Skip header and navigation
CMA PolicyBase

Policies that advocate for the medical profession and Canadians


17 records – page 1 of 2.

Health equity and the social determinants of health: A role for the medical profession

https://policybase.cma.ca/en/permalink/policy10672
Last Reviewed
2020-02-29
Date
2012-12-08
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2012-12-08
Topics
Population health/ health equity/ public health
Text
Health equity is created when individuals have the opportunity to achieve their full health potential; equity is undermined when preventable and avoidable systematic conditions constrain life choices.1 These conditions are known as the social determinants of health. The World Health Organization (WHO) defines the social determinants of health as the circumstances in which people are born, develop, live and age.2 In 2002, researchers and policy experts at a York University conference identified the following list: income and income distribution; early life; education; housing; food security; employment and working conditions; unemployment and job security; social safety net; social inclusion/exclusion; and health services. 3 Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.4 Any actions to improve health and tackle health inequity must address the social determinants and their impact on daily life.5 THE SOCIAL DETERMINANTS OF HEALTH AND HEALTH STATUS Social status is one of the strongest predictors of health at the population level. There is a social gradient of health such that those with higher social status experience greater health than those with lower social status. The social gradient is evident not only when comparing the most disadvantaged to the most advantaged; within each strata, even among those holding stable middle-class jobs, those at the lowest end fare less well than those at the higher end. The Whitehall study of civil servants in the United Kingdom found that lower ranking staff have a greater disease burden and shorter life expectancy than higher-ranking staff.6 Differences in medical care did not account for the differences in mortality.7 This gradient has been demonstrated for just about any health condition.8 Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.9 In 2001, people in the neighbourhoods with the highest 20% income lived about three years longer than those in the poorest 20% neighbourhoods (four years for men; two years for women).10 Dietary deficiencies, common in food insecure households, can lead to an increased chance of chronic disease and greater difficulty in disease management. It is estimated that about 1.1 million households in Canada experience food insecurity, with the risk increasing in single-parent households and in families on social assistance.11 Studies suggest that adverse socio-economic conditions in childhood can be a greater predictor of cardiovascular disease and diabetes in adults than later life circumstances and behavioural choices.12 Effective early childhood development offers the best opportunity to reduce the social gradient and improve the social determinants of health,13 and offers the greatest return on investment.14 Low income contributes not only to material deprivation but social isolation as well. Without financial resources, it is more difficult for individuals to participate in cultural, educational and recreational activities or to benefit from tax incentives. Suicide rates in the lowest income neighbourhoods are almost twice as high as in the wealthiest neighbourhoods.15 This social isolation and its effects are most striking in Canada's homeless population. Being homeless is correlated with higher rates of physical and mental illness. In Canada, premature death is eight to 10 times higher among the homeless.16 The gradient in other social determinants can have an adverse impact as well. A study conducted in the Netherlands estimated that average morbidity and mortality in the overall population could be reduced 25-50% if men with lower levels of education had the same mortality and morbidity levels as those men with a university education.17 Employment status also follows this gradient, such that having a job is better than being unemployed. 18 Unemployment is correlated with increased blood pressure, self-reported ill health, drug abuse, and reductions in normal activity due to illness or injury.19 Unemployment is associated with increases in domestic violence, family breakups and crime. Finally, job security is relevant.20 Mortality rates are higher among temporary rather than permanent workers.21 Canada's Aboriginal people face the greatest health consequences as a result of the social determinants of health. Poverty, inadequate or substandard housing, unemployment, lack of access to health services, and low levels of education characterize a disproportionately large number of Aboriginal peoples.22 The crude mortality rate for First Nations is higher and life expectancy lower than the Canadian average.23 Aboriginal peoples experience higher rates of chronic disease, addictions, mental illness and childhood abuse.24 Aboriginal peoples have higher rates of suicide, with suicide being the leading cause of potential years of life lost in both the First Nations and Inuit populations.25 THE SOCIAL DETERMINANTS OF HEALTH AND CANADA'S HEALTH SYSTEM These differences in health outcomes have an impact on the health care system. Most major diseases including heart disease and mental illness follow a social gradient with those in lowest socio-economic groups having the greatest burden of illness.26 Those within the lowest socio-economic status are 1.4 times more likely to have a chronic disease, and 1.9 times more likely to be hospitalized for care of that disease.27 Chronic diseases such as diabetes account for 67% of direct health care costs and 60% indirect costs.28 Research has shown that Canadians with low incomes are higher users of general practitioner, mental health, and hospital services.29 People in the lowest income group were almost twice as likely as those in the highest income group to visit the emergency department for treatment. 30 Part of this may be caused by differences in access to care. Low-income Canadians are more likely to report that they have not received needed health care in the past 12 months.31 Those in the lowest income groups are 50% less likely than those in the highest income group to see a specialist or get care in the evenings or on weekends, and 40% more likely to wait more than five days for a doctor's appointment.32 Barriers to health care access are not the only issue. Research in the U.K.33 and U.S.34 has found that compliance with medical treatment tends to be lower in disadvantaged groups, leading to pain, missed appointments, increased use of family practice services and increased emergency department visits, and corresponding increases in cost. In the U.S., non-adherence has been attributed to 100,000 deaths annually.35 Researchers have reported that those in the lowest income groups are three times less likely to fill prescriptions, and 60% less able to get needed tests because of cost.36 These differences have financial costs. In Manitoba for example, research conducted in 1994 showed that those in the lowest income decile used services totaling $216 million (12.2%). In the same year, those in the highest income decile consumed $97 million (5.5%) of expenditures. If expenditures for the bottom half of the population by income had been the same as the median, Manitoba would have saved $319 million or 23.1% of their health care budget. 37 According to a 2011 report, low-income residents in Saskatoon consume an additional $179 million in health care costs than middle income earners.38 To reduce the burden of illness and therefore system costs, Canada needs to improve the underlying social and economic determinants of health of Canadians. However, until these changes have time to improve the health status of the population, there will still be a large burden of illness correlated to these underlying deficiencies. As a result, the health system will need to be adequately resourced to address the consequences of the social determinants of health. AREAS FOR ACTION The WHO Commission on the Social Determinants of Health identified four categories through which actions on social determinants can be taken. These include: * reducing social stratification by reducing inequalities in power, prestige, and income linked to socio-economic position; * decreasing the exposure of individuals and populations to the health-damaging factors they may face; * reducing the vulnerability of people to the health damaging conditions they face; and * intervening through health care to reduce the consequences of ill health caused by the underlying determinants.39 All of these areas offer possibilities for action by the physician community. The following section provides suggestions for action by the medical profession through: CMA and national level initiatives; medical education; leadership and research; and clinical practice. CMA and national level initiatives Despite the strong relationship between the social determinants of health and health, little in the way of effective action has resulted. CMA and its partners can and should, advocate for research and push for informed healthy public policy, including health impact assessments for government policies. Additionally, targeted population health programs aimed at addressing the underlying determinants should be supported. All Canadians need a better understanding of the health trends and the impacts of various social and economic indicators. Information about the differences in specific health indicators, collected over time,40 is essential to the task of describing underlying health trends and the impacts of social and economic interventions. Data within primary care practices could be assembled into (anonymous) community-wide health information databases, to address this need. CMA recommends that: 1. The federal government recognize the relationship of the social determinants of health on the demands of the health care system and that it implement a requirement for all cabinet decision-making to include a Health Impact Assessment. 2. Options be examined for minimizing financial barriers to necessary medical care including pharmaceuticals and medical devices necessary for health. 3. Federal and provincial/territorial governments examine ways to improve the social and economic circumstances of all Canadians. 4. Efforts be made to educate the public about the effect of social determinants on individual and population health. 