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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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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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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 Letter to the Senate Committee on Legal and Constitutional Affairs regarding Bill C-2, An Act to amend the Criminal Code and to make consequential amendments to other Acts

https://policybase.cma.ca/en/permalink/policy9110
Last Reviewed
2020-02-29
Date
2008-02-19
Topics
Health care and patient safety
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2008-02-19
Topics
Health care and patient safety
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) welcomes the opportunity to provide comments to the Senate Committee on Legal and Constitutional Affairs concerning its study of Bill C-2 (An Act to amend the Criminal Code and to make consequential amendments to other Acts). We will confine our comments to the portion of the proposed legislation that relates to impaired driving. Canada's physicians support measures aimed at reducing the incidence of drug-impaired driving. We believe impaired driving, whether by alcohol or another drug, to be an important public health issue for Canadians that requires action by all governments and other concerned groups. Published reports indicate that the prevalence of driving under the influence of cannabis is on the rise in Canada. We note that: * Results from the Canadian Addictions Survey suggest that 4% of the population have driven under the influence of cannabis in the past year, an increase from the 1.5% in 2003 and that rates are higher among young people.1 * It was estimated that in 2003, 27.45% of traffic fatalities involved alcohol, 9.15% involved alcohol and drugs, and 3.66% involved drugs alone while 13.71% of crash injuries involved only alcohol, 4.57% involved alcohol and drugs, and 1.83% involved drugs alone.2 * In a 2002 survey, 17.7% of drivers reported driving within 2 hours of using a prescribed medication, over-the-counter remedy, marijuana, or other illicit drug during the past 12 months. * These results suggest that an estimated 3.7 million Canadians drove after taking some medication or drug that could potentially affect their ability to drive safely. * The most common drugs used were over-the-counter medications (15.9%), prescription drugs (2.3%), marijuana (1.5%), and other illegal drugs (0.9%). * Young males were most likely to report using marijuana and other illegal drugs. * While 86% of the drivers were aware that a conviction for impaired driving results in a criminal record, 66% erroneously believed that the penalties for drug-impaired driving were less severe than those for alcohol-impaired driving. In fact, the penalties are identical. * Over 80% of drivers agreed that drivers suspected of being under the influence of drugs should be required to participate in physical coordination testing for drug impairment. However, only about 70% of drivers agreed that all drivers involved in a serious collision or suspected of drug impairment should be required to provide a blood sample.3 The CMA has, on several occasions, provided detailed recommendations on legislative changes concerning impaired driving. In 1999, the CMA presented a brief to the House of Commons Standing Committee on Justice and Human Rights during its review of the impaired driving provisions of the Criminal Code. While our 1999 brief focused primarily on driving under the influence of alcohol, many of the recommendations are also relevant to the issue of driving under the influence of drugs. In June 2007, the CMA provided comments to the Standing Committee on Justice and Human Rights of the House of Commons during their study of Bill C-32 (An Act to amend the Criminal Code (impaired driving) and to make consequential amendments to other Acts) which was later incorporated in the omnibus Bill now before your Committee. Last year, the CMA published the 7th edition of its guide, Determining Medical Fitness to Operate Motor Vehicles. It includes chapters on the importance of screening for alcohol or drug dependency and states that the abuse of such substances is incompatible with the safe operation of a vehicle. This publication is widely viewed by clinical and medical-legal practitioners as the authoritative Canadian source on the topic of driver competence. While changing the Criminal Code is an important step, the CMA believes further actions are also warranted. In our 2002 presentation to the Special Senate Committee on Illegal Drugs, the CMA put forth our long standing position regarding the need for a comprehensive long-term effort that incorporates both deterrent legislation and public awareness and education campaigns. We believe such an approach, together with comprehensive treatment and cessation programs, constitutes the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. Drug-impaired drivers may be occasional users of drugs or they may also suffer from substance dependence, a well-recognized form of disease. Physicians should be assisted to screen for drug dependency, when indicated, using validated instruments. Government must create and fund appropriate assessment and treatment interventions. Physicians can assist in establishing programs in the community aimed at the recognition of the early signs of dependency. These programs should recognize the chronic, relapsing nature of drug addiction as a disease, as opposed to simply viewing it as criminal behaviour. While supporting the intent of the proposed legislation, the CMA urges caution on several significant issues, with regard to Clause 20 that amends the act as follows: 254.1 (1) The Governor in Council may make regulations (a) respecting the qualifications and training of evaluating officers; (b) prescribing the physical coordination tests to be conducted under paragraph 254(2)(a); and (c) prescribing the tests to be conducted and procedures to be followed during an evaluation under subsection 254(3.1). CMA contends that it is important that medical professionals and addiction medicine specialists in particular, should be consulted regarding the training offered to officers to conduct roadside assessment and sample collection. Provisions in the Act conferring upon police the power to compel roadside examination raises the important issue of security of the person and the privacy of health information. As well, information obtained at the roadside is personal medical information and regulations must ensure that it be treated with the same degree of confidentiality as any other element of an individual's medical record. Thus, the CMA would respectfully submit that Clause 25 of Bill-C2 on the issue of unauthorized use or disclosure of the results needs to be strengthened because the wording is too broad, unduly infringes privacy and shows insufficient respect for the health information privacy interests at stake. For instance, clause 25(2) would permit the use, or allow the disclosure of the results "for the purpose of the administration or enforcement of the law of a province". This latter phrase needs to be narrowed in its scope so that it would not, on its face, encompass such a broad category of laws. Moreover, clause 25(4) would allow the disclosure of the results "to any other person, if the results are made anonymous and the disclosure is made for statistical or other research purposes" CMA would expect the federal government to exercise great caution in this instance, particularly since the results could concern individuals who are not actually convicted of an offence. One should query whether the Clause 25(4) should even exist in a Criminal Code as it would not appear to be a matter required to be addressed. If it is, then CMA would ask the government to conduct a rigorous privacy impact assessment on these components of the Bill, studying in particular, such matters as sample size, degree of anonymity, and other privacy related issues, especially given the highly sensitive nature of the material. CMA would ask whether clause 25(5) should specify that the offence for improper use or disclosure should be more serious than a summary conviction. Finally, it is important to base any roadside testing methods and threshold decisions on robust biological and clinical research. CMA also notes with interest Clause 21, specifically the creation of a new offence of being "over 80" (referring to 80mg of alcohol in 100ml of blood, or a .08 blood alcohol concentration level or BAC) and causing an accident that results in bodily harm which will carry a maximum sentence of 10 years and life imprisonment for causing an accident resulting in death. (Clause 21) We would also urge the Committee to take the opportunity that the review of this proposed legislation provides to recommend to Parliament a lower BAC level. Since 1988 the CMA has supported 50 mg% as the general legal limit. Studies suggest that a BAC limit of 50 mg% could translate into a 6% to 18% reduction in total motor vehicle fatalities or 185 to 555 fewer fatalities per year in Canada.4 A lower limit would recognize the significant detrimental effects on driving-related skills that occur below the current legal BAC.5 In our 1999 response to the Standing Committee on Justice and Human Rights' issue paper on impaired driving6 and again in 2002 when we joined forces with Mothers Against Drunk Driving (MADD), CMA has consistently called for the federal government to reduce Canada's legal BAC to .05. Canada continues to lag behind countries such as Austria, Australia, Belgium, Denmark, France and Germany, which have set a lower legal limit. 