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.
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.
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
5 Zemek et al. J Pediatr 2017; 181: 222-8 (https://doi.org/10.1016/j.jpeds.2016.10.067)
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
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.
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
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.
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.
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.
Dr. Paul Watson
Dr. Pierre Fremont
Chair of the CFPC’s SEM Committee and Past President of CASEM
Past President of CASEM
Dr. Gigi Osler
Contacts: Dawn Haworth, Executive Director, CASEM
613 748 5851 – ext 1
Artem Safarov, Director of Health Policy and Government Relations, CFPC
905-629-0900 x 249
The Canadian Medical Association (CMA) submission to the House of Commons Standing Committee on Finance discusses the important role of the federal government in ensuring Canada's health care system is cost-effective, accountable and accessible across the country in order to support the country's economic advantage. Investing in health and health care is required to generate wealth. As in other leading industrialized countries, the federal government needs to play a stewardship role in the effective allocation of health-related resources to foster a productive workforce and a strong economy.
The purpose of this brief is to provide decision-makers with information on areas in which the federal government can contribute to improving the health of Canadians and the health care system - an issue Canadians consistently rank as their top concern.
The CMA recommends that:
Recommendation # 1
The federal government endorse the Principles to Guide Health Care Transformation, developed by the CMA together with the Canadian Nurses Association and since endorsed by over 120 national organizations.
The federal government engage the provinces and territories in a consultative process to identify pan-Canadian metrics and measurement that link health expenditures to nationally comparable health outcomes. The purpose of which is to demonstrate accountability to Canadians.
Recommendation # 3
The federal government recognize the implications of the social determinants of health on the demands on the health care system.
Recommendation # 4
The federal government require that the federal cabinet's decision-making process include a Health Impact Assessment.
Recommendation # 5
The federal government, in consultation with provincial and territorial governments and other stakeholders, establish a program of comprehensive prescription drug coverage to be administered through provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drugs.
Recommendation # 6
The federal government, together with the provinces and territories, develop and implement a pan-Canadian strategy for continuing care, which would integrate home care and facility-based long-term, respite and palliative care services fully within health care systems.
Recommendation # 7
A targeted health infrastructure fund be established as part of the federal government's long-term plan for public infrastructure. The purpose of this fund would be to address infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times.
Recommendation # 8
The federal government expand the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates.
Recommendation # 9
The federal government establish programs to encourage Canadians to save for their long-term care needs by pre-funding long-term care through for example, private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance, such as an RESP-type savings vehicle.
Recommendation # 10
The federal government develop and implement a national dementia strategy. Such a strategy will contribute to addressing the alternative level of care crisis impacting the efficiency of the overall health care system.
Despite significant investments in health care and improvements in medical treatment and technologies, health outcomes in Canada are not improving. The incidence of chronic disease, such as diabetes and the corresponding risk factors, among them obesity, continues to rise. These negative outcomes can have a significant impact on the prosperity of the country as health is necessary for individuals to lead a prosperous and autonomous life. While the federal government's investment in the sector has continually increased, it is generally agreed that, in terms of its health care system, Canada is no longer a strong performer compared to similar nations.
As in other leading industrialized countries, the Government of Canada needs to play a stewardship role in the effective allocation of health-related resources, which in turn will foster a productive workforce and a strong economy. The federal government also has a role in addressing the social and economic factors that affect the health of Canadians. These factors are often referred to as the social determinants of health and were a central theme at the CMA's annual General Council meeting this year.
This brief provides tangible recommendations on how the federal government can contribute to the transformation of Canada's health care system and to improving the health of Canadians.
1. The Role of the Federal Government
Issue: The federal government has the levers to foster a healthy, productive workforce.
This section discusses opportunities for the federal government to address the challenges facing Canada's overall health care system.
Even though the fiscal arrangement for the future Canada Health Transfers has been established, the federal government has other significant responsibilities with respect to the health of Canadians and the overall health care system.
This view is shared by a majority of Canadians. Recent polling found that: 75 per cent of Canadians believe health care should be the federal government's top priority; 87 per cent believe that the federal government should pay more attention to health care, and 85 per cent believe the federal government should play a leading role in protecting and strengthening the health care system.
An important role to be fulfilled by the federal government is to ensure Canada's health care system is cost-effective, accountable and accessible across the country. Health expenditures account for an increasing proportion of provincial and territorial budgets, and many warn of increasing future demands on health care. In his Economic and Fiscal Outlook Report of May 17, 2012, the Parliamentary Budget Officer stated that "the provincial-territorial long-term fiscal situation has deteriorated." Measures that transfer costs from one level of government to another do not improve Canada's overall fiscal situation.