5. Appropriate data be collected and reported on annually. This data should be locally usable, nationally comparable and based on milestones across the life course. Medical education Medical education is an effective means to provide physicians with the information and tools they require to understand the impact of social determinants on the health of their patients and deal with them accordingly.41 In 2001, Health Canada published a report in which they stated that the primary goal of medical education should be the preparation of graduates who know how to reduce the burden of illness and improve the health of the communities in which they practice.42 Among the report's recommendations was a call for greater integration of the social determinants in medical curricula.43 Although the CanMEDS framework has been a part of the Royal College of Physicians and Surgeons of Canada's accreditation process since 2005, challenges to the integration of these competencies remain.44 The report called for a greater emphasis on providing medical students with firsthand experiences in the community and with distinct populations (service learning),45 which addresses the difficulties in teaching the social aspects of medicine within a traditional classroom or hospital setting.46 Many such programs exist across the country.47 However, these programs are still limited and there is a need to increase the availability of longitudinal programs which allow students to build on the skills they develop throughout medical school. Increasingly residency programs which focus on the social determinants of health are being offered.48 These programs are a means of providing physicians with the proper tools to communicate with patients from diverse backgrounds49 and reduce behaviours that marginalized patients have identified as barriers to health services.50 It also provides residents with physician role models who are active in the community. However, medical residents note a lack of opportunities to participate in advocacy during residency.51 Further, while experiential programs are effective in helping to reduce barriers between physicians and patients from disadvantaged backgrounds, greater recruitment of medical students from these marginalized populations should also be explored and encouraged. Finally, physicians in practice need to be kept up to date on new literature and interventions regarding the social determinants. Innovations which help address health equity in practice should be shared with interested physicians. In particular, there is a need for accredited continuing medical education (CME) and a means to encourage uptake.52 CMA recommends that: 6. Greater integration of information on the social determinants and health inequity be provided in medical school to support the CanMEDS health advocate role 7. All medical schools and residency programs offer service learning programs, to provide students with an opportunity to work with diverse populations in inner city, rural and remote settings, and to improve their skills in managing the impact of the social determinants on their patients. 8. CME on the social determinants of health and the physician role in health equity be offered and incentivized for practising physicians. Leadership and research Within many communities in Canada, there are physicians who are working to address social determinants and health equity within the patient populations they serve. This is done in many cases through collaboration with partners within and outside of the health care system. Providing these local physician leaders with the tools they need to build these partnerships, and influence the policies and programs that affect their communities is a strategy that needs to be explored. Evidence-based research about health equity, the clinical setting and the role of physicians is underdeveloped. Interested physicians may wish to participate in research about practice level innovations, as a means of contributing to the evidence base for 'health equity' interventions or simply to share best practices with interested colleagues. Further, physicians can provide the medical support to encourage the adoption of early childhood development practices for example, which support later adult health. In time, research will contribute to training, continuing medical education and potentially to clinical practice guidelines. Physicians can provide leadership in health impact assessments and equity audits within the health care system as well. Data is essential to identify health equity challenges within a program, to propose and test measures that address the issues underlying the disparities. Formal audits and good measurement are essential to develop evidence-based policy improvements.53 Innovative programs such as those within the Saskatoon Health Region and the Centre for Addiction and Mental Health in Toronto are examples of using these tools to improve access and reduce inequities. CMA recommends that: 9. Physicians who undertake leadership and advocacy roles should be protected from repercussions in the workplace, e.g., the loss of hospital privileges. 10. Physician leaders explore opportunities to strengthen the primary care public health interface within their communities by working with existing agencies and community resources. 11. Physician leaders work with their local health organizations and systems to conduct health equity impact assessments in order to identify challenges and find solutions to improve access and quality of care. 12. Physicians be encouraged to participate in or support research on best practices for the social determinants of health and health equity. Once identified, information sharing should be established in Canada and internationally. Clinical practice In consultation with identified health equity physician champions, a number of clinical interventions have been identified which are being undertaken by physicians across the country. These interventions could be undertaken in many practice settings given the right supports, and could be carried out by various members of the collaborative care team.1 First, a comprehensive social history is essential to understand how to provide care for each patient in the context of their life.54 There are a number of tools that can be used for such a consultation and more are in development.55 However, consolidation of the best ideas into a tool that is suitable for the majority of health care settings is needed. There is some concern that asking these questions is outside of the physician role. The CanMEDS health advocate role clearly sees these types of activities as part of the physician role.56 The 'Four Principles of Family Medicine' defined by the College of Family Physicians of Canada, affirms this role for physicians as well.57 Community knowledge was identified as a strategy for helping patients. Physicians who were aware of community programs and services were able to refer patients if/when social issues arose.58 Many communities and some health providers have developed community resource guides.59 For some physicians, developing a network of community resources was the best way to understand the supports available. As a corollary, physicians noted their work in helping their patients become aware of and apply for the various social programs to which they are entitled. The programs vary by community and province/territory, and include disability, nutritional supports and many others. Most if not all of these programs require physicians to complete a form in order for the individual to qualify. Resources are available for some of these programs,60 but more centralized supports for physicians regardless of practice location or province/territory are needed. Physicians advocate on behalf of their patients by writing letters confirming the medical limitations of various health conditions or the medical harm of certain exposures.61 For example, a letter confirming the role of mold in triggering asthma may lead to improvements in the community housing of an asthmatic. Additionally, letters might help patients get the health care services and referrals that they require. As identified leaders within the community, support from a physician may be a 'game-changer' for patients. Finally, the design of the clinic, such as hours of operation or location, will influence the ability of people to reach care.62 CMA recommends that: 13. Tools be provided for physicians to assess their patients for social and economic causes of ill health and to determine the impact of these factors on treatment design. 14. Local databases of community services and programs (health and social) be developed and provided to physicians. Where possible, targeted guides should be developed for the health sector. 15. Collaborative team-based practice be supported and encouraged. 16. Resources or services be made available to physicians so that they can help their patients identify the provincial/territorial and federal programs for which they may qualify. 17. Physicians be cognizant of equity considerations when considering their practice design and patient resources. 18. All patients be treated equitably and have reasonable access to appropriate care, regardless of the funding model of their physician. CONCLUSION Socio-economic factors play a larger role in creating (or damaging) health than either biological factors or the health care system. Health equity is increasingly recognized as a necessary means by which we will make gains in the health status of all Canadians and retain a sustainable publicly funded health care system. Addressing inequalities in health is a pillar of CMA's Health Care Transformation initiative. Physicians as clinicians, learners, teachers, leaders and as a profession can take steps to address the problems on behalf of their patients. REFERENCES 1 A full review of the consultations is provided in the companion paper The Physician and Health Equity: Opportunities in Practice. 1 Khalema, N. Ernest (2005) Who's Healthy? Who's Not? A Social Justice Perspective on Health Inequities. Available at: http://www.uofaweb.ualberta.ca/chps/crosslinks_march05.cfm 2 World Health Organization (2008) Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Available at: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf 3 Public Health Agency of Canada (N.D.) The Social Determinants of Health: An Overview of the Implications for Policy and the Role of the Health Sector. Available at: http://www.phac-aspc.gc.ca/ph-sp/oi-ar/pdf/01_overview_e.pdf 4 Keon, Wilbert J. & Lucie Pépin (2008) Population Health Policy: Issues and Options. Available at: http://www.parl.gc.ca/Content/SEN/Committee/392/soci/rep/rep10apr08-e.pdf 5 Friel, Sharon (2009) Health equity in Australia: A policy framework based on action on the social determinants of obesity, alcohol and tobacco. The National Preventative Health Taskforce. Available at: http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/0FBE203C1C547A82CA257529000231BF/$File/commpaper-hlth-equity-friel.pdf 6 Wilkinson, Richard & Michael Marmot eds. (2003) Social Determinants of Health: The Solid Facts: Second Edition. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf 7 Khalema, N. Ernest (2005) Who's Healthy?... 8 Dunn, James R. (2002) The Health Determinants Partnership Making Connections Project: Are Widening Income Inequalities Making Canada Less Healthy? Available at: http://www.opha.on.ca/our_voice/collaborations/makeconnxn/HDP-proj-full.pdf 9 Ibid 10 Wilkins, Russ; Berthelot, Jean-Marie; and Ng E. [2002]. Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to 1996. Health Reports 13 [Supplement]: pp. 45-71 11 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health: The Canadian Facts. Available at: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf 12 Raphael, Dennis (2003) "Addressing The Social Determinants of Health In Canada: Bridging The Gap Between Research Findings and Public Policy." Policy Options. March 2003 pp.35-40. 13 World Health Organization (2008) Closing the gap in a generation... 14 Hay, David I. (2006) Economic Arguments for Action on the Social Determinants of Health. Canadian Policy Research Networks. Available at: http://www.cprn.org/documents/46128_en.pdf 15 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health... 16 Ibid. 17 Whitehead, Margaret & Goran Dahlgren (2006) Concepts and principles for tackling social inequities in health: Levelling up Part 1. World Health Organization Europe. Available at: http://www.euro.who.int/__data/assets/pdf_file/0010/74737/E89383.pdf 18 Wilkinson, Richard & Michael Marmot eds. (2003) "Social Determinants of Health... 19 Ferrie, Jane E. (1999) "Health consequences of job insecurity." In Labour Market Changes and Job Security: A Challenge for Social Welfare and Health Promotion. World Health Organization. Available at: http://www.euro.who.int/__data/assets/pdf_file/0005/98411/E66205.pdf 20 Marmot, Michael (2010) Fair Society Healthy Lives: The Marmot Review: Executive Summary. Available at: http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLivesExecSummary.pdf 21 World Health Organization (2008) Closing the gap in a generation... 22 Aboriginal Healing Foundation, Frequently Asked Questions (Ottawa: Canadian Government Publishing Directorate, 2009) Available at: http://www.ahf.ca/faq 23Health Council of Canada, "The Health Status Of Canada's First Nations, Métis And Inuit Peoples", 2005, Available at:http://healthcouncilcanada.ca.c9.previewyoursite.com/docs/papers/2005/BkgrdHealthyCdnsENG.pdf 24 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health... 