7 CMA expressed the opinion that injuries and deaths resulting from impaired driving must be recognized as a major public health concern. Therefore we once again recommend lowering the legal BAC limit to 50 mg%. or .05%. We also wanted to note our support for Clause 23 which addresses the issue of liability by extending the existing umbrella of immunity for qualified medical practitioners to the new provision under 254(3.4) 23. Subsection 257(2) of the Act is replaced by the following: (2) No qualified medical practitioner by whom or under whose direction a sample of blood is taken from a person under subsection 254(3) or (3.4) or section 256, and no qualified technician acting under the direction of a qualified medical practitioner, incurs any criminal or civil liability for anything necessarily done with reasonable care and skill when taking the sample. Finally, CMA believes that comprehensive long-term efforts that incorporate deterrent legislation, such as Bill C-2, must be accompanied by a public awareness and education strategy. This constitutes the most effective long-term approach to reducing the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports this multidimensional approach to the issue of the operation of a motor vehicle regardless of whether impairment is caused by alcohol or drugs. Again, the CMA appreciates the opportunity to provide input into the legislative proposal on drug-impaired driving. We stress that these legislative changes alone would not adequately address the issue of reducing injuries and fatalities due to drug-impaired driving, but support their intent as a partial, but important measure. Yours sincerely, Brian Day, MD President 1 Bedard, M, Dubois S, Weaver, B. The impact of cannabis on driving, Canadian Journal of Public Health, Vol 98, 6-11, 2006 2 G. Mercer, Estimating the Presence of Alcohol and Drug Impairment in Traffic Crashes and their Costs to Canadians: 1999 to 2003 (Vancouver: Applied Research and Evaluation Services, 2005). 3 D. Beirness, H. Simpson and K. Desmond, The Road Safety Monitor 2002: Drugs and Driving (Ottawa: Traffic Injury Research Foundation, 2003). Online: www.trafficinjuryResearch.com/whatNew/newsItemPDFs/RSM_02_Drugs_and_ Driving.pdf 4 Mann, Robert E., Scott Macdonald, Gina Stoduto, Abdul Shaikh and Susan Bondy (1998) Assessing the Potential Impact of Lowering the Blood Alcohol Limit to 50 MG % in Canada. Ottawa: Transport Canada, TP 13321 E. 5 Moskowitz, H. and Robinson, C.D. (1988). Effects of Low Doses of Alcohol on Driving Skills: A Review of the Evidence. Washington, DC: National Highway Traffic Safety Administration, DOT-HS-800-599 as cited in Mann, et al., note 8 at page 12-13 6 Proposed Amendments to the Criminal Code of Canada (Impaired Driving): Response to Issue Paper of the Standing Committee on Justice and Human Rights. March 5, 1999 7 Mann et al
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CMA Presentation to the House of Commons Standing Committee on Health : Statutory review of the 10-Year Plan to Strengthen Health Care

https://policybase.cma.ca/en/permalink/policy9135
Last Reviewed
2020-02-29
Date
2008-05-27
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2008-05-27
Topics
Health systems, system funding and performance
Text
The CMA appreciates the opportunity to present to the Standing Committee on Health today. My presentation will focus on: 1. Wait Times 2. Health Human Resources; and 3. Patient Focused Care Wait Times In regard to the issue of wait times, I would echo the two main points of my colleagues from the Wait Time Alliance: * First, while progress is being made on wait times, that progress is limited and not consistent across the country; and second, * Health workforce and infrastructure capacity shortages remain the primary barriers to effectively addressing wait times. Wait times don't only exact a heavy human toll - they also carry severe economic costs. A CMA-commissioned report released earlier this year found that the economic cost of having patients wait longer than medically recommended was $14.8 billion in 2007. That stunning total was for just four of the five procedures identified as priorities in the 10-year plan - joint replacement, diagnostic imagining and cataract and bypass surgery - and it was only for one year. Over a million Canadians continue to suffer on wait lists because of deficiencies in our system. This is unacceptable. We need to "break the back" of wait times for the sake of our patients and for the economic health of Canada. This will require: * More federal leadership, not less; * A revolutionary change in the "focus" of our health care system; and * Substantial investments. Health Human Resources The 10-Year Plan to Strengthen Health Care acknowledged the need to increase the supply of health care professionals in Canada. However, not enough progress has been made. Canada is 26,000 doctors short of the average of developed countries, and we now rank a lowly 24th among OECD countries in doctors per population. A poll released today by the CMA found that Canada's doctor shortage ranked second only to the economy as a top public issue. In this same poll, 91% of Canadians say having a plan to address the doctor shortage will influence their vote in the next federal election. Federal political parties who ignore this issue in the next election could pay a price at the polls. In the 10-year plan to strengthen health care, $1-billion was set aside for the last four years (2010-2014) of the agreement. We can't afford to wait that long. This funding should be immediately fast-tracked to focus on the three priority areas in the CMA's "More Doctors. More Care" Campaign: * One, expanding health professional education and training capacity; * Two, ensuring self sufficiency in health human resources by investing in long-term health human resource planning; and. * Three, investing in health information technology to make our health care system more responsive and efficient. In terms of IT, we should be ashamed that we only spend a third of the OECD average on IT in our hospitals. Canada's poor record in avoidable adverse effects is, in part, due to our system's inability to share available information in a timely manner. Patient Focused Care Many countries have systems that provide universal care, have no wait lists and cost the same or less to run as our system does. Wait lists can and must be eliminated in Canada. The momentum to do just that depends simply on making the system work for patients, not on forcing patients to work the system. We must reposition patients to the centre of our health-care system, which requires that we move beyond block funding or global budgets for health institutions. We need a system where funds follow the patient - patient-focused funding. Block funding blocks access. Patient-focused funding will increase productivity, lead to greater efficiencies and reduce wait lists. A patient will become a value to an institution, not a cost. Canada remains the last country in the developed world to fund hospitals with block funding. In England, patient-focused funding helped eliminate wait lists in less than four years. Conclusion So, my question to the Committee is why do we wait? Why do we continue to keep patients on wait lists when research shows it costs a lot less to cut wait times then it does to have them? Why do we not make the necessary reforms and investments to provide Canadians with timely access to quality care? 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's letter to Mr. James Rajotte, MP Chair, Standing Committee on Industry, Science and Technology: Review of the service sector in Canada