Despite the importance of the health care sector to Canada's economy and quality of life, it is generally agreed that in health care, Canada is no longer a strong performer relative to similar nations. For instance, OECD Health Data 2012 ranks Canada seventh highest of 34 member states in per capita health care spending,1 while Canada's health care system continues to rank below most of our comparator countries in terms of performance. In addition, recent projections indicate that the overall spending on health as a percentage of GDP will continue to increase.2
However, the health sector has an important role in sustaining Canada's economic recovery and enhancing economic growth. In fact, the health sector supports a healthy and productive workforce by providing over one million high-value jobs, representing about 10 per cent of Canada's labour force. The contribution of Canada's health care system to the international competitiveness of our economy has been repeatedly demonstrated in KPMG's Competitive Alternatives report.3
Taken together, these issues highlight significant potential for the health sector, through efficiency improvements gained by health care transformation, to support long-term economic recovery and growth in Canada.
Finally, while the provinces and territories have initiated positive steps to collaborate on the sharing of best practices in health care, federal leadership could contribute to these efforts by addressing the overall performance of the health care system in Canada.
The federal government should collaborate with the provinces and territories to introduce a pan-Canadian framework for reporting to Canadians on performance, outcomes and expenditures, including on whether national standards of quality and timeliness have been met.
The federal government would also fall under this framework, as it is responsible for the delivery of health care services to a large population. In fact, in health care delivery, it is the fifth-largest jurisdiction in Canada.
The CMA recommends that:
* The federal government engage the provinces and territories in a consultative process to identify pan-Canadian metrics and measurement that link health expenditures to nationally comparable health outcomes. The purpose of which is to demonstrate accountability to Canadians.
2. The need for a Health Impact Assessment (HIA)
Issue: All federal government decisions need to be viewed through the lens of their possible impact on health, health care and Canada's overall health objectives.
While a strong health care system is vital, improvements to it alone will not improve health outcomes or reduce the disparities that currently exist in disease burden and health risks. Research suggests that 50 per cent of population health is determined by our social and economic environment.4 What is needed is a process to address the social determinants that can be barriers or enablers to health and to ensure healthy public policy for all Canadians.
A Health Impact Assessment (HIA) is a systematic process for making evidence-based judgments on the health impacts of any given policy and to identify and recommend strategies to protect and promote health. The HIA is used in several countries, including Australia, New Zealand, Norway, the Netherlands and the United States.
The HIA can ensure that all government departments are able to consider the health impacts of their programs and policies by anticipating possible unintended health consequences or impacts on health care spending. The implementation of an evidence-based HIA is one way in which the federal government can play a leadership role in health care and strengthen accountability to Canadians.
The CMA recommends that:
* The federal government recognize the implications of the social determinants of health on the demands on the health care system; and that,
* The federal government require that the federal cabinet's decision-making process include a Health Impact Assessment to ensure that the health of Canadians is a key factor in every policy decision it makes and unintended consequences are avoided.
3. Contribute to Health Care Transformation (HCT)
Issue: A transformed health care system will be more effective and comprehensive and will strengthen Canada's competitive advantage.
In 2010, as part of its Health Care Transformation (HCT) initiative, the CMA broadly consulted Canadians across the country on their views on health care. Canadians said they do not believe they are getting good value from their health care system, a feeling borne out by studies comparing Canada's health care system to those in leading countries in Europe. Following this consultation, in partnership with the Canadian Nurses Association, the CMA developed Principles to Guide Health Care Transformation in Canada to guide the transformation of Canada's health care system. To date, over 120 national medical, health and organizations have endorsed these principles.
During the HCT consultation, we also heard that Canadians are concerned about inequities in access to care beyond the basic medicare basket, particularly in the area of prescription drugs. In fact, reports in 2002 by the Senate Standing Committee on Social Affairs, Science and Technology (Kirby) and the Commission on the Future of Health Care in Canada (Romanow) forged a consensus on the need for "catastrophic" pharmaceutical coverage, which may be defined as out-of-pocket prescription drug expenditures that exceed a certain threshold of household income.
Under the National Pharmaceuticals Strategy (NPS), cost projections of catastrophic pharmaceutical coverage were explored and seemed to favour the use of a variable percentage threshold linked to income. However, there has been no public reporting on progress since 2006.5 Moreover, there is also an issue of expensive drugs that may be used for common diseases. Finally, as highlighted by recent experiences, Canada does not have a monitoring and early notification system for drug shortages nor a systematic mechanism to prevent interruptions in the provision of medically necessary medications.