25Health Council of Canada, (2005)"The Health Status Of Canada's First Nations, Métis And Inuit Peoples... 26 Dunn, James R. (2002) The Health Determinants Partnership... 27 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians with Ambulatory Care Sensitive Conditions. http://secure.cihi.ca/cihiweb/products/PHC_Experiences_AiB2012_E.pdf 28 Munro, Daniel (2008) "Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the Socio-Economic Determinants of Health." The Conference Board of Canada. Available at: http://www.conferenceboard.ca/Libraries/NETWORK_PUBLIC/dec2008_report_healthypeople.sflb 29 Williamson, Deanna L. et.al. (2006) "Low-income Canadians' experiences with health-related services: Implications for health care reform." Health Policy. 76(2006) pp. 106-121. 30 CIHI/CPHI (2012) Disparities in Primary Health Care Experiences Among Canadians... 31 Williamson, Deanna L. et.al. (2006) "Low-income Canadians'... 32 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health... 33 Neal, Richard D. et.al. (2001) "Missed appointments in general practice: retrospective data analysis from four practices." British Journal of General Practice. 51 pp.830-832. 34 Kennedy, Jae & Christopher Erb (2002) "Prescription Noncompliance due to Cost Among Adults with Disabilities in the United States." American Journal of Public Health. Vol.92 No.7 pp. 1120-1124. 35 Bibbins-Domingo, Kirsten & M. Robin DiMatteo. Chapter 8: Assessing and Promoting Medication Adherence. pp. 81-90 in King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients... 36 Mikkonen, Juha & Dennis Raphael (2010) Social Determinants of Health... 37 Dunn, James R. (2002) The Health Determinants Partnership... 38 Saskatoon Poverty Reduction Partnership (2011) from poverty to possibility...and prosperity: A Preview to the Saskatoon Community Action Plan to Reduce Poverty. Available at: http://www.saskatoonpoverty2possibility.ca/pdf/SPRP%20Possibilities%20Doc_Nov%202011.pdf 39 World Health Organization (2005) Action On The Social Determinants Of Health: Learning From Previous Experiences. Available at: http://www.who.int/social_determinants/resources/action_sd.pdf 40 Braveman, Paula (2003) "Monitoring Equity in Health and Healthcare: A Conceptual Framework."Journal of Health, Population and Nutrition. Sep;21(3):181-192. 41 Royal College of Physicians (2010) How doctors can close the gap: Tackling the social determinants of health through culture change, advocacy and education. Available at: http://www.marmotreview.org/AssetLibrary/resources/new%20external%20reports/RCP-report-how-doctors-can-close-the-gap.pdf 42 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools. Available at: http://www.medicine.usask.ca/leadership/social-accountability/pdfs%20and%20powerpoint/SA%20-%20A%20vision%20for%20Canadian%20Medical%20Schools%20-%20Health%20Canada.pdf 43 Ibid. 44 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate: Translating the Quest for Social Responsibility into Medical Education and Practice." Academic Medicine. Vol.86 No.9 pp.1108-1113. 45 Health Canada (2001) Social Accountability: A Vision for Canadian Medical Schools... 46 Meili, Ryan; Fuller, Daniel; & Jessica Lydiate. (2011) "Teaching social accountability by making the links: Qualitative evaluation of student experiences in a service-learning project." Medical Teacher. 33; 659-666. 47 Ford-Jones, Lee; Levin, Leo; Schneider, Rayfel; & Denis Daneman (2012) "A New Social Pediatrics Elective-A Tool for Moving to Life Course Developmental Health." The Journal of Pediatrics. V.160 Iss. 3 pp.357-358; Meili, Ryan; Ganem-Cuenca, Alejandra; Wing-sea Leung, Jannie; & Donna Zaleschuk (2011) "The CARE Model of Social Accountability: Promoting Cultural Change." Academic Medicine. Vol.86 No.9 pp.1114-1119. 48 Cuthbertson, Lana "U of A helps doctors understand way of life in the inner city." Edmonton Journal Dec 22, 2010. Available at: http://www2.canada.com/edmontonjournal/news/cityplus/story.html?id=943d7dc3-927b-4429-878b-09b6e00595e1 49 Willems, S.; Maesschalck De, S.; Deveugele, M.; Derese, A. & J. De Maeseneer (2005) "Socio-economic status of the patient and doctor-patient communication: does it make a difference?" Patient Education and Counseling. 56 pp. 139-146. 50 Bloch, Gary; Rozmovits, Linda & Broden Giambone (2011) "Barriers to primary care responsiveness to poverty as a risk factor for health." BioMed Central Family Practice. Available at: http://www.biomedcentral.com/content/pdf/1471-2296-12-62.pdf; Schillinger, Dean; Villela, Theresa J. & George William Saba. Chapter 6: Creating a Context for Effective Intervention in the Clinical Care of Vulnerable Patients. pp.59-67. In King, Talmadge E, Jr. & Margaret B. Wheeler ed. (2007) Medical Management of Vulnerable and Underserved Patients. 51 Dharamsi, Shafik; Ho, Anita; Spadafora, Salvatore; and Robert Woollard (2011) "The Physician as Health Advocate... 52 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities... 53 Meili, Ryan (2012) A Healthy Society: How A Focus On Health Can Revive Canadian Democracy. Saskatoon: Canada. Purich Publishing Limited. pp.36 54 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities... 55 Bloch, Gary (2011) "Poverty: A clinical tool for primary care "Family & Community Medicine, University of Toronto. Available at: http://www.healthprovidersagainstpoverty.ca/system/files/Poverty%20A%20Clinical%20Tool%20for%20Primary%20Care%20%28version%20with%20References%29_0.pdf ; Bricic, Vanessa; Eberdt, Caroline & Janusz Kaczorowski (2011) "Development of a Tool to Identify Poverty in a Family Practice Setting: A Pilot Study." International Journal of Family Medicine. Available at: http://www.hindawi.com/journals/ijfm/2011/812182/ ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, female health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders ; Based on form developed by: Drs. V. Dubey, R.Mathew & K. Iglar; Revised by Health Providers Against Poverty (2008) " Preventative Care Checklist Form: For average-risk, routine, male health assessments." Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders 56 Frank, Dr. Jason R. ed. (2005) "The CanMEDS 2005 Physician Competency Framework: Better standards. Better physicians. Better Care." Office of Education: The Royal College of Physicians and Surgeons of Canada. Available at: http://rcpsc.medical.org/canmeds/CanMEDS2005/CanMEDS2005_e.pdf 57 Tannenbaum, David et.al. (2011) "Triple C Competency-based Curriculum: Report of the Working Group on Postgraduate Curriculum Review-Part 1 58 UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities... 59 Doyle-Trace L, Labuda S. Community Resources in Cote-des-Neiges. Montreal: St Mary's Hospital Family Medicine Centre, 2011. (This guide was developed by medical residents Lara Doyle-Trace and Suzan Labuda at McGill University.); Mobile Outreach Street Health (N.D.) Pocket MOSH: a little MOSH for your pocket: A Practitioners Guide to MOSH and the Community We Serve. Available at: http://www.cdha.nshealth.ca/mobile-outreach-street-health 60 Health Providers Against Poverty (N.D.) Tools and Resources. Available at: http://www.healthprovidersagainstpoverty.ca/Resourcesforhealthcareproviders 61 Meili, Ryan (2012) A Healthy Society: How A Focus...pp.61; UCL Institute of Health Equity (2012) The Role of the Health Workforce in Tackling Health Inequalities... 62 Rachlis, Michael (2008) Operationalizing Health Equity: How Ontario's Health Services Can Contribute to Reducing Health Disparities. Wellesley Institute. Available at: http://wellesleyinstitute.com/files/OperationalizingHealthEquity.pdf
Documents
Less detail

Restricting marketing of unhealthy foods and beverages to children and youth in Canada: A Canadian health care and scientific organization policy consensus statement

https://policybase.cma.ca/en/permalink/policy10676
Last Reviewed
2020-02-29
Date
2012-12-08
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2012-12-08
Topics
Population health/ health equity/ public health
Text
Restricting Marketing of Unhealthy Foods and Beverages to Children and Youth in Canada: A Canadian Health Care and Scientific Organization Policy Consensus Statement POLICY GOAL Federal government to immediately begin a legislative process to restrict all marketing targeted to children under the age of 13 of foods and beverages high in saturated fats, trans-fatty acids, free sugars or sodium and that in the interim the food industry immediately ceases marketing of such food to children. PURPOSE OF STATEMENT This policy consensus statement was developed to reflect the growing body of evidence linking the promotion and consumption of diets high in saturated fats, trans-fatty acids, free sugars or sodium1 to cardiovascular and chronic disease (hypertension, dyslipidemia, diabetes mellitus, obesity, cancer, and heart disease and stroke)— leading preventable risk factors and causes of death and disability within Canada and worldwide. (1-3) (1) For the remainder of the document, reference to foods high in saturated fats, trans-fatty acids, free sugars or sodium will be framed as foods high in fats, sugars or sodium. The current generation of Canadian children is expected to live shorter, less healthy lives as a result of unhealthy eating. (4) Canadians’ overconsumption of fat, sodium and sugar, rising rates of childhood obesity, growing numbers of people with cancer, heart disease and stroke, and the combined strain they exert on the health care system and quality of life for Canadians necessitates immediate action for Canadian governments and policy-makers. Restricting the marketing of unhealthy foods and beverages directed at children is gaining increasing international attention as a cost-effective, population-based intervention to reduce the prevalence and the burden of chronic and cardiovascular diseases through reducing children’s exposure to, and consumption of, disease-causing foods. (2,5,6) In May 2010, the World Health Organization (WHO released a set of recommendations on the marketing of foods and non-alcoholic beverages to children (5) and called on governments worldwide to reduce the exposure of children to advertising messages that promote foods high in saturated fats, trans-fatty acids, free sugars or sodium and to reduce the use of powerful marketing techniques. In June 2012, the follow-up document, A Framework for Implementing the Set of Recommendations on the Marketing of Foods and Non-Alcoholic Beverages to Children, (7) was released. The policy aim should be to reduce the impact on children of marketing of foods high in saturated fats, trans-fatty acids, free sugars, or sodium. WHO (2010): Recommendation 1 What this policy consensus statement offers is the perspective of many major national health care professional and scientific organizations to guide Canadian governments and non-government organizations on actions that need to be taken to protect the health of our future generations, in part by restricting the adverse influence of marketing of foods high in fat, sugar or sodium to Canadian children and youth. SUMMARY OF EVIDENCE AND RATIONALE -Young children lack the cognitive ability to understand the persuasive intent of marketing or assess commercial claims critically. (8) in 1989 the Supreme Court of Canada ruled that “advertisers should not be able to capitalize upon children’s credulity” and “advertising directed at young children is per se manipulative”.