https://policybase.cma.ca/en/permalink/policy9114
Last Reviewed
2020-02-29
Date
2008-02-23
Topics
Health human resources
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2008-02-23
Topics
Health human resources
Health systems, system funding and performance
Text
On behalf of the Canadian Medical Association (CMA), I want to thank you for the opportunity to provide the following information to the House of Commons Standing Committee on Industry, Science and Technology during its review of the service sector in Canada. The committee's study of the strengths and challenges facing this sector, overall employment percentage, overall average of salaries across the sector its impact on Canada's overall economy and the role of the Government of Canada in strengthening this sector comes at an opportune time. CANADA'S HEALTH SERVICES SECTOR Canada's health services sector is facing a critical shortage of physicians and other health care professionals and the CMA and our over 67,000 physician members are pleased to have the opportunity to present practical solutions within the jurisdiction of the federal government - working collaboratively with provincial/territorial governments and other health system stakeholders. Health care delivery in Canada is a $160 billion industry, representing over 10% of our country's gross domestic product (GDP).1 The 30,120 physicians' offices across Canada make important contributions to our economy. In 2003, the latest year for which data are available, offices of physicians employed 142,000 Canadians and contributed $11.6 billion to the Canadian economy.2 This represents almost 39 per cent of all Health Service Delivery establishments, and almost 11% of all HSD employees. As a standard measure of economic productivity, physician offices report the highest levels of GDP per employee within the Health Service Delivery sector. On this measure, they are approximately twice as productive as other components of Health Service Delivery. THE CHALLENGE There are simply not enough physicians to continue providing the quality health care that Canadians expect and deserve. Here are the facts: - Almost 5 million Canadians do not have access to a family physician; - By 2018 an additional 4.5 million Canadians could be without a doctor; - Canada ranks 24th in Organisation for Economic Co-operation and Development (OECD) nations in terms of physicians-per-population ratio. Canada would need 26,000 more doctors right now to meet the OECD average; - Canada spends only a third of the OECD average on information technology (IT) and diagnostic equipment in our hospitals; and - Canada has the highest hospital occupancy rate of all OECD countries and among the highest waits for access to specialty care services. The lack of physicians and other health care providers has resulted in restricted access to health care services and the growth of wait times for necessary medical procedures. In January 2008, CMA released new research by the Centre for Spatial Economics that proved that, in addition to the human health cost, waiting for care results in dramatic and excessive costs to our economy. Researchers addressed just four priority areas targeted in the 2004 First Ministers Health Accord. They used government and other data to determine how many Canadians were waiting longer than the maximum medical consensus established by the Wait Time Alliance. Selected for analysis were: joint replacement, cataract surgery, heart bypass grafts, and MRI scans. Costs, as calculated for all provinces varied from $2,900 to over $26,000 per patient. The cumulative cost of waiting in 2007, for treatment in just 4 areas, was $14.8 billion. This reduced economic activity lowered government revenues in 2007 by $4.4 billion. That is equivalent to over 1/3rd of the total Ontario health budget. The reduction in economic activity included the impact of the patient's inability to work while waiting, and direct losses from decreased production of goods and services, reduced income, and lowered discretionary spending. It is important to note that the figure of 14.8 billion dollars is based only on patients that exceed designated maximum waiting times in just 4 clinical areas. In the example of hip replacements, the research only factored in costs for waits that exceed 6 months. Of those waiting longer than the maximum recommended time, average waits were 1 year for hip and knee replacement surgery, 7 months for cataract surgery, and twice maximum for heart bypass surgery. Those who didn't make the MRI target waited an average of 12 weeks. Reduced economic activity included informal caregiver costs. These costs are generated when caregivers reduce work hours to care for family members on wait lists, or attend appointments with family members. Patients languishing on wait lists also incur additional costs for drug and other treatments that timely care would eliminate. Estimates in this study are extremely conservative. They address only the wait time to treatment after a specialist's consultation and recommendation. And exclude the growing, and significant costs of waiting to see the GP or specialist. They do not include anyone who is not working. They do not include the costs, short and long term, of the deterioration that occurs while waiting. THE SOLUTIONS To solve Canada's doctor shortage, the CMA believes governments must: - Adopt a long-term policy of self-sufficiency to provide Canadians with the health care professionals they need when and where they need them; - Establish a dedicated health human resource renewal fund to educate, retain and enhance the lives of health care professionals; and - Invest in health technology, infrastructure and innovation to make our health care system more responsive and efficient. SELF-SUFFICIENCY Over the past decade, there have been increasing concerns that Canada is not producing an adequate number of health providers to meet the growing demand for health services - now and into the future. These concerns have been consistently registered by physicians, nurses, pharmacists, technicians, in addition to other groups that represent other providers and the institutional and heath facilities community. Furthermore, the policy challenges related to health human resources (HHR) have been identified in several seminal reports - including the Royal Commission on the Future of Health Care in Canada, the Standing Senate Committee on Social Affairs, Science & Technology, and the Health Council of Canada.3 A growing number of health providers are looking to retire over the next decade (or leave the health system all together) relative to the number of trainees who are entering the health system, and at a time where a growing number of Canadians will be turning to the health system for diagnosis and treatment. Over 6% of physicians who responded to the National Physician Survey 20074 said they plan to retire from clinical practice and 1% plan to permanently leave practice for other reasons in the next 2 years. The effect of these changes could mean that, as the baby boom generation gets older, over 4,000 physicians will cease their medical practice within the next 2 years, making it even more difficult for Canadians to find a family physician. At the same time, the HHR challenges facing Canada's health care system are not unique to our country - over the next decade all western developed countries can expect intensified global competition for talent when it comes to health providers.5 While there are, no doubt, other provider groups who are also concerned about the future supply of health providers, there is a growing national consensus that, in addition to the primary role that the provinces and territories play in supporting the training of health providers across the country, there is a significant, catalytic and strong complementary role for the federal government in the area of health human resources. CMA, like many health care organizations, is of the view that there is a legitimate role for the federal government to strengthen its working relationship with the provinces and territories, and health providers through the creation of a time-limited, issue-specific and strategically-targeted fund to accelerate training capacity in the health system. The World Medical Association's ethical guidelines for international recruitment of physicians16 (2003), fully supported by the CMA, recommend that every country "should do its utmost to educate an adequate number of physicians, taking into account its needs and resources. A country