Thus far, the term "catastrophic" has been used by First Ministers and the NPS to describe their vision of national pharmaceutical coverage. As defined by the World Health Organization, catastrophic expenditure reflects a level of out-of-pocket health expenditures so high that households have to cut down on necessities such as food and clothing and items related to children's education.6 In the CMA's view, this does not go far enough and what Canada must strive for is "comprehensive" coverage that covers the whole population and effectively pools risk across individuals, public and private plans, and jurisdictions.
There are several indicators that show health care services and coverage are not keeping up with Canadians' needs and vary depending on where one lives in Canada. Wide variation in access to pharmaceutical treatments remains the most glaring example of inequity in our
health care system - all Canadians should have a basic level of drug coverage. Further, long wait times for medical care can be found in smaller provinces and drug coverage and services for seniors are particularly poor in Atlantic Canada.
The fact remains that one in 10 Canadians cannot afford the medications they are prescribed.7 For this reason, ensuring access by all Canadians to needed prescription drugs is an essential element in the CMA's proposed framework for Health Care Transformation.
By working to establish comprehensive prescription coverage, the federal government would not only uphold its commitment to ensure the best health for Canadians, but also contribute to the transformation of our country's most cherished social program.
The CMA recommends that:
* The federal government endorse the Principles to Guide Health Care Transformation, developed by the CMA together with the Canadian Nurses Association and since endorsed by over 120 organizations.
* The federal government, in consultation with provincial, territorial and other stakeholders, establish a program of comprehensive prescription drug coverage to be administered through provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drugs.
4. Meeting the health and health care needs of Canadians
Issue: Measures should be taken to prepare for the looming demographic change and address the needs of Canada's aging population
Steps need to be taken to ensure that Canada is prepared to handle the growing long-term care needs of its citizens. These should include funding for much-needed infrastructure and additional support for both health care providers and informal caregivers.
In its most recent report, the Wait Time Alliance noted a link between the rise in diagnosis of dementia and the rise in alternate-levels-of-care (ALC) patient stays in hospitals. These are patients who are in hospital while they await an alternative level of care in a more appropriate setting, often a long-term facility. The shortage of long-term care facilities is a major impediment to achieving efficiency in the health care system and yet another issue for which the federal government is well positioned to collaborate and coordinate on a pan-Canadian strategy.
Under its next long-term infrastructure program, the federal government should include a targeted health sector infrastructure fund for long-term care facilities. This should be part of a pan-Canadian strategy to redirect care from hospitals to homes, communities and long-term care facilities, where patients can receive more appropriate care at a lower cost.
We can expect that many more facilities will be required to meet the long-term care needs of Canadians. The most recent census data shows that over the last decade there has been a 38 per cent increase in the number of seniors living in special care facilities.8 Based on residency rates of the present population, Canada will need over 800,000 long-term care beds by 2047.
Considering the average size of existing long-term care facilities it is estimated that meeting this future demand will require construction of almost 6,000 additional long-term care facilities over the next 35 years, almost 170 a year.9
Another related issue that has the potential to affect productivity is the burden of providing care to family members. Without adequate long-term care resources and support for home care, Canada's labour force may experience a productivity drag as a result of increased leave and absenteeism to care for elderly relatives.
The 2011 federal budget took a first step at providing tax relief for informal caregivers with the introduction of the Family Caregiver Tax Credit. However, this credit of up to $300 a year by no means provides sufficient support for informal caregivers. A 2004 Canadian study estimated that the annual cost of a caregiver's time at market rates for moderately to severely disabled home care clients ranged from $5,221 to $13,374, depending on the community in which they reside.10 Expanding the Family Caregiver Tax Credit would help, but the CMA believes that additional support for informal caregivers will also be needed in the coming years.
Also, according to a 2012 World Health Organization (WHO) report on dementia,11 Canada is one of the few members of the G7 without a national strategy on dementia. There is a lack of awareness and understanding of dementia, which results in stigmatization and barriers to diagnosis and care, and has an impact on caregivers, families and societies - physically, psychologically and economically. Canada's aging population, and the projected rise in Alzheimer's disease and related dementias, pose an emerging health crisis that require federal leadership.
The CMA recommends that:
* The federal government, in partnership with the provinces and territories, develop and implement an integrated, pan-Canadian strategy for continuing care, which would integrate home care and facility-based long-term, respite and palliative care services fully within health care systems. Such a strategy would help prepare for the looming demographic change and the address the needs of Canada's aging population.
* A targeted health infrastructure fund be established as part of the federal government's next long-term plan for public infrastructure. The purpose of this fund would be to support communities across Canada in addressing infrastructure shortages in the health sector that prevent the optimization of health human resources and exacerbate wait times.