(5) -The marketing and advertising of information or products known to be injurious to children’s health and wellbeing is unethical and infringes on the UN Convention on the Rights of the Child which stipulates that, “In all actions concerning children … the best interests of the child shall be a primary consideration.” (9) - Unhealthy food advertising during children’s television programs in Canada is higher than in many countries, with children being exposed to advertisements for unhealthy foods and beverages up to 6 times per hour. (10) - Unhealthy food and beverage advertising influences children’s food preferences, purchase requests and consumption patterns and has been shown to be a probable cause of childhood overweight and obesity by the WHO. (1,8,11) - The vast majority of Canadians (82%) want government intervention to place limits on advertising unhealthy foods and beverages to children. (12) - The regulation of food marketing to children is an effective and cost-saving population-based intervention to improve health and prevent disease. (13,14) - Several bills have been introduced into the House of Commons to amend the Competition Act and the Food and Drug Act to restrict commercial advertising, including food, to children under 13 years of age. None have yet been passed. (15) - Canada’s current approach to restricting advertising to children is not effective and is not in line with the 2010 WHO recommendations on the marketing of foods and beverages to children, nor is it keeping pace with the direction of policies being adopted internationally, which ban or restrict unhealthy food and beverage marketing targeted to children. (16,17) LEGISLATIVE RULING The Supreme Court of Canada concluded that “advertising directed at young children is per se manipulative” Irwin Toy Ltd. v. Québec (AG), 1989 FOOD MARKETING TO CHILDREN: A TIMELY OPPORTUNITY FOR CANADA Childhood obesity and chronic disease prevention are collective priorities for action of federal, provincial and territorial (F/P/T) governments. (3,5,18,19) Strategy 2.3b of the 2011 Federal, Provincial and Territorial Framework for Action to Promote Healthy Weights stipulates “looking at ways to decrease the marketing of foods and beverages high in fat, sugar and/or sodium to children. “(5, p. 31) The 2010 Sodium Reduction Strategy for Canada has also identified the need to “continue to explore options to reduce the exposure of children to marketing for foods that are high in sodium" as a key activity for F/P/T governments to consider. (19, p. 31) In their 2010 set of recommendations, the WHO stipulated that governments are best positioned to lead and ensure effective policy development, implementation and evaluation. (6) To date, there has been no substantive movement by the federal government to develop coordinated national-level policies that change the way unhealthy foods and beverages are produced, marketed and sold. Current federal, provincial and industry-led self-regulatory codes are inconsistent in their scope and remain ineffective in their ability to sufficiently reduce children’s exposure to unhealthy food marketing, nor have they been adequately updated to address the influx of new marketing mediums to which children and youth in Canada are increasingly subjected. Quebec implemented regulations in 1980 restricting all commercial advertising. (20) Although the ban has received international recognition and is viewed as world leading, several limitations remain, in part due exposure of Quebec children to marketing from outside Quebec, weak enforcement of the regulations and narrow application of its provisions. Accordingly, the undersigned are calling on the federal government to provide strong leadership and establish a legislative process for the development of regulations that restrict all commercial marketing of foods and beverages high in saturated fats, trans-fatty acids, free sugars or sodium to children. Strong federal government action and commitment are required to change the trajectory of chronic diseases in Canada and institute lasting changes in public health. Specifically: Efforts must be made to ensure that children…are protected against the impact of marketing [of foods with a high content of fat, sugar and sodium] and given the opportunity to grow and develop in an enabling food environment — one that fosters and encourages healthy dietary choices and promotes the maintenance of healthy weight. (7, p. 6) Such efforts to protect the health of children must go beyond the realm of federal responsibility and involve engagement, dialogue, leadership and advocacy by all relevant stakeholders, including all elected officials, the food and marketing sector, public health, health care professional and scientific organizations, and most importantly civil society. The undersigned support the development of policies that are regulatory in nature to create national and/or regional uniformity in implementation and compliance by industry. “Realizing the responsibility of governments both to protect the health of children and to set definitions in policy according to public health goals and challenges — as well as to ensure policy is legally enforced — statutory regulation has the greatest potential to achieve the intended or desired policy impact.” WHO (2012), p. 33 POLICY/LEGISLATIVE SPECIFICATIONS The following outline key definitions and components of an effective and comprehensive policy on unhealthy food and beverage marketing to children and should be used to guide national policy scope and impact. - Age of Child: In the context of broadcast regulations, the definition of “age of child” typically ranges from under 13 years to under 16 years. In Canada, Quebec’s Consumer Protection Act (20) applies to children under 13 years of age. Consistent with existing legislation, this report recommends that policies restricting marketing of unhealthy foods and beverages be directed to children less than 13 years of age at a minimum. While the science on the impact of marketing on children over 13 is less extensive, emerging research reveals that older children still require protection and may be more vulnerable to newer forms of marketing (i.e., digital media ), in which food and beverage companies are playing an increasingly prominent role. (21-23) Strong consideration should be given to extending the age of restricting the marketing of unhealthy food and beverage to age 16. - Unhealthy Food and Beverages: In the absence of a national standardized definition for “healthy” or “unhealthy” foods, this document defines unhealthy foods broadly as foods with a high content of saturated fats, trans-fatty acids, free sugars or sodium, as per the WHO recommendations. (5) It is recommended that a robust and comprehensive definition be developed by an interdisciplinary stakeholder working group. - Focus on Marketing: Marketing is more than advertising and involves: …any form of commercial communication or message that is designed to, or has the effect of, increasing the recognition, appeal and/ or consumption of particular products and services. It comprises anything that acts to advertise or otherwise promote a product or service. (6, p. 9) This definition goes beyond the current legal definition of advertisement outlined in the Food and Drug Act as “any representation by any means whatever for the purpose of promoting directly or indirectly the sale or disposal of any food, drug, cosmetic or device.” (24) - Marketing Techniques, Communication Channels and Locations: Legislation restricting unhealthy food marketing needs to be sufficiently comprehensive to address the broad scope of marketing and advertising techniques that have a particularly powerful effect on children and youth. This includes, but is not limited to, the following: . Television . Internet . Radio . Magazines . Direct electronic marketing (email, SMS) . Mobile phones . Video and adver-games . Characters, brand mascots and/or celebrities, including those that are advertiser-generated . Product placement . Cross-promotions . Point-of-purchase displays . Cinemas and theatres . Competitions and premiums (free toys) . Children’s institutions, services, events and activities (schools, event sponsorship) . “Viral and buzz marketing” (25,26) . Directed to Children: The criteria used by the Quebec Consumer Protection Act (20) to determine whether an advertisement is “directed at children” offers a starting point in developing national legislation regarding child-directed media. The loopholes in the Quebec Consumer Protection Act criteria, namely allowing advertising of unhealthy foods and beverages directed at adults during children’s programming, will necessitate the development of an alternative approach or set of criteria that reflects the range of media to which children are exposed and when they are exposed, in addition to the proportion of the audience that is made up of children. Quebec Consumer Protection Act Article 249 To determine whether or not an advertisement is directed at persons under thirteen years of age, account must be taken of the context of its presentation, and in particular of: a)the nature and intended purpose of the goods advertised; b)the manner of presenting such advertisement; c)the time and place it is shown. ACTION RECOMMENDATIONS 1. Federal Government Leadership 1.1 Immediately and publicly operationalize the WHO set of recommendations on the marketing of foods and non-alcoholic beverages to children. In working toward the implementation of the WHO recommendations, the federal government is strongly urged to accelerate implementation of the WHO Framework for Implementing the Set of Recommendations on the Marketing of Foods and Beverages to Children. To this end, the Government of Canada is urged to: 1.2 Convene a Federal, Provincial and Territorial Working Group on Food Marketing to Children to develop, implement and monitor policies to restrict unhealthy food and beverage marketing to children. As stipulated within the WHO Implementation Framework: The government-led working group should ultimately reach consensus on the priorities for intervention, identify the available policy measures and decide how they best can be implemented. (7, p.13) 1.3 In developing policies, it is recommended that the working group: - Develop standardized criteria and an operational definition to distinguish and classify “unhealthy” foods. Definitions should be developed using objective, evidence-based methods and should be developed and approved independent of commercial interests. - Develop a set of definitions/specifications that will guide policy scope and implementation. Consistent with the WHO recommendations, the working group is encouraged to apply the policy specifications identified above. - Set measurable outcomes, targets and timelines for achievement of targets for industry and broadcasters to restrict unhealthy food marketing to children in all forms and settings. It is recommended that policies be implemented as soon as possible and within a 3-year time frame. - Establish mechanisms for close monitoring and enforcement through defined rewards and/or penalties by an independent regulatory agency that has the power and infrastructure to evaluate questionable advertisements and enforce penalties for non-compliance.(2) (2) Such an infrastructure could be supported though the Canadian Radio-television and Telecommunications Commission (CRTC), similar to the authority of the US Federal Trade Commission (FTC), the Canadian Food Inspection Agency or the Food and Drug Act via the development of an advertising investigation arm. The nature and extent of penalties imposed should be sufficiently stringent to deter violations. Enforcement mechanisms should be explicit, and infringing companies should be exposed publicly. - Develop evaluation mechanisms to assess process, impact and outcomes of food marketing restriction policies. Components should include scheduled reviews (5 years or as agreed upon) to update policies and/or strategies. To showcase accountability, evaluation findings should be publicly disseminated. 1.4 Provide adequate funding to support the successful implementation and monitoring of the food marketing restriction policies. 1.5 Collaborate with the Canadian Institutes of Health Research and other granting councils to fund research to generate baseline data and address gaps related to the impact of marketing in all media on children and how to most effectively restrict advertising unhealthy foods to children. (27) 1.6 Fund and commission a Canadian economic modeling study to assess the cost-effectiveness and the relative strength of the effect of marketing in comparison to other influences on children’s diets and diet-related health outcomes. Similar studies have been undertaken elsewhere and highlight cost– benefit savings from restricting unhealthy food marketing. (13,14) 1.7 Call on industry to immediately stop marketing foods to children that are high in fats, sugar or sodium. 