed business persons, billing provincial Medicare plans on a fee-for-service basis, according to tariffs agreed upon by provincial medical associations. This means that human rights legislation does not protect most physicians. Therefore, while physicians are still free to practice medicine after they reach the age of 65 (i.e. contract to provide medical care to patients, and bill the provincial insurer for insured services), renewal of their admitting privileges depends on the policies or regulations of individual hospitals. In light of the evidence supporting an existing shortage of physicians, federal and provincial/territorial decision makers should be acutely aware of the detrimental effect mandatory retirement has with regard to health human resource planning initiatives. Currently, 10.7% of practising Canadian physicians are over the age of 65. Many of these physicians practice quite actively. In 2003, a CMA survey indicated that physicians over 65 reported working on average 46 hours per week, excluding on-call responsibilities. To remove this experienced cohort of practitioners from the practice setting would be to further exacerbate the growing medical professional shortage. It is shortsighted to uphold restrictions on the practice of medicine by physicians, solely on the basis of age. Continuing professional development for practicing physicians throughout their medical careers is mandated by both the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada as a requirement of maintenance of certification. In a system which self-regulates based on competency, barriers to practice that are age-based are both unnecessary and discriminatory. The CMA respectfully requests you to follow the lead of your predecessor and raise the issue of mandatory retirement with your provincial/territorial counterparts. There should be no disparity nation wide; age-based barriers to practicing medicine should not be tolerated for physician employees or independent contractors alike. In some cases, federal, provincial and territorial human rights legislation may need to be amended. Equally as important, these concerns must be factored into discussions around health human resource planning. Thank you for your time and interest in this very important matter. We look forward with anticipation to your response. For your information, a more detailed account of mandatory retirement follows in the addendum to this letter. Should you have any further questions, I would be pleased to discuss this issue in further detail with you and your staff. Sincerely, Dr. Sunil Patel President, Canadian Medical Association cc: Presidents, Provincial / Territorial Medical Associations BACKGROUNDER: MANDATORY RETIREMENT Preface: Since its introduction in 1884 by German Chancellor Otto von Bismarck, the age of 65 has become firmly entrenched as "retirement age". Mandatory retirement can be considered a form of discrimination or bias, insofar as scientific data does not support the principle of retirement on the basis of attainment of a specific chronological age. While human rights legislation governs the mandatory age of retirement for employees (including some physicians) with variations from province to province, the extent to which provincial human rights legislation applies to the mandatory retirement of physicians varies, depending on whether the physician is an employee of the hospital or an independent contractor. Legislative and regulatory framework: Human Rights Legislation vis-à-vis Mandatory Retirement Federal and provincial/territorial human rights legislation govern mandatory retirement for physician employees, depending on whether their employers are under federal or provincial jurisdiction. As most health institutions are under provincial jurisdiction, the vast majority of physician employees are protected by provincial human rights legislation. Each province and territory has enacted human rights legislation that governs in their respective areas of jurisdiction. The legislation tends to be analogous from one province to the next, but there are differences worth noting. Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of seven provinces and territories. Four provinces do not consider mandatory retirement to be discrimination if the employee is 65 years or older. In two provinces, if mandatory retirement is provided for in a retirement or pension plan, it does not amount to discrimination. Jurisdiction Provisions governing mandatory retirement age Canada Mandatory retirement is not a discriminatory practice when a person has reached the normal retirement age for employees performing the same type of work. Consequently, in that case, the Act allows for mandatory retirement. Alberta Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of this province. British Columbia Older employees are protected until the age of 65 against discrimination based on age. Consequently, employees aged 65 or over cannot file a complaint if they are obliged to retire for that reason. Manitoba Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of this province. New Brunswick Termination of employment provided for in a retirement or pension plan does not constitute a discriminatory measure. In the absence of such a plan, however, employees who are obliged to retire may file a complaint for discrimination based on age, under the legislation on human rights. Newfoundland and Labrador Termination of employment provided for in a retirement or pension plan does not constitute a discriminatory measure. In the absence of such a plan, however, employees who are obliged to retire may file a complaint for discrimination based on age. They may use this recourse until the age of 65. Jurisdiction Provisions governing mandatory retirement age Northwest Territories Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of this territory. Nova Scotia Mandatory retirement at age 65 does not constitute a discriminatory measure if it is standard in the workplace in question. However, the Human Rights Commission of this province investigates when