* The federal government expand the relief programs for informal caregivers to provide guaranteed access to respite services for people dealing with emergency situations, as well as increase the Family Caregiver Tax Credit to better reflect the annual cost of family caregivers' time at market rates.
* The federal government establish programs to encourage Canadians to save for their long-term care needs by pre-funding long-term care through for example, private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance, such as an RESP-type savings vehicle.
* The federal government develop and implement a national dementia strategy. Such a strategy will contribute to addressing the alternative level of care crisis impacting the efficiency of the overall health care system.
1 OECD Health Data 2012 - http://www.oecd.org/health/healthgrowthinhealthspendinggrindstoahalt.htm
2 CD Howe Commentary Chronic healthcare spending disease: a macro diagnosis and prognosis and
Livio Di Matteo and ROSANNA DI MATTEO, The Fiscal Sustainability of Canadian Publicly Funded Healthcare Systems and the Policy Response to the Fiscal Gap CHSRF series of reports on financing models: Paper 5, January 2012. http://www.chsrf.ca/Libraries/Commissioned_Research_Reports/Dimatteo-Fiscal-E.sflb.ashx
3 KPMG. Competitive Alternatives: KPMG's Guide to International Business Location Costs. 2012 edition
4 The Standing Senate Committee on Social Affairs, Science and Technology Final Report of Senate Subcommittee on Population Health. June 2009.
5 Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceutical Strategy Progress Report. June 2006. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 08-05-08.
6 Xu K, Evans D, Carrin G, Aguillar-Riviera A. Designing health financing systems to reduce catastrophic health expenditure. Geneva: World Health Organization, 2005.
7 Law MR, Cheng L, Dhalla IA et al. The effect of cost on adherence to prescription medications in Canada. CMAJ February 21, 2012 vol. 184 no. 3
8 Statistics Canada. September 19, 2012. Living arrangements of seniors: Families, households and marital status Structural type of dwelling and collectives, 2011 Census of Population.
9 According to the Canadian Healthcare Association (New Directions for Facility-Based Long-Term care), in 2007 there were 2,577 long-term care facilities in Canada and 217,969 beds. We used the average number of beds per facility to calculate the number of facilities required to meet expected future demand.
10 Chappell, N.L., B.H. Dlitt, M.J. Hollander, J.A. Miller and C. McWilliam. 2004. "Comparative Costs of Home Care and Residential Care." The Gerontologist 44(3): 389-400
Bill C-38 covers a lot of ground and we welcome the occasion to discuss it.
Right at the outset, let me remind you that the Canadian Medical Association has a long tradition of staunch non-partisanship. Our mandate is to be the national advocate for the highest standards in health and health care.
In a bill as wide-ranging as this one, there is a great deal I could talk about. In the time allotted, however, I am going to frame my brief remarks around three themes... namely:
First, what is very clearly in the bill;
Second, what is lacking in the bill, and
Third, what I would characterize as a general lack of clarity and consultation on certain aspects of the federal government's actions on health care.
First, I will comment on one of the key measures contained in the budget bill.
We are greatly concerned about the move to raise the age of eligibility for Old Age Security.
Many seniors have low incomes and delaying this relatively modest payment by two years is certain to have a negative impact.
For many older Canadians, who tend to have more complex health problems, medication is a life line. We know that, already, many cannot afford their meds.
Gnawing away at Canada's social safety net will no doubt force hard choices on some of tomorrow's seniors... the choice between whether to buy groceries or to buy their medicine.
I think it is safe to say it would not hold up to a cost-benefit analysis.
People who skip their meds, or lack a nutritious diet or enough heat in their homes, will be sicker.
In the end, this will put a greater burden on our health care system.
Let me now turn to a couple of things we were hoping to see in the budget but that are not there.
As we all know, the Finance Minister announced the government's plans for the Canada Health Transfer in December.
The CMA was encouraged when the Minister of Health subsequently spoke about collaborating with the provinces and territories on developing accountability measures for this funding.
We look forward to this accountability plan for the minimum of $446 billion that will flow to the provinces and territories in federal transfers for health over the next twelve years.
In both 2008 and 2009, the Euro-Canada Health Consumer Index ranked Canada last out of 30 countries in terms of value for money spent on health care.
We believe that federal government should lever its spending on health care to bring change to the system.
It could introduce incentives, measurable goals, pan-Canadian metrics and measurement that would link health care spending to comparable health outcomes.
This would recognize, too, that the federal government is itself the fifth-largest jurisdiction in health care delivery.
We believe the federal government has a role to play in leading this change and that transferring billions of federal dollars in the absence of this leadership shortchanges Canadians.