2. Provincial, Territorial and Municipal Governments 2.1 Wherever possible, incorporate strategies to reduce the impact of unhealthy food and beverage marketing to children into provincial and local (public) health or related strategic action plans, and consider all settings that are frequented by children. 2.2 Pass and/or amend policies and legislation restricting unhealthy food and beverage marketing to children that go beyond limitations stipulated in federal legislation and regulations and industry voluntary codes. 2.3 Until federal legislation is in place, strike a P/T Steering Committee on Unhealthy Food Marketing to Children to establish interprovincial consistency related to key definitions and criteria and mechanisms for enforcement, as proposed above. 2.4 Collaborate with local health authorities, non- governmental organizations and other stakeholders to develop and implement education and awareness programs on the harmful impacts of marketing, including but not limited to unhealthy food and beverage advertising. 2.5 Call on industry to immediately stop marketing foods to children that are high in fats, sugar or sodium. 3. Non-governmental Organizations (NGOs), Health Care Organizations, Health Care Professionals 3.1 Publicly endorse this position statement and advocate to all Canadian governments to restrict marketing of unhealthy foods to children and youth in Canada. 3.2 Collaborate with governments at all levels to facilitate implementation and enforcement of federal/provincial/municipal regulations or policies. 3.3 Wherever possible, incorporate and address the need for restrictions on unhealthy food and beverage marketing to children into position papers, strategic plans, conferences, programs and other communication mediums. 3.4 Support, fund and/or commission research to address identified research gaps, including the changing contexts and modes of marketing and their implications on the nutritional status, health and well-being of children and youth 3.5 Call on industry to immediately stop the marketing of foods high in fat, sugar or sodium. 4. Marketing and Commercial Industry 4.1 Immediately cease marketing foods high in fats, sugar or sodium. 4.2 Amend the Canadian Children’s Food and Beverage Advertising Initiative (CAI) nutrition criteria used to re-define “better-for-you products” to be consistent with currently available international standards that are healthier and with Canadian nutrient profiling standards, once developed. BACKGROUND AND EVIDENCE BASE Non-communicable diseases (diabetes, stroke, heart attack, cancer, chronic respiratory disease) are a leading cause of death worldwide and are linked by several common risk factors including high blood pressure, high blood cholesterol, obesity, unhealthy diets and physical inactivity. (1,2,3 28) The WHO has predicted that premature death from chronic disease will increase by 17% over the next decade if the roots of the problem are not addressed. (2) Diet-related chronic disease risk stems from long- term dietary patterns which start in childhood (8,28). Canadian statistics reveal children, consume too much fat, sodium and sugars (foods that cause chronic disease) and eat too little fiber, fruits and vegetables (foods that prevent chronic disease). (3) There is evidence that (television) advertising of foods high in fat, sugar or sodium is associated with childhood overweight and obesity. (6,11) Children and youth in Canada are exposed to a barrage of marketing and promotion of unhealthy foods and beverages through a variety of channels and techniques – tactics which undermine and contradict government, health care professional and scientific recommendations for healthy eating. (10,26) Available research indicates that food marketing to children influences their food preferences, beliefs, purchase requests and food consumption patterns. (8,29) A US study showed that children who were exposed to food and beverage advertisements consumed 45% more snacks than their unexposed counterparts. (30) Similarly, preschoolers who were exposed to commercials for vegetables (broccoli and carrots) had a significantly higher preference for these vegetables after multiple exposures (n=4) compared to the control group. (31) Economic modeling studies have shown that restricting children’s exposure to food and beverage advertising is a cost effective population based approach to childhood obesity prevention, with the largest overall gain in disability adjusted life years. (13,14). Canada has yet to conduct a comparable analysis. Marketing and Ethics Foods and beverages high in fats, sugars or sodium is one of many health compromising products marketed to children. It has been argued that policy approaches ought to extend beyond marketing of unhealthy foods and beverages to one that restricts marketing of all products to children, as practiced in Quebec (7,26,32). Article 36 of the Convention on the Rights of the Child, to which Canada is a signatory, states that, “children should be protected from any activity that takes advantage of them or could harm their welfare and development.” (9) Restricting marketing of all products has been argued to be the most comprehensive policy option in that it aims to protect children from any commercial interest and is grounded in the argument that children have the right to a commercial-free childhood (7, 25,26,32). The focus on restricting unhealthy food and beverage marketing was based in consultations with national health organizations whose mandates, at the time of writing, were more aligned with a focus on unhealthy foods and beverages. This policy statement is not opposed to, and does not preclude further policy enhancements to protect children from all commercial marketing, and therefore encourages further advocacy in this area. In order to inform the debate and help underpin future policy direction, further research is needed. Canada’s Food and Beverage Marketing Environment Television remains a primary medium for children’s exposure to advertising, with Canadian children aged 2–11 watching an average of 18 hours of television per week. (26) In the past two decades, the food marketing and promotion environment has expanded to include Internet marketing, product placement in television programs, films and DVDs, computer and video games, peer-to-peer or viral marketing, supermarket sales promotions, cross- promotions between films and television programs, use of licensed characters and spokes-characters, celebrity endorsements, advertising in children’s magazines, outdoor advertising, print marketing, sponsorship of school and sporting activities, advertising on mobile phones, and branding on toys and clothing. (25,26) A systematic review of 41 international studies looking at the content analysis of children’s food commercials found that the majority advertised unhealthy foods, namely pre-sugared cereals, soft drinks, confectionary and savoury snacks and fast food restaurants. (33) In an analysis of food advertising on children’s television channels across 11 countries, Canada (Alberta sample) had the second-highest rate of food and beverage advertising (7 advertisements per hour), 80% of which were for unhealthy foods and beverages defined as “high in undesirable nutrients and/or energy.” (10) Illustrating the influence of food packaging in supermarkets, two Canadian studies found that for six food product categories 75% of the products were directed solely at children through use of colour, cartoon mascots, pointed appeals to parents and/or cross-merchandising claims, games or activities. Of the 63% of products with nutrition claims, 89% were classified as being “of poor nutritional quality” due to high levels of sugar, fat, or sodium when judged against US-based nutrition criteria. Less than 1% of food messages specifically targeted to children were for fruits and vegetables. (34,35) Food is also unhealthily marketed in schools. A recent study of 4,936 Canadian students from grades 7 to 10 found that 62% reported the presence of snack-vending machines in their schools, and that this presence was associated with students’ frequency of consuming vended goods. (36) In another Canadian analysis, 28% of elementary schools reported the presence of some form of advertising in the school and 19% had an exclusive marketing arrangement with Coke or Pepsi. (37) Given children’s vulnerability, a key tenant of the WHO recommendations on marketing to children is that “settings where children gather should be free from all forms of marketing of foods high in saturated fats, trans-fatty acids, and free sugars or sodium.” (6, p.9) and need to be included in development of food marketing policies directed at children. The Canadian public wants government oversight in restricting unhealthy food marketing to children. A nation-wide survey of over 1200 Canadian adults found 82% want limits placed on unhealthy food and beverage advertising to children; 53% support restricting all marketing of high-fat, high-sugar or high-sodium foods aimed directly at children and youth. (12) Canada’s Commercial Advertising Environment Internationally, 26 countries have made explicit statements on food marketing to children and 20 have, or are in the process of, developing policies in the form of statutory measures, official guidelines or approved forms of self-regulation. (38) The differences in the nature and degree of these restrictions is considerable, with significant variation regarding definition of child, products covered, communication and marketing strategies permitted and expectations regarding implementation, monitoring and evaluation. (38,39) With the exception of Quebec, Canada’s advertising policy environment is restricted to self-regulated rather than legislative measures with little monitoring and oversight in terms of measuring the impact of regulations on the intensity and frequency of advertising unhealthy foods and beverages to children. (39) Federal Restrictions Nationally, the Food and Drug Act and the Competition Act provide overarching rules on commercial advertising and (loosely) prohibit selling or advertising in a manner that is considered false, misleading or deceptive to consumers. These laws, however, contain no provisions dealing specifically with unhealthy food advertising or marketing to children and youth. (26) The Consumer Package and Labeling Act outlines federal requirements concerning the packaging, labeling, sale, importation and advertising of prepackaged non- food consumer products. Packaging and labels, however, are not included under the scope of advertising and therefore not subject to the administration and enforcement of the Act and regulations. (26) Such loopholes have prompted the introduction of three private member's bills into the House of Commons to amend both the Competition Act and the Food and Drugs Act. Tabled in 2007, 2009 and 2012, respectively, none of the bills have, to date, advanced past the First Reading. (15) Industry Restrictions The Canadian Code of Advertising Standards (Code) and the Broadcast Code for Advertising to Children (BCAC) together cover Canadian broadcast and non- broadcast advertising. (23) While both have explicit provisions/clauses to cover advertising directed to children (12 years and younger), neither address or explicitly cover unhealthy food and beverage advertising. Further excluded are other heavily used and persuasive forms of marketing directed to children, including in-store promotions, packaging, logos, and advertising in schools or at events, as well as foreign media. (40) Formed in 2008, the Canadian Children’s Food and Beverage Advertising Initiative (CAI) defines marketing standards and criteria to identify the products that are appropriate or not to advertise to children under 12 years old. Under this initiative, participating food companies (N=19) are encouraged to direct 100% of their advertising to children under 12 to “better-for-you” products. (41) In 2010, the scope of CAI was expanded to include other media forms, namely video