an employee aged 65 or over is not treated in the same manner as others of the same age where retirement is concerned. Nunavut Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of this territory. Ontario Older employees are protected against age-based discrimination up to the age of 65. Consequently, employees aged 65 or over cannot file a complaint if they are obliged to retire for this reason. Prince Edward Island Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of this province. Quebec Mandatory retirement constitutes a form of discrimination according to the Charter of Human Rights and Freedoms and, more explicitly, is forbidden by the Act Respecting Labour Standards. Saskatchewan Older employees are protected against age-based discrimination up to the age of 65. Consequently, employees aged 65 or over cannot file a complaint if they are obliged to retire for this reason. Yukon Mandatory retirement constitutes a discriminatory measure for employers under the jurisdiction of this territory. Employment Status of Practicing Physicians Most physicians operate as independent contractors, billing provincial Medicare plans on a fee-for-service basis. Human rights legislation therefore does not protect the majority of physicians because the application of the legislation is limited to certain specific relationships, such as the traditional employment relationship. In other words, since physicians are more likely to be engaged by their patients to provide care than by the hospitals in which they provide it, the relationship between physicians and hospitals is more similar to a service contract than to a traditional employment contract. As a result, physicians who are independent contractors are free to practice medicine after they reach the age of 65. Depending on the hospital specific regulatory framework however, physicians may or may not be allowed to maintain their admitting privileges. Colleges of Physicians and Surgeons Regulatory bodies that license physicians do not place any restrictions on physician practice based solely on age. The Colleges of Physicians and Surgeons are not involved in administering hospital admitting privileges. None of the provincial or territorial colleges restrict licenses to practice medicine on the basis of a physician's age. Physicians who are employed in a traditional employment or master/servant relationship are covered by applicable human rights legislation, depending on whether their employers are federally or provincially/ territorially regulated. This means that some physicians can be forced into retirement at the age of 65, while others cannot. Policy Considerations: The Changing Physician Workforce Mandatory age-based retirement for health care workers has been a contested policy for almost 25 years. The issue assumes significant value for the CMA membership. Most physicians, operating as independent contractors, are not protected by human rights legislation in terms of retirement. Hospital admitting privileges are administered by the individual institutions, and renewal of such privileges may be subject to hospital policies on mandatory retirement. As more and more physicians choose to work in a traditional employment situation, the lack of human rights protection for physicians in private practice will be thrown in sharp relief. Health Human Resources Labour shortages challenge arguments for mandatory retirement. The health sector in particular has been hit hard by human resource shortages, which are predicted to increase as the baby-boom generation begins to retire in 2012. According to a study released by the Institute for Research on Public Policy (IRPP), challenges associated with the aging workforce in Canada will require greater flexibility, by way of removing barriers to labour force participation among individuals nearing retirement.1 Physician Health and Wellbeing For many people, employment provides a fundamental sense of dignity and self-worth. Practicing medicine promotes independence, security, self-esteem and a sense of participation in the community. Involuntary termination of employment can cause psychological and emotional distress. Physician malaise is a burgeoning concern and its address has become a strategic priority for the Canadian Medical Association. Protection of physicians, be they employees or independent contractors, from mandatory retirement is a strategy which would see one dimension of physician anxiety diminished and would therefore be supported by the CMA. Mandatory retirement can have a particularly serious financial impact on physicians. Employer pension plans are often not available in employment relationships which feature part-time or provisional employees. In order to secure or maintain their standard of living upon retirement, physicians must save extensively via RRSPs or private pension plans. Those physicians with family members to support, such as young adults in post secondary education, children with disabilities, or older family members fear that they will not be able to do so if forced to leave the practice of medicine. Liability Issues While the threat of malpractice may present as one logical argument in support of a mandatory retirement age, the statistics do not support such a claim. The Canadian Medical Protective Association (CMPA) maintains that there is no significant correlation between physicians' physical age and the corresponding number of lawsuits. Dr. Norman Brown of the CMPA notes that of the over 500 new lawsuits a year, there is not a significant number involving elderly physicians. Conclusion: The public interest is best served by ensuring that all competent physicians, regardless of age, are able to practice medicine. Artificial barriers to practice based on age are simply discriminatory and counter productive in an era of health human resource shortages. 1 Merette, Marcel. (2003) "The Bright Side: A Positive View on the Economics of Aging." Institute for Research on Public Policy. Nov 18/03.
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16 records – page 1 of 2.