This budget thus represents an opportunity lost to find ways to transform the health care system and help Canadians get better value and better patient care for the money they spend on health care.
The other major piece missing from this budget is any move to establish a national pharmaceutical strategy.
A pharmaceutical strategy that would ensure consistent coverage and secure supply across the country remains unfinished business from eight years ago.
Access to pharmaceutical treatments remains the most glaring example of inequity of our health care system.
I should point out that the Senate Social Affairs Committee in its recent report on the 2004 Health Accord also recommended the implementation of a national pharmaceutical strategy.
Now I come to the third part of my remarks, which is about a general lack of clarity in regard to certain aspects of the federal government's responsibilities vis-a- vis health care.
Since the budget was tabled, the federal government has announced $100 million in cuts to the Interim Federal Health Program and eliminated the National Aboriginal Health Organization.
As far as we know, no one was consulted on these changes, and since they are not in the budget bill, there is no opportunity for debate on the potential implications on the health of Canadians.
We are also uncertain about the impact of changes in service delivery at Veterans Affairs Canada, changes in the mental health programs at the Department of National Defence, and plans to consolidate some of the functions of the Health Canada and the Canadian Public Health Agency.
There are many unknowns and these are serious matters that warrant serious consideration.
The government committed that it would not balance the books on the backs of the provinces, yet there appears to be a trend toward the downloading of health care costs to federal client groups or the provinces and territories or individuals.
As we have seen in the past, cost downloading is not the same as cost saving.
In fact, when health is impacted, the costs will be inevitably higher, both in dollars and in human suffering.
Re: Standing Committee on Health’s study on violence faced by healthcare workers
Dear Mr. Casey:
I am writing on behalf of the Canadian Medical Association (CMA) to submit recommendations for
consideration by the Standing Committee on Health (the Committee) as part of the study on violence
faced by healthcare workers.
The CMA is deeply concerned with the state of workplace safety in all health care settings, including
hospitals, long-term care, and home care settings. As in all experiences of violence, it is
unacceptable for healthcare workers to be victims of violence in the provision of care to patients.
While there is limited data nationally to understand the incidence of violence against healthcare
workers, anecdotal evidence suggests that these experiences are increasing in frequency and severity.
A 2010 survey of members of the College of Family Physicians of Canada shockingly found that, in
the previous month, nearly one-third of respondents had been exposed to some form of aggressive
behaviour from a patient (90%) or patient’s family (70%). The study concluded that “Canadian family
physicians in active practice are subjected to regular abuse from their patients or family members of
These concerns were brought to the CMA’s General Council in 2015, where our members passed a
resolution calling for:
“the federal government to amend the Criminal Code by making it a specific criminal offence to
assault health care providers performing their duties.”
The CMA is prioritizing initiatives that support physician health and wellness. Increasingly, there is a
recognition of the role of the workplace, primarily health care settings, and safe working conditions as
having an important influence of physician health and wellness.
1 Miedema BB, Hamilton R, Tatemichi S et al. Monthly incidence rates of abusive encounters for Canadian family physicians by patients and their families. Int J Family
Med. 2010; 2010: 387202. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275928/pdf/IJFM2010-387202.pdf (accessed 2019 May 9).
Mr. Bill Casey
Addressing violence against providers in healthcare settings will require action from both federal and
provincial/territorial governments. In light of the above, the CMA respectfully submits the following
recommendations for consideration by the Committee in its study on violence against healthcare
1) The CMA recommends that the Committee on Health support the call to amend the Criminal
Code of Canada to introduce a new criminal offence for assault against a healthcare
provider performing their duty.
2) The CMA recommends that the Committee on Health support establishing monitoring of
violence against healthcare workers, that is consistent across jurisdictions, and have an active
role in responding appropriately to trends.
3) The CMA recommends that the Committee on Health support federal leadership in a pan-
Canadian approach to support workplace safety in healthcare settings, including
collaborating with the provinces and territories to improve violence prevention.
Finally, the CMA welcomes and supports the petition recently tabled in the House of Commons by
Dr. Doug Eyolfson, calling for the Minister of Health “to develop a pan-Canadian prevention strategy
to address growing incidents of violence against health care workers.”
In closing, the CMA is encouraged that the Committee is undertaking this study. I look forward to the
Committee’s report on this topic and the opportunity to collaborate on federal and
provincial/territorial action in this matter.
F. Gigi Osler, BScMed, MD, FRCSC
c.c.: Marilyn Gladu, M.P., Vice Chair, Standing Committee on Health
Don Davies, M.P., Vice Chair Standing Committee on Health