games, child- directed DVDs and mobile media. Despite reportedly high compliance by CAI participants, (41) several fundamental loopholes undermine its level of protection and effectiveness, namely: - Participation is voluntary, exempting non- participators such as President’s Choice, Wendy’s and A&W, from committing to CAI core principles. - Companies are allowed to create their own nutrient criteria for defining “better-for-you” or “healthier dietary choice” products. (32) A 2010 analysis revealed that up to 62% of these products would not be acceptable to promote to children by other countries’ advertising nutrition standards. (16) - Companies are able to adopt their own definition of what constitutes “directed at children” under 12 years. (32) Participants' definitions of child audience composition percentage range from 25% to 50%, significantly more lenient than current Quebec legislation and other international regulatory systems. (7,42,43) - The initiative excludes a number of marketing and advertising techniques primarily directed at children, namely advertiser-generated characters (e.g., Tony the Tiger), product packaging, displays of food and beverage products, fundraising, public service messaging and educational programs. (26,27) Provincial Restrictions The Quebec Consumer Protection Act states that “no person may make use of commercial advertising directed at persons under thirteen years of age.” (26) Despite its merits, the effectiveness of the Quebec ban has been compromised. In its current form, the ban does not protect children from cross-border leakage of child-directed advertisements from other provinces. (40) One study found that while the ban reduced fast food consumption by US$88 million per year and decreased purchase propensity by 13% per week, the outcomes primarily affected French-speaking households with children, not their English-speaking counterparts. (44) A more recent study looking at the ban’s impact on television advertising arrived at similar conclusions and found that Quebec French subjects were exposed to significantly fewer candy and snack promotions (25.4%, p<0.001) compared to the Ontario English (33.7%) and Quebec English (39.8%) groups. (40) The ban has further been criticized for having a weak definition of “advertisement”, which allows adult-targeted advertisements for unhealthy foods during children’s programming (37) and having weak regulatory and monitoring structures. (37,40) In assessing the effectiveness of Quebec’s legislation in reducing children’s exposure to unhealthy food advertising, it is important to note that the ban was not developed to target or reduce the marketing of foods and beverages specifically, but rather to reduce the commercialization of childhood. (27) Public Policy: The Way Forward Several legislative approaches have been undertaken internationally to restrict unhealthy food and beverage marketing. (7,43,45) While more research is needed with regards to the impact of restricting unhealthy food and beverage marketing on child health outcomes (i.e., obesity), a US study estimated that between 14-33% of instances of childhood obesity could be prevented by eliminating television advertising for unhealthy food. (46) An Australian study found that a restriction on non-core-food advertisement between 7am and 8:30pm could reduce children’s exposure to unhealthy food advertising by almost 80%. (47) An evaluation of the UK regulations which restricts television advertising of all foods high in fat, sugar and sodium found that since its introduction there has been a 37% reduction in unhealthy food advertisement seen by children. (25) Restrictions on food marketing are being increasingly advocated internationally. A 2011 International Policy Consensus Conference identified regulating marketing to children as a key policy strategy to prevent childhood obesity. (48) A similar recommendation was made at the September 2011 United Nations high-level meeting on the prevention and control of non- communicable diseases. Restrictions on television advertising for less healthful foods has also been identified as an effective (Class I; Grade B) population-based strategy to improve dietary behaviors in children by the American Heart Association. (49) Within Canada, non-governmental and other health organizations are assuming an equally active role. Among others, the Chronic Disease Prevention Alliance of Canada, the Dietitians of Canada, the Alberta Policy Coalition for Chronic Disease Prevention, the Simcoe Board of Health, the Thunder Bay and District Board of Health and the Kingston, Frontenac, Lennox and Addington Board of Health have issued position papers or statements urging the federal government to implement more stringent regulations on food and beverage marketing to children. (26,42,48) Conclusions The current voluntary, industry self-regulated and ineffective system of restricting the marketing and advertising of foods and beverages fails to protect Canadian Children and thereby contributes to the rising rates of childhood obesity and the likelihood of premature death and disability in our children’s and future generations. Strong federal government leadership and nationwide action from other levels of government and other key stakeholders are needed. Regulation restricting unhealthy food advertising is internationally supported, with a growing evidence base for expanding such regulation to all forms of food marketing. This policy statement offer an integrated, pragmatic and timely response to the national stated priorities of childhood obesity and chronic disease prevention in Canada and supports the F/P/T vision of making Canada, “…a country that creates and maintains the conditions for healthy weights so that children can have the healthiest possible lives.” (4) This policy statement was funded by The Heart and Stroke Foundation of Canada (HSFC) and the Institute of Circulatory and Respiratory Health (CIHR) Chair in Hypertension Prevention and Control, prepared with the assistance of an ad hoc Expert Scientific Working Group, reviewed and approved by the Hypertension Advisory Committee and endorsed by the undersigned national health organizations. HYPERTENSION ADVISORY COMMITTEE Manuel Arango, Heart and Stroke Foundation of Canada Norm Campbell, Canadian Society of Internal Medicine Judi Farrell, Hypertension Canada Mark Gelfer, College of Family Physicians of Canada Dorothy Morris, Canadian Council of Cardiovascular Nurses Rosana Pellizzari, Public Health Physicians of Canada Andrew Pipe, Canadian Cardiovascular Society Maura Rickets, Canadian Medical Association Ross Tsuyuki, Canadian Pharmacists Association Kevin Willis, Canadian Stroke Network STAFF Norm Campbell, HSFC/CIHR Chair in Hypertension Prevention and Control, Chair Tara Duhaney, Policy Director, Hypertension Advisory Committee REFERENCES 1. World Health Organization. Diet, Nutrition, and the Prevention of Chronic Diseases. WHO Technical Report Series No. 916. Geneva, WHO; 2003. Available at: http://www.who.int/hpr/NPH/docs/who_fao_expert_report.pdf. Accessed December 2011 2. World Health Organization. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. Geneva: WHO; 2008. Available at: http://www.who.int/nmh/Actionplan-PC-NCD- 2008.pdf. Accessed December 2011 3. Public Health Agency of Canada. Tracking Heart Disease and Stroke in Canada. Ottawa, 2009. Available at: http://www.phac- aspc.gc.ca/publicat/2009/cvd-avc/pdf/cvd-avs-2009- eng.pdf. Accessed January 2012 4. Olshansky SJ, Passaro DJ, Hershow RC et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med. 2005; 352:1138-45 5. Public Health Agency of Canada. Curbing Childhood Obesity: A Federal, Provincial and Territorial Framework for Action to Promote Healthy Weights. Ottawa, PHAC; 2011 Available at: http://www.phac- aspc.gc.ca/hp-ps/hl-mvs/framework- cadre/2011/assets/pdf/co-os-2011-eng.pdf. Accessed January 2012 6. World Health Organization. Set of recommendations on the marketing of foods and non-alcoholic beverages to children. Geneva: WHO; 2010. Available at http://www.who.int/dietphysicalactivity/publications/recsmarketing/en/index.html. Accessed December 2011 7. World Health Organization. A Framework for Implementing the Set of Recommendations on the Marketing of Foods and Non-Alcoholic Beverages to Children. Geveva: WHO; 2012. Available at: http://www.who.int/dietphysicalactivity/MarketingFramework2012.pdf. Accessed June 2012 8. Kunkel D, Wilcox B, Cantor J, Palmer E, Linn S, Dowrick P. Report of the APA Taskforce on Advertising and Children. Washington: American Psychological Association; 2004. Available at: http://www.apa.org/pi/families/resources/advertising-children.pdf. Accessed January 2012 9. United Nations. Convention on the Rights of the Child. Geneva: United Nations, 2009 Available at: http://www2.ohchr.org/english/law/crc.htm. Accessed February, 2012 10. Kelly B, Halford JCG, Boyland E, Chapman K, Bautista- Castaño I, Berg C, et al. Television food advertising to children: A global perspective. Am J Public Health. 2010;100:1730-5. Available at: http://www.studenttutor.ca/resources/Television%20Food%20Advertising- %20a%20Global%20Perspective.pdf 11. McGinnis JM, Gootman JA, Kraak VI (Eds.) Food Marketing to Children and Youth: Threat or Opportunity? Committee on Food Marketing and the Diets of Children and Youth. Washington, DC: IOM; 2006. 12. Ipsos Reid. Canadians’ Perceptions of, and Support for, Potential Measures to Prevent and Reduce Childhood Obesity. Prepared for the Public Health Agency of Canada. Ottawa, November 2011. Available at: http://www.sportmatters.ca/files/Reports/Ipsos%20Obesity%202011.pdf. Accessed February 2012 13. Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo- Barron V, Chisholm D. Tackling of Unhealthy Diets, physical inactivity, and obesity: Health effects and cost-effectiveness. Lancet 2010; 376 (9754): 1775- 84 Available at: http://www.who.int/choice/publications/Obesity_Lancet.pdf 14. Magnus A, Habby MM, Carter R, Swinburn B. The cost-effectiveness of removing television advertising of high fat and/or high sugar food and beverages to Australian children. Int J Obes.2009; 33: 1094-1102. Available at: http://eurobesitas.ch/articles/pdf/Magnus_ijo2009156a.pdf 15. Parliament of Canada. Private Member’s Bills. Available at: http://www.parl.gc.ca/LegisInfo/BillDetails.aspx?billId=4328259&Mode=1&View=3&Language=E. Accessed April 2012 16. Conrad S. Innovations in Policy Evaluation: Examining the food and beverages included in the Canadian Children’s Food and Beverage Advertising Initiative. Ottawa: Public Health Agency of Canada; 2010 17. Alberta Policy Coalition for Cancer Prevention. Using Public Policy to Promote Healthy Weights for Canadian Children. Submission to the “Our Health, Our Future – National Dialogue on Healthy Weights” consultation, 2011. 18. Public Health Agency of Canada. The integrated pan- Canadian healthy living strategy. 2005. Available at: http://www.phac-aspc.gc.ca/hl-vs- strat/pdf/hls_e.pdf. Accessed January 2012 19. Health Canada. Sodium Reduction Strategy for Canada: Recommendations of the Sodium Working Group. Ottawa, Ontario, July 2010. Available at: http://publications.gc.ca/collections/collection_2010/sc-hc/H164-121-2010-eng.pdf. Accessed December 2011 20. Quebec Consumer Protection Office. The Consumer Protection Act: Application Guide for Sections 248 and 249. Quebec, 1980 21. Montgomery K, Chester J. Interactive Food and Beverage Marketing: Targeting Adolescents in the Digital Age. J Adolesc Health. 2009: S18-S29. Available at: http://digitalads.org/documents/PIIS1054139X09001499.pdf 22. Harris JL, Brownell KD, Bargh JA. The Food Marketing Defense Model: Integrating Psychological Research to Protect Youth and Inform Public Policy. Soc Issues Policy Rev. 2009; 3(1): 211-271. Available at: http://www.yale.edu/acmelab/articles/Harris%20Brownell%20Bargh%20SIPR.pdf 23. Pechman C, Levine L, Loughlin S, Leslie F. Impulsive and Self-Conscious: Adolescents' Vulnerability to Advertising and Promotion. Journal of Public Policy and Marketing. 