should not rely on immigration from other countries to meet its need for physicians."7 However, in reality Canada continues to rely heavily on recruitment of internationally educated health professionals. Approximately one-third of the increase in physician supply each year is due to International Medical Graduates (IMGs) who are either recruited directly to practice or who have taken significant postgraduate medical training in Canada. In nursing, the number of internationally educated nurses applying for licensure is increasing rapidly, almost tripling from 1999 to 2003. Previous recommendations of the CMA to the House of Commons included improved medium- to longer-term supply projection models; sufficient opportunities for Canadians to train for health professional careers in Canada; and integration of international graduates, who are permanent residents or citizens of Canada, into practice. The CMA recognizes that professionals are working in an increasingly global world in terms of the exchange of scientific information, mutual recognition of qualifications between countries and the movement of people. The greatest barrier to enhancing Canada's ability to become more self-sufficient, in terms of physician resources, is the capacity of our medical schools. Despite recent increases in enrolment, Canada continues to turn away approximately 3 equally qualified students for every 1 that is accepted into an undergraduate medical program. This has resulted in over 1500 Canadian students, with the financial means to do so, who are training in medical schools outside of Canada. INTERNATIONAL MEDICAL GRADUATES In the larger context, Canada's current fertility rate is not sufficient to support self-sufficiency in general in relation to any professions. And, while self-sufficiency in the production of physicians is a desirable goal, it is also important to promote the international exchange of teaching and research, particularly in an increasingly global society. In this regard, IMGs should be considered as a planning component for a sustainable Canadian physician workforce. Historically IMGs have entered the practice of medicine through a variety of routes, which most typically include a recognized period of post-MD training in Canada. CMA's best estimate is that there are about 400 IMGs newly licensed to practice in Canada each year who have not completed postgraduate training in Canada. In addition, there are another 300 or so who are exiting Canadian postgraduate training programs and heading into practice. In fact, for the past few years, the College of Physicians and Surgeons of Ontario has licensed more IMGs than new Ontario medical graduates. In recent years, there have been an increasing number of opportunities for IMGs already living in Canada to achieve the required credentials for licensure. The number of ministry-funded IMG postgraduate residents has more than tripled in the past seven years from 294 to 1065 trainees. In 2007, there were almost 1500 IMGs who were qualified to compete in the Canadian Resident Matching Service (CaRMS) match. By the end of the second round, close to 300 had matched and about 60 were placed through other provincial programs. Recommendation The federal government should make a clear policy commitment to increasing self-sufficiency in the education and training of health professionals in Canada that would incorporate the following. - Short term - increase number of community preceptors to train Canadian graduates and assess internationally educated health professionals already living in Canada. Recognition of the time and value of community teaching is needed. - Medium term - support increased capacity for academic health science centres and other institutions that train health professionals. - Long term - creation of new academic health science centres to increase capacity for self-sufficiency. REPATRIATING CANADIAN DOCTORS WORKING ABROAD It is known that there are thousands of Canadian-trained health professionals practising in the United States and abroad. Between 1991 and 2004, almost 8,000 physicians left Canada (although some 4,000 returned for a net loss of 4,000).8 Of this number, roughly 80% went to the US.9 During the 1990s, approximately 27,000 nurses migrated from Canada to the US.1011 A more recent indicator of nursing outmigration is that in 2006, 943 Canadian-trained Registered Nurses and Licensed Practical Nurses wrote the US licensing board examination for the first time.12 Data for other health professional disciplines are not readily available. In 2007, with the assistance of the American Medical Association, the Canadian Medical Association (CMA) surveyed all (n=5,156) Canadian-trained physicians practicing in the US who were age 55 or under, with regard to the likelihood of their return to Canada and the importance of various factors that might be incentives to return. A 32% response rate was achieved with a single mailing with no follow-up - this is considered exceptionally high. While only 13% of respondents indicated that they were likely or very likely to return to Canada, a further 25% were neutral in their opinion. What is more telling is that more than one-half of respondents indicated that they would be willing to be contacted by CMA to explore practice opportunities and provided their contact information for this purpose. When asked about a range of potential incentives to return to Canada, 57% agreed that a relocation allowance would be somewhat or very important.13 It must be stressed, however, that it is clear from the results that a number of factors would need to be taken into consideration, such as practice opportunities. This would also be true of other disciplines; in the case of nursing, nurses will only come back for full-time jobs and healthy work environments.14 Nonetheless, expatriate Canadian medical graduates should be good candidates for recruitment on the basis of the greater likelihood that they will meet Canadian standards for full medical licensure, and it is expected that this would also apply to nursing and other disciplines. As well, significant progress has been made in restoring and adding capacity to our medical schools but, to achieve self-sufficiency, much more needs to be done. For example, we must try and repatriate Canadian medical students and doctors who are studying and working abroad. There are currently some 1500 Canadian medical students and residents training abroad, we must act now, before things get worse. During that past few years there have been efforts to enhance national coordination in the health human resources arena. One area of national focus has been the integration of International Medical Graduates, since extended to nursing and other disciplines. There have been several initiatives undertaken in this area such as the establishment of the Canadian Information Centre for International Medical Graduates15 which provides a clearinghouse of information and links to provincial/territorial jurisdictions. Relocation grants, from $10,000 up to $20,000 could be offered to Canadian-trained physicians practising in the US. It is suggested that advertising be concentrated in and around US cities where Canada maintains a consulate/office (in states with a significant concentration with recruitment candidates) and in major national and selected state health professional journals. The cost of a repatriation secretariat is estimated at $162,500 per year. Assuming that 1,500 health professionals are recruited back over the 3-year period, the total cost would range from $21.5 million to $36.5 million. This would further translate to a per recruit cost that ranges from $14,325 to $24,325. Even at the high end of the range this would be cost-effective as compared to the total cost of training a practice-entry level graduate of any licensed health professional discipline in Canada. Recommendation In light of the foregoing, the CMA has recommended that the federal government should establish a Health Professional Repatriation Program in the amount of $30 million over 3 years that would include the following: - secretariat within Health Canada that would include a clearinghouse function on issues associated with returning to Canada such as licensure, citizenship and taxation; - An advertising campaign in the US to encourage health professionals practicing south of the border to return home; and - A program of one-time relocation grants for health professionals returning to active practice in Canada. NATIONAL HEALTH HUMAN RESOURCES INFRASTRUCTURE FUND The implementation of Medicare in Canada in the 1960s required a major investment in