2005; 24 (2): 202-221. Available at: http://www.marketingpower.com/ResourceLibrary/ Publications/JournalofPublicPolicyandMarketing/2005/24/2/jppm.24.2.202.pdf 24. Health Canada. Food and Drugs Act . R.S., c. F-27. Ottawa: Health Canada; 1985. Available at: http://laws-lois.justice.gc.ca/eng/acts/F-27/. Accessed February 2012 25. Mackay S, Antonopoulos N, Martin J, Swinburn B. A comprehensive approach to protecting children from unhealthy food advertising. Melbourne, Australia: Obesity Policy Coalition; 2011. Available at: http://www.ada.org.au/app_cmslib/media/lib/1105/ m308363_v1_protecting-children- email1%20final%2013.04.11.pdf. Accessed January 2012 26. Cook B. Policy Options to Improve the Children’s Advertising Environment in Canada. Report for the Public Health Agency of Canada Health Portfolio Task Group on Obesity and Marketing. Toronto; 2009. 27. Toronto Board of Health. Food and Beverage Marketing to Children. Staff Report to the Board of Health. Toronto: Board of Health; 2008. Available at: http://www.toronto.ca/legdocs/mmis/2008/hl/bgrd/backgroundfile-11151.pdf. Accessed January 2012 28. The Conference Board of Canada. Improving Health Outcomes: The Role of Food in Addressing Chronic Diseases. Conference Board of Canada, 2010. Available at: http://www.conferenceboard.ca/temp/be083acf- 4c96-4eda-ae80-ee44d264758a/12- 177_FoodandChronicDisease.pdf. Accessed June 2012 29. Cairns G, Angus K, Hastings G, Caraher M. Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary. Appetite. 2012 (in press). Available at: http://www.sciencedirect.com/science/article/pii/S0195666312001511 30. Harris JL, Bargh JA, Brownell KD. Priming Effects of Television Food Advertising on Eating Behavior. Health Psychol. 2009; 28(4):404-13. Available at: http://www.yale.edu/acmelab/articles/Harris_Bargh_Brownell_Health_Psych.pdf 31. Nicklas TA, Goh ET, Goodell LS et al. Impact of commercials on food preferences of low-income, minority preschoolers. J Nutr Educ Behav. 2011; 43(1):35-41. 32. Elliott C. Marketing Foods to Children: Are We Asking the Right Questions. Child Obes. 2012; 8(3): 191-194 33. Hastings G, Stead M, McDermott L, Forsyth A, Mackintosh AM, Rayner M, Godfrey C, Caraher M, Angus K. Review of research on the effects of food promotion to children. Final Report to the UK Food Standards Agency. Glasgow, Scotland: University of Strathclyde Centre for Social Marketing; 2003. Available at: http://www.food.gov.uk/multimedia/pdfs/promofoodchildrenexec.pdf. Accessed February 2012 34. Elliott C. Marketing fun foods: A profile and analysis of supermarket food messages targeted at children. Can Public Policy. 2008; 34:259-73 35. Elliott C. Assessing fun foods: Nutritional content and analysis of supermarket foods targeted at children. Obes Rev. 2008; 9: 368-377. Available at: http://www.cbc.ca/thenational/includes/pdf/elliott2.pdf 36. Minaker LM, Storey KE, Raine KD, Spence JC, Forbes LE, Plotnikoff RC, McCargar LJ. Associations between the perceived presence of vending machines and food and beverage logos in schools and adolescents' diet and weight status. Public Health Nutr. 2011; 14(8):1350-6 37. Cook B. Marketing to Children in Canada: Summary of Key Issues. Report for the Public Health Agency of Canada. 2007. Available at: http://www.cdpac.ca/media.php?mid=426. Accessed January 2012 38. Hawkes C, Lobstein T. Regulating the commercial promotion of food to children: a survey of actions worldwide. Int J Pediatr Obes. 2011; 6(2):83-94. 39. Hawkes C, Harris J. An analysis of the content of food industry pledges on marketing to children. Public Health Nutr. 2011; 14:1403-1414. Available at: http://ruddcenter.yale.edu/resources/upload/docs/ what/advertising/MarketingPledgesAnalysis_PHN_5.11.pdf 40. Potvin-Kent M, Dubois, L, Wanless A. Food marketing on children's television in two different policy environments. Int J of Pediatr Obes. 2011; 6(2): e433-e441. Available at: http://info.babymilkaction.org/sites/info.babymilkaction.org/files/PotvinKent%20IJPO%202011.pdf 41. Advertising Standards Canada. Canadian children’s food and beverage advertising initiative: 2010 compliance report. Available at: http://www.adstandards.com/en/childrensinitiative/ 2010ComplianceReport.pdf. Accessed March 2012 42. Dietitians of Canada. Advertising of Food and Beverage to Children. Position of Dietitians of Canada. 2010. Available at: http://www.dietitians.ca/Downloadable- Content/Public/Advertising-to-Children-position- paper.aspx. Accessed January 2012 43. Hawkes C. Marketing food to children: a global regulatory environment. World Health Organization. 2004(b). Available at: http://whqlibdoc.who.int/publications/2004/9241591579.pdf. Accessed February 2012 44. Dhar T, Baylis K. Fast-food Consumption and the Ban on Advertising Targeting Children: The Quebec Experience. Journal of Marketing Research. 2011; 48 (5): 799-813. Available at: http://www.marketingpower.com/aboutama/documents/jmr_forthcoming/fast_food_consumption.pdf 45. World Health Organization. Marketing of Food and Non-Alcoholic Beverages of Children. Report of a WHO Forum and Technical Meeting. Geneva: WHO; 2006. Available at: http://www.who.int/dietphysicalactivity/publications/Oslo%20meeting%20layout%2027%20NOVEMBER. pdf. Accessed January 2012 46. Veerman JL, Van Beeck, Barendregt JJ, Mackenbach JP. By how much would limiting TV food advertising reduce childhood obesity? Eur J Public Health. 2009; 19(4): 365-9. Available at: http://eurpub.oxfordjournals.org/content/19/4/365. full.pdf+html 47. Kelly B, King L, Mauman A, Smith BJ, Flood V. The effects of different regulation systems on television food advertising to children. Aust N Z J Public Health. 2007; 31(4): 340-343. 48. Alberta Policy Coalition for Chronic Disease Prevention. Canadian Obesity Network - International Consensus: Take Action to Prevent Childhood Obesity (Press Release). 2011. Available at: http://www.abpolicycoalitionforprevention.ca/ 49. Mozaffarian D, Afshin A, Benowitz NL et al. Population Approaches to Improve Diet, Physical Activity, and Smoking Habits: A Scientific Statement From the American Heart Association. Circulation. 2012;126(12):1514-1563
Documents
Less detail

The treating physician's role in helping patients return to work after an illness or injury (Update 2013)

https://policybase.cma.ca/en/permalink/policy10754
Last Reviewed
2020-02-29
Date
2013-05-25
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2013-05-25
Replaces
The physician's role in helping patients return to work after an illness or injury (Update 2010)
Topics
Physician practice/ compensation/ forms
Text
This policy addresses the role of the treating physician in assisting their patients return to work after an illness or injury. The treating physician's role is to diagnose and treat the illness or injury, to advise and support the patient, to provide and communicate appropriate information to the patient and the employer, and to work closely with other involved health care professionals to facilitate the patient's safe and timely return to the most productive employment possible. Fulfilling this role requires the treating physician to understand the patient's roles in the family and the workplace. Furthermore, it requires the treating physician to recognize and support the employee-employer relationship and the primary importance of this relationship in the return to work. Finally, it requires the treating physician to have a good understanding of the potential roles of a return-to-work coordinator and of other health care professionals and employment personnel in assisting and promoting the return to work. Introduction The CMA recognizes the importance of a patient returning to all possible functional activities relevant to his or her life as soon as possible after an injury or illness. Prolonged absence from one's normal roles, including absence from the workplace, is detrimental to a person's mental, physical and social well-being. The treating physician should therefore encourage a patient's return to function and work as soon as possible after an illness or injury, provided that a return to work does not endanger the patient, his or her co-workers or society. A safe and timely return to work benefits the patient/employee and his or her family by enhancing recovery and reducing disability. A safe and timely return to work by the employee also preserves a skilled and stable workforce for employers and society and reduces demands on health and social services as well as on disability plans. In recent years, an increasing level of responsibility in the return-to-work process has been placed on treating physicians. There has been an increased demand for medical information and advice from physicians and other health care providers concerning patient functionality, restricted work and modifications to the workplace to help accommodate the disabled patient. i There has also been a blurring of the lines between the provision of forms/reports for benefits and dealing with requests for information related to helping patients return to work (e.g., completing Functional Abilities Forms). Treating physicians are often asked to provide information related to complex issues affecting patients in the workplace and to assist in the eligibility of insurance claims while lacking information related to job description or the insurance company's definition of disability. There is also the issue of consent, where employers/insurers are asking employees to sign "blanket consents," which include information well outside what is medically necessary to determine eligibility to return to work. In addition, the complex nature of the return-to-work process can lead to conflict between employees, physicians, and employers. Finally, the majority of physicians outside occupational medicine have not received training on the return-to-work process and thus may feel uncomfortable providing these types of services. Cooperation from the employee, employer, insurer and health care provider is necessary to ensure a safe and timely return to work for the patient. The purpose of this statement is to address the role of the treating physician in the patient's return to work. A treating physician refers to a physician from any medical specialty - including a family physician - who preferably knows the patient the best. The CMA supports a shift away from reliance on physician certification for work absences and a move toward greater cooperation between the employee and his or her employer with the use of medical input, advice and support from the employee's treating physician and other involved health care professionals.ii Although this policy addresses the treating physician's role in helping patients return to work after an illness or injury, many of the concepts are applicable to accommodating employees who are in need of a modified work arrangement with their employer. The Role of the Employer The employee and the employer generally have an established relationship and this is central to the return-to-work process. In all cases of impairment or disability, an unbiased workplace supervisor, manager or employer representative must be a closely involved partner in this process. Employers increasingly recognize the value of making changes to the workplace than can facilitate a return to work. The employer's role is to ensure that the workplace culture supports a safe and timely return to work; for example, by being flexible in modifying tasks, schedules and environmental conditions to meet the temporary or permanent needs of the employee. Employees are often unaware of their employer's capacity to accommodate special needs. Direct communication by an employee with his or her employer after an illness or injury often enhances the employee's perception of his or her ability to work. With careful planning and appropriate physician input and advice to both the employee and the employer, an employee may often successfully return to work before full recovery. The employer and employee have a responsibility to provide the treating physician with any employment-related information that can be useful in giving medical advice and support. It is the employer's responsibility to provide the treating physician with a written job description, identifying the job risks and available work modifications, upon request. The Role of the Treating Physician The treating physician's role in helping a patient return to work has four main elements: 1. Providing to the patient medically necessary services related to the injury or illness to achieve optimum health and functionality; 2. Providing objective, accurate and timely medical information for the consideration of eligibility of insurance benefits; 3. Providing objective, accurate and timely medical information as part of the timely return-to-work program; andiii 4. Considering whether to serve as a Timely Return-to-Work Coordinator when requested by the employer/employee or other third party (outlined below). In relation to the first three elements, the treating physician should remain cognizant of the potential for legal proceedings and should, therefore, ensure, as always, that any statements made regarding a patient's capacity to return to work are defensible in a court of law. The physician should ensure that any statements made are, to the best of the physician's knowledge, accurate and based upon current clinical information about the patientiv. If the physician relies on information that cannot be substantiated independently, then the physician should note in the report the source of the information and the fact that it has not been independently confirmed. Comments unrelated to the treating physician's professional opinion or that are extraneous to the stated objectives should not be included in the report. Reports should be written in language that is appropriate for the intended audience. This may require the physician to avoid medical short forms, or jargon. Where this is not possible, the physician should include, in addition to technical medical terminology, more colloquial terms or explanations to ensure the reader understands the report's contents. Where the physician is not able to answer some of the questions, even with the assistance of the patient, the physician should indicate his or her inability to respond. For more information with respect to completing forms and reports, please refer to Canadian Medical Protective Association articles entitled "Forms and Reports: The Case for Care (2002)" v and "Reasonable Delays for Filling out Insurance Forms (2007)." vi Considerations for Treating Physicians who wish to Participate in the Timely Return-to-Work Process Treating physicians need to ensure that a timely return-to-work plan is incorporated into the care plan for their patient. A timely return-to-work program is one that is initiated early and ensures a safe return to work at the earliest and most appropriate time. The treatment or care plan should be evidence-based, when possible, and should identify the best sequence and timing of interventions for the patient. The treating physician should facilitate the patient's return to work by encouraging him or her early in treatment or rehabilitation to take an active role in and take responsibility for the return to work, and to communicate directly and regularly with his or her employers. Furthermore, the physician should discuss expected healing and recovery times with the patient, as well as the positive role in physical and psychological healing of a graduated increase in activity. Unnecessary waiting periods and other obstacles in the care plan should be identified and discussed, when relevant, by those involved in the patient/employee's return to work. In some cases, it may be appropriate for the treating physician to advise the patient that a timely return to work can facilitate his or her recovery by helping to restore or improve functional capabilities. The physician should be familiar with the family and community support systems available to the patient. Moreover, the physician should be knowledgeable about and use, when appropriate, the services of a multidisciplinary team of health care professionals, who can be helpful in facilitating the patient's safe and timely return to work. In cases of employers with occupational medical departments, the treating physician, with the patient's prior expressed consent, may contact the occupational physician or nurse to understand specific workplace policies, supportive in-house resources, essential job demands and possible health and safety hazards in the patient's workplace. Where occupational medical resources are available, the treating physician generally assumes a supportive or advisory medical role. For assistance with specific cases, provincial and territorial medical associations and the Occupational Medicine Specialists of Canada, as well as the Occupational and Environmental Medicine Association of Canada, have information identifying physicians who specialize in assisting with the return to work. vii In complex cases, the treating physician should consider referring the patient/employee to medical specialists or other appropriate health care professionals for a comprehensive, objective assessment of his or her functional capabilities and limitations and their relation to the demands of the employee's job. The Return-to-Work Coordinator The CMA supports the concept of the return-to-work coordinator as described in the Ontario Medical Association Position Paper, "The Role of the Primary Care Physician in Timely Return to Work."viii A return-to-work coordinator may be a health care professional who "works with the employer and the patient/employee to assist in developing and overseeing a timely return to work program that is individualized to the employee and meets the requirements of the employer. A return to work plan or program is "a compilation of services required to safely and effectively return an individual to work as soon as possible." ix Return to work requires that the employee's capabilities match or exceed the physical, psychological and cognitive requirements of the work offered. It may involve designing a modified work setting and timetable to facilitate reintegration in the workplace based on the patient's physical and psychological condition. Specific services of the return-to-work coordinator may include: * Compiling all medical information, along with the employee's workplace and job functions information. * Providing advice on the limitations, restrictions and modifications that may be necessary to accommodate the employee in a timely return-to-work program. * Periodically reviewing the prescribed program and suggesting modifications until the patient eventually assumes full-duty status or has resumed work in a modified manner acceptable to all parties. The treating physician has the choice to assume this role or it may be assumed by an alternate health care provider. It is the employer/insurer's responsibility to ensure that a health care provider is assigned to this role. The treating physician also has the choice to suggest the patient/employee undergo a functional capacity assessment or an independent medical examination (IME). Treating physicians should only provide such services if they have the necessary training and expertise. The CMA believes educational sessions should be provided to support treating physicians who feel they need them and who wish to assume the role of the timely return-to-work coordinator. If the treating physician agrees to participate in developing a modified work plan, the physician should consider and make recommendations related to the employee's task limitations, schedule modifications, environmental restrictions and medical aids or personal protective equipment. Whenever possible, the physician should state whether restrictions are permanent or temporary and give an estimate of recovery time. The physician should also specify the date when the patient's progress and his or her work restrictions need to be reassessed. The treating physician must be aware of the risks to the patient, his or her coworkers or the public that could arise from the patient's condition or drug therapy. If the patient's medical condition and the nature of the work performed are likely to endanger the safety of others significantly, the physician must put the public interest before that of the patient/employee. When the treating physician, acting as a return-to-work coordinator, believes that the patient has recovered sufficiently to return to work safely, the patient should be clearly informed of this judgment. If the employer and the employee cannot agree on a return-to-work plan, the employer should contact the treating physician and employee to identify the minimum level of capability that can be accommodated in the workplace. When there is a conflict between the employer and the employee, it is recommended that the treating physician use, where available, the skills of an occupational physician. The CMA recommends that, when conflicts occur, conflict-resolution processes be put in place to address all participants' concerns. The treating physician's role should be limited to providing relevant clinical information about the functional limitations of the employee and recommending any corresponding work restrictions. Ultimately, the employer determines the type of work available and whether a physician's recommendations concerning an employee's return to work can be accommodated. Under provincial and territorial human rights laws, an employer may not discriminate on the basis of disability or other illness and has legal obligations with respect to the accommodation of employees. For details, refer to the Human Rights Code in the relevant jurisdiction. The CMA holds that legislation should be enacted in all jurisdictions to protect physicians from liability associated with such decisions. Respecting Patient Confidentiality and Managing Medical Information Medical records are confidential. Physicians must respect the patient's right to confidentiality except where required or permitted by law to disclose requested information. In general, physicians should not, without the patient's consent, give information to anyone concerning the condition of a patient or any service rendered to a patient, unless required by law to do so. For example, in some cases, provincial or territorial legislation may require physicians to provide information to workers' compensation boards without prior patient approval. Physicians should be aware of the legal requirements with regard to prior patient approval and of the legal requirements in their province or territory. Where a physician has the discretion to make a disclosure (i.e., where it is permitted by law but not required), the decision should be made bearing in mind the duty of confidentiality and the facts of the case. Physicians will want to consider if it is appropriate under the circumstances to advise the patient when a disclosure has been made pursuant to applicable legislation.x In circumstances where a physician provides a third party with information or an opinion for an individual he/she is not otherwise treating (for example during an IME mandated by the employer), the duty to provide the individual with access to the information, opinion and or notes prepared for the opinion will vary according to the applicable law, the nature of the agreement with the third party and the consent of the individual. Physicians should be aware that their working notes may be, in some circumstances, accessible to an individual being examined for the purpose of a third-party process. Physicians conducting an IME and preparing a report on behalf of a third party should ensure the individual being examined understands the nature and extent of the physician's responsibility to the third party, including that the report will be forwarded to this third party. Moreover, an IME is distinct from a regular physician-patient encounter and, as such, it does not obligate the independent examiner to treat or provide health care to the examinee. However, should the medical examiner discover an unexpected significant clinical finding which requires essential intervention, then he or she should advise the examinee of this fact to enable the examinee to obtain timely medical attention. The treating physician