the capacity to train more health professionals. The 1966 Health Resources Fund Act played a key role in enabling a significant expansion in training capacity across the provinces for a range of health professionals. Forty years later, Canada faces growing shortages across most health disciplines. Clearly another giant step up is required in the human and physical infrastructure needed to train health professionals if Canadians are to have timely access to care. During the years of fiscal famine of the 1990s, health professional enrolment was either reduced (e.g., 10% in the case of medicine) or flat-lined. While there have been increases since 2000, we are about to face the double impact of both an aging population as the first of the baby boomers reach 65 in 2011 and aging health professions. For example, more than 1 out of 3 physicians (35%) are aged 55 or older. As mentioned, as many as 4,000 physicians are expected to retire in the next 2 years. If we are going to have sufficient numbers of health providers to meet the needs of the next few decades, it is imperative to expand the human and physician infrastructure capacity of our health professional education and training system. The federal investments in health human resources over 2003-2005 of some $200 million have been welcome, but fall far short of what is needed. It is proposed that the federal government implement a National Health Human Resources Infrastructure Fund in the amount of $1 billion over 5 years that would be made available to the provinces/territories on an equal per capita basis, and awarded through a competitive process that would include federal/ provincial/territorial representation with consultation/engagement of health professional organizations. The fund would address the following elements: 1. The direct costs of training providers and developing leaders (e.g., cost of recruiting and supporting more community- based teachers/preceptors). 2. The indirect or infrastructure costs associated with the educational enterprise (e.g., physical plant [housekeeping, maintenance]; support for departments [information systems, library resources, occupational health, etc.]; education offices, and the materials and equipment necessary for clinical practice and practical training. 3. Resources that improve the country's overall data management capacity when it comes to health human resources, and in particular, facilitate the ability to model and forecast health human resource requirements in the face of the changing demand for health services. Clearly it would be necessary to develop guidelines around the types of expenditures that would be eligible as was done for the 1966 Health Resources Fund, and more recently for the Medical Equipment Fund II. CMA Recommendation The federal government should establish a National Health Human Resources Fund in the amount of $1 billion over 5 years to expand health professional education and training capacity by providing funding to support the: - direct costs of training providers - indirect or infrastructure costs associated with the educational enterprise - resources that improve Canada's data collection and management capacity in the area of health human resources. HEALTH INNOVATION More than 85% of the health care delivered in Canada occurs within the community. This is the most under-invested segment of the health care delivery system in terms of information technology. Dr. Brian Postl in his June 2006 wait-time report16 to the federal government noted health information technology is essential in improving wait times. He quantified the investment needed at $2.4 billion with the largest portion of this investment ($1.9 billion) targeted to automating physician offices, which are located at the front line of care in community settings and are key to managing and resolving the wait time issue in Canada. Why invest in physician office automation? Because it will lead to improved productivity from the provider community through more efficient resource usage and through improved coordination in the delivery of care; it will enable labour mobility of health care workers through portability of records; it will support the wait time agenda by improving the flow of timely information; it will build an electronic infrastructure platform to enhance patient care and health research and will provide a direct financing vehicle for the federal government to influence and shape the health care sector. The federal government has made similar types of infrastructure investment. The CFI Program was established to fund research infrastructure, which consists of the state-of-the-art equipment, buildings, laboratories and databases required to conduct research. Investing in EMR infrastructure will lead to the creation of state of the art clinical environments across Canada, electronic data base of health information and the foundational underpinnings of a health information network to support enhanced population health and health research. Under this scenario the federal contribution would provide a direct benefit to physicians without any need for provincial or territorial involvement. Second, the federal government could use existing government machinery to manage the program. Third, the federal contribution to infrastructure would only flow after a physician has introduced an EMR into his/her clinic ensuring that the funding is directly tied to building the EMR infrastructure platform. The recent National Physician Survey notes that some progress is being made across the country to automate community clinics. However without incentives the adoption trend will be incremental and extend over a further 20-year time frame. Financial incentives can shorten the timelines since it addresses one of the main adoption barriers physicians identify.17 Diffusion theory18 of new technologies into any sector of the economy demonstrates that without appropriate incentives it will take approximately 25 years the technology to reach the saturation point of integration. It is estimated that a financial incentive can shorten this timeline by 15 years. Recommendation The federal government, over a 5-year time frame, should provide a full tax credit to any physician who takes the steps to automate his or her clinical office. The tax credit would only apply to 1-time costs to establish a state of the art clinical environment. It is estimated, on average, 1-time costs would be $22,000. Total costs of the program if fully subscribed would amount to $880 million. CONCLUSION The health services sector makes significant contributions to the Canadian economy, both in terms of direct stimulus and by keeping Canadians healthy and productive. However, Canada's health services sector is facing a critical shortage of physicians and other health care professionals. By: - Adopting a long-term policy of self-sufficiency to provide Canadians with the health care professionals they need when and where they need them; - Establishing a dedicated health human resource renewal fund to educate, retain and enhance the lives of health care professionals; - Investing in health technology, infrastructure and innovation to make our health care system more responsive and efficient; the federal government, in partnership with provincial/territorial governments and other health system stakeholders can strengthen this sector. A strong health services sector means healthy Canadians and a vibrant Canadian economy. Again, on behalf of the Canadian Medical Association, Canada's doctors appreciate the opportunity to provide information to the Committee. Sincerely, Brian Day, MD President, Canadian Medical Association 1 National Health Expenditure Trends, 1975-2007. Canadian Institute for Health Information. 2007 2 Source: Business Register (STC 2003) and TIM (Informetrica Limited) 3 The Royal Commission on the Future of Health Care in Canada, November 2002. Senate Standing Committee on Social Affairs, Science & Technology, October 2002. The Health Council of Canada "Modernizing the Management of Health Human Resources in Canada: Identifying Areas for Accelerated Change: November 2005. 4 The National Physician Survey is a major ongoing research project conducted by the College of Family Physicians of Canada, Canadian Medical Association and Royal College of Physicians and Surgeons of Canada that gathers the opinions of all physicians, 2nd year medical residents and medical students from across the country. It is the largest census survey of its kind and is an important barometer of where the country's present and future doctors are on a wide range of critical issues. 5 The Economist, The Battle for BrainPower - A Survey of Talent, October 7, 2006. 7 World Medical Association. The World Medical Association Statement on Ethical Guidelines for the International Recruitment of Physicians. Geneva: The World Medical Association; 2003. Available: www.wma.net/e/policy/e14.htm 8 Canadian Institute for Health Information. 2. Canadian Institute for Health Information. 10 Zaho J, Drew D, Murray T. Barin drain and brain gain: the migration of knowledge workers from and to Canada. Education Quarterly Review 2000;6(3):8-35. 12 Little L, Canadian Nurses Association, personal communication, January 8, 2008. 13 Buske L. Analysis of the survey of Canadian graduates practicing in the United States. October 2007. http://www.cma.ca/multimedia/CMA/Content_Images/Policy_Advocacy/Policy_Research/US_survey_ver_4.pdf. Accessed 02/04/08. 14 Little L, Canadian Nurses Association, personal communication, January 28, 2008. 15 www.img-canada.ca 16 Postl, B. Final Report of the Federal Advisor on Wait Times. Ottawa: Minister of Health Canada, Health Council of Canada; 2005. 17 Canadian Medical Association/Canada Infoway. Physician Technology Usage and Attitudes Survey. Ottawa: CMA/CanadaInfoway; 2005. Available: www.cma.ca/index.cfm/ci_id/49044/la_id/1.htm (accessed 8 Jan 2008). 18 Bower, Anthony. The Diffusion and Value of Healthcare Information Technology. Santa Monica (CA): RAND Corporation; 2005
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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
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Improving access to world-class health care by accelerating health information technology investments: CMA's 2009 pre-budget brief to the Standing Committee on Finance

https://policybase.cma.ca/en/permalink/policy9399
Last Reviewed
2020-02-29
Date
2008-08-15
Topics
Health human resources
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2020-02-29
Date
2008-08-15
Topics
Health human resources
Health systems, system funding and performance
Text
By many measures Canada's health care system is underperforming. One symptom of this weak performance are exceedingly long wait times that have an impact on care and cost patients, the system and governments money1. There are a number of responses to this poor performance including increasing the supply of health human resources2. Another response is to maximize the resources we have on the front lines and work smarter through information technology. This productivity approach is aligned with the assumptions set out in the federal government's Advantage Canada strategy. This strategy involves principally a 'knowledge advantage' and an 'infrastructure advantage'. Consequently, the Canadian Medical Association (CMA) is recommending that the federal government make a strategic "strings attached" $570-million investment to create an interconnected health information technology network3 through a Health Information System Transition Fund and time-limited accelerated IT tax incentives. This investment aims to integrate all Canadian patient health care records, an effort that will take time. However, there are foundations upon which to build thanks to federal government investments - most recently in providing $400 million for wait-time related health information systems. But for these investments to bear fruit further connectivity and integration is vital. In other words, our current system is like having an ATM card that only works at the bank's head office. We believe that additional investments must concentrate on connecting patient records in physician offices with hospitals and medical laboratories. Physicians also believe in accountability, and suggest investments should not be made unless the clinical community confirms a high level of system integration. The CMA recommends that the federal government should invest $570 million over five years in an interconnected pan-Canadian health information system that includes: => A $225 million, 5-year Health Information System Transition Fund aimed at change management training and support to convert 26-million patient records in 36,000 physician offices and community care facilities into interoperable electronic records across Canada. => $305 million for a 3-year time-limited and accelerated Capital Cost Allowance for software and hardware costs related to health information technologies that connect patient records from physician offices to laboratories and hospitals. => $10 million to sponsor a cross-country education campaign to inform Canadians of the health and system benefits of e-health connectivityi. => $2 million annually for Canada Research Chairs to promote and demonstrate the value of interconnectivity in health information between the faculties of Medicine, Management and Engineering. The federal government must also encourage provinces to increase their support of these initiatives and work to reduce the barriers to health information system interfacing, by ensuring patient record systems use similar codes in labs, hospitals and physician offices. Federal government guidance, encouragement and cooperation with the provinces is integral to making these connectivity investments a success. It is time that the federal government helped finish the job of health information system connectivity. A health information network will improve patient outcomes, system efficiency, increase accountability and save billions of dollars. 1. Why advance e-health interconnectivity now? Our health system e-performance is poor Both national and international studies confirm that Canada lags behind nearly every major industrial country when it comes to health information technology (Figure 8). The impact of this underinvestment is longer wait times, poorer quality, and a severe lack of financial accountability especially of federal dollars. Investments in connectivity are needed now because Canada's health care system compares poorly in both value and efficiency compared to other countries. The Conference Board of Canadaii, the OECDiii, the World Health Organizationiv, the Commonwealth Fundv, and the Frontier Centre for Public Policy all rate Canada's health care system poorly in terms of "value for money" as well as efficiency. Benchmarking health information connectivity-where we stand, where we must go According to the 2007 National Physician Survey, just 30% of physicians have an electronic interface with a medical laboratory or diagnostic imaging facility, while fewer than 5% have such an interface with a pharmacy/pharmacistvi. Imagine if just 30% of Canadian banks had ATMs throughout the country? This is a difference of not only convenience, but quality and cost savings. In comparison, Denmark and New Zealand have near 100% use of electronic medical records (EMRs) in ambulatory care. According to Dr. Allan Brookstonevii an EMR expert, "If most physicians in a health region or geographic area implemented an EMR system, the incentive for a local hospital or region to connect to those physicians would be significantly enhanced". In an emergency situation right now in Canada it is easier to access critical financial information than critical health information. This reality is not a matter of technology but the lack of will to put it in place. 2. Why the federal government should be interested in e-health interconnectivity. -Health information technology connectivity yields returns on investment: 8:1 International strategy and technology consulting firm Booz Allen Hamilton found that viii the benefits of an interconnected Electronic Health Record (EHR) in Canada could provide annual system-wide savings of $6.1 billion. These savings would come from reduced duplicate testing, transcription savings, fewer chart pulls and filing time, reductions in office supplies and reduced expenditures due to fewer adverse drug reactions. The study went on to state that the benefits to health care outcomes would equal or surpass these annual savings, thus providing a possible combined annual savings of $12.2 billion. In addition, a comprehensive literature reviewix comparing health IT productivity gains to similar industries in the U.S. concludes that effective EMR implementation and networking could eventually save more than $81 billion annually by improving health care efficiency and safety. Similarly, health information technology-enabled prevention and management of chronic disease could eventually double those savings while increasing health and other social benefits. Assuming that the Canadian health system is one-tenth the size of US system, savings would range from $8 to $16 billion annually. Connected health information technology - increasing performance and accountability A fundamental question the Standing Committee on Finance may ask is where $22 billion (growing at 6 % annually) in federal health care transfers to the provinces is going and what are the results of this support? Right now, we do not know exactly. Health care in Canada represents 10% of our economy ($160 billion annually and growing at 6% per year) and is larger than the total agricultural sector. The question Canadians are asking is not whether tax dollars should be spent on health care, but whether the money being spent is worth the services receivedx. Moreover, in health care, there are legitimate questions as to whether improvements to date have justified the associated costs. The public institutions and organizations that deliver health care in Canada could deliver more value than they do at present. With a national health information (management) system in place they could work to reduce variations in the quality of service and in the way services are used across the system. However at a national level, we do not have an accounting systemxi in place to uniformly measure quality across the country. 3. Who: Canadians - our patients - want and need e-health interconnectivity. Health information technology is critical to managing wait times Quality of care is an important concern for Canadians, but first they must be able to get the care they need. But waiting for health care is the principal concern for Canadiansxii. Excessive wait times result in mental anguish for patients and their families and also cost the Canadian economy billions of dollars each year. In 2007 a study commissioned by the CMAxiii conservatively calculated that excessive wait times in just four procedures (joint replacements, cataract surgery, coronary artery bypass grafts and MRIs) cost the economy over $14 billion in lost output and government revenues. It is important to note that beyond these hospital procedures there is potential to reduce wait times and cost in physician offices through information technology. This is why we have suggested accelerating the capital cost allowance tax for EMR related software and hardware purchases and that they go to community care and physician offices where most patient visits occur every day. Figure 1 below shows that in Ontario for example, just 3,000 out of an average of 247,000 patient visits per day or 1.2% of the total are made in hospitals. That is why this submission is aimed at (the circle area in the chart) increasing connectivity and tying investments to the 99% of the places where patients visit most. Figure 1 Patient visits per day in Ontario, Source: Canada Health Infoway Most of the emphasis on connectivity in Canadian health care to date has not focused on the point of care -even though the number of patient interactions with hospitals is greatly exceeded by the number of visits to physicians' officesxiv. Thus patient-physician office interactions outnumber patient-hospital interactions by a ratio of 18 to 1. It is also important that patients understand the value of electronic health records, which is why we are recommending a $10 million cross-country educational campaign to impact the demand side of this critical health and industrial equation. 4. Why physicians are involved in e-health interconnectivity The physician community can play a pivotal role in helping the federal governments make a connected health care system a realizable goal in the years to come. Through a multi-stakeholder process encompassing the entire health care team, the CMA will work toward achieving cooperation and buy-in. This will require a true partnership between provincial medical associations, provincial and territorial governments and Canada Health Infoway (CHI). Accelerating Advantage Canada through health information technologies The CMA's pre-budget submission, related to health system connectivity, incorporates the five tenets of Advantage Canadaxv. This submission principally addresses the infrastructure and knowledge advantages that are involved in investing in an interconnected network that is useless unless the 'knowledge' advantage to provide stewardship of the Electronic Health Record through our physicians' is in place. That is why we recommend that the federal government help support research, development and knowledge transfer at our major universities in health information technology by supporting 10 Canada Research Chairs in the faculties of Medicine, Management and Engineering. In addition, a pan-Canadian health information technology network will provide the kind of infrastructure that supports labour mobility where for example a migrant worker from Atlantic Canada can access his health records in Fort McMurray Alberta. 5. How to speed-up health information technology connectivity -a green tax incentive approach Thus far the strategy applied to health information connectivity in Canada has been focused on a top-down approach that has produced limited success. That is why the CMA is suggesting that the federal government accelerate the Capital Cost Allowance (CCA) on EMR-related software and hardware equipment over the next three years - an early-bird special or incentive. The CMA does not pretend to be tax policy experts however we do appreciate the federal governments' recent increase in the CCA rates for software and hardware. Our recommendation would mean changing the current software CCA (Class 12xvi) from 100% over two years to 100% in the first year specifically for EMR related investments. And for EMR hardware (Class 50xvii) accelerate the CCA to 100% in the first year from the current 55% rate for a limited time only of three years. These accelerated CCA rate proposals are also consistent with the governments' environmentally friendly CCA initiative as EMRs would save tonnes of paper for years. Mixed results for Canada Health Infoway => Health Information System Transition Fund The CMA lauds the federal government's 2008 Budget for making a $400-million investment in Canada Health Infoway (CHI) to support early movement toward patient wait time guarantees through the development of health information systems and electronic health records. At the same time the physician community believes that CHI has had mixed results, especially when it comes to digitizing and integrating patient records at the places where most patients contact the health care system: physician offices, laboratories and emergency rooms. However, we believe with targeted, conditional policies CHI can be an effective vehicle to accelerate the transition of current health centre paper practices into electronic operations through a time limited five-years Health Information Transition Fund. We also believe that federal transition funds should be matched at a fifty-fifty rate by the provinces. Although this may not be easy, there are other non-monetary policy levers (e.g. regulatory) that the federal government could and should use to persuade the provinces of the value of investing in electronic health record system integration. This is particularly true since the provinces will yield most of the return on the investment. It is imperative that the current health information technology gap be closed and be set at levels for similar service-intensive industries (see Figure 2 in the Appendix 1). That is why; beyond the figures outlined in this submission, the CMA recommends continued federal health information technology support for the next 10 years. Conclusion - Big investments. but big payoffs too As the Health Council of Canada stated in their 2008 annual reportxviii, "Change is underway, but too slowly". The OECD, WHO, The Commonwealth Fund and the Conference Board of Canada's research all strongly suggest that Canada lags behind the rest of the industrialized world in terms of health information technology investments and system integration. The investments made so far may seem large but they will be wasted if a second effort in connecting the entire system is not made now. It is time that the federal government finishes the job of health information system connectivity at the point of care. A Pan-Canadian network of health information will improve patient outcomes, health system efficiency and dramatically increase system accountability. The Health Council of Canada also said that, "These [health information technology] are big investments but the payoff is big too". Accordingly we suggest that over the next five years the following investments will improve the running of Medicare as well as the Canadian economy. The CMA recommends that the federal government should invest $570 million over five years in an interconnected pan-Canadian health information system that includes: => A $225 million, 5-year Health Information System Transition Fund aimed at change management training and support involved in converting 26 million patient records in 36,000 physician offices and community care facilities into interoperable electronic records across Canada. => $305 million for a 3-year time limited accelerated Capital Cost Allowance for EMR software and hardware costs related to health information technologies that connect patient records from physician offices to laboratories and hospitals. => $10 million to sponsor a cross-country education campaign to inform Canadians of the health and system benefits of e-health connectivityxix. => $2 million annually for Canada Research Chairs promoting the value of interconnectivity in health information between the faculties of Medicine, Management and Engineering. References 1The cumulative economic cost of waiting for treatment across just 4 priority areas in 2007 was an estimated $14.8 billion. This reduction in economic activity lowered federal and provincial government revenues in 2007 by a combined $4.4 billion. See:www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf 2 Almost 5-million Canadians do not have a family physician. Canada would need 26,000 more doctors to meet the OECD average of physicians per population. Physicians spend more time on paperwork and less with patients than they did 20 years ago. See: "More Doctors. More Care.": www.moredoctors.ca/take_action/ 3 Please see Table l in Appendix 1 for full investment horizon details. i Patient perspective on electronic medical record. Meldgaard M; International Society of Technology Assessment in Health Care. Meeting (19th : 2003 : Canmore, Alta.). Annu Meet Int Soc Technol Assess Health Care Int Soc Technol Assess Health Care Meet. 2003; 19: abstract no. 148. CONCLUSIONS: Patient confidence and perceived quality of care is influenced by a well informed forward-looking staff as can be obtained in settings where EPR is successfully implemented. Patient satisfaction and the functional level of EPR implementation are interdependent. ii A Report Card on Canada see: http://sso.conferenceboard.ca/HCP/overview/health-overview.aspx iii Organization for Economic Co-operation and Development [OECD] (2007). OECD Health Data 2007. Version 07/18/2007. CD-ROM. Paris: OECD. iv World Health Organization [WHO] (2007). World Health Statistics 2007. see: http://www.who. v Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care May 15, 2007 (updated May 16, 2007)
Volume 59 Authors: Karen Davis, Ph.D., Cathy Schoen, M.S., Stephen C. Schoenbaum, M.D., M.P.H., Michelle M. Doty, Ph.D., M.P.H., Alyssa L. Holmgren, M.P.A., Jennifer L. Kriss, and Katherine K. Shea Editor(s):Deborah Lorber see: www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678 vi See Tables Q39 and Q40a in the 2007 National Physician Survey at:www.nationalphysiciansurvey.ca/nps/ vii Dr. Alan Brookstone is a family physician in Richmond, BC and the founder of CanadianEMR. The quote was taken from: Online resource enables MDs to rate EMRs. See: www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Future_Practice/English/2007/November/Online-e.pdf The CanadianEMR Physician Resource Directory provides access to a province specific searchable list of vendors of products and services to support the EMR-based practice. http://www.canadianemr.ca/ viii Booz, Allan, Hamilton Study, Pan-Canadian Electronic Health Record, Canada's Health Infoway's 10-Year Investment Strategy, March 2005-09-06. ix Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs Richard Hillestad, James Bigelow, Anthony Bower, Federico Girosi, Robin Meili, Richard Scoville and Roger Taylor, Health Affairs, 24, no. 5 (2005): 1103-1117. x In November 2008 the Auditor General of Canada will present it's performance audit on, "Reporting on Health Indicators-Health Canada" to Parliament. See: www.oag-bvg.gc.ca/internet/English/oag-bvg_e_29401.html xi There has been heavy emphasis is being placed on "accountability" and "performance measurement," endorsed by the Romanow Commission (Commission on the Future of Healthcare in Canada 2002), the Kirby Committee (Standing Senate Committee on Social Affairs, Science and Technology 2002), and the First Ministers' accord (First Ministers 2004). See Raisa Deber Why Did the World Health Organization Rate Canada's Health System as 30th? Some Thoughts on League Tables. Some Thoughts on League Tables xii The results of an Ipsos Reid poll (January 2008) finds that eight in ten (78%) Canadians believe that hospital and other health care wait times cost Canada money because people who are waiting for treatment are less productive and miss work. This is compared to just two in ten (19%) who think that wait times save Canada money because governments don't have to put as many resources into healthcare. xiii The economic cost of wait times in Canada, January 2008. This study was commissioned by the Canadian Medical Association (CMA) to analyze the economic costs of wait times in Canada's medical system. The CMA's membership includes more than 67,000 physicians, medical residents and medical students. It plays a key role by representing the interests of these members and their patients on the national stage. Located in Ottawa, the CMA has roots across the country through its close ties to its 12 provincial and territorial divisions. See: www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/pdf/2008/EconomicReport.pdf xiv Sources: Physician visits - CIHI - Physicians in Canada: Fee-for-Service Utilization 2005-2006. Table 1-21. Hospital contacts - CIHI - Trends in Acute Inpatient Hospitalizations and Day surgery Visits in Canada 1995-1996 to 2005-2006 and CIHI -National Ambulatory Care Reporting System - Visit Disposition by Triage Level for All Emergency Visits - 2005-2006. xvAdvantage Canada builds on Canada's strengths and seeks to gain a global competitive advantage in five areas: 1. Tax Advantage-Reducing taxes for all Canadians and establishing the lowest tax rate on new business investment in the G7. 2. Fiscal Advantage-Eliminating Canada's total government net debt in less than a generation. 3. Entrepreneurial Advantage-Reducing unnecessary regulation and red tape and increasing competition in the Canadian marketplace. 4. Knowledge Advantage-Creating the best-educated, most-skilled and most flexible workforce in the world. 5. Infrastructure Advantage-Building the modern infrastructure we need. xvi Software: CLASS 12 , (100 per cent) Property not included in any other class that is.... (o) computer software acquired after May 25, 1976, but not including systems software or property acquired after August 8, 1989 and before 1993 that is described in paragraph (s). xvii Hardware: CLASS 45 , (45 per cent) Property acquired after March 22, 2004 (other than property acquired before 2005 in respect of which an election is made under subsection 1101(5q)) that is general-purpose electronic data processing equipment and systems software for that equipment, including ancillary data processing equipment. Draft Regulation (a) electronic process control or monitor equipment; (b) electronic communications control equipment; (c) systems software for equipment referred to in paragraph (a) or (b); or (d) data handling equipment (other than data handling equipment that is ancillary to general-purpose electronic data processing equipment). Class 50 (55 per cent) Property acquired after March 18, 2007 that is general-purpose electronic data processing equipment and systems software for that equipment, including ancillary data processing equipment, but not including property that is principally or is used principally as (a) electronic process control or monitor equipment; (b) electronic communications control equipment; (c) systems software for equipment referred to in paragraph (a) or (b); or (d) data handling equipment (other than data handling equipment that is ancillary to general-purpose electronic data processing equipment). xviii Health Council of Canada, Rekindling Reform: Health Care Renewal in Canada, 2003 - 2008, June 2008 (page 23). See: www.healthcouncilcanada.ca/docs/rpts/2008/HCC%205YRPLAN%20(WEB)_FA.pdf Appendix 1 (Table does not display correctly -- See PDF) Table 1 -Health Interconnectivity investments over five years. Figure 2 -Major Canadian health centers are well below industry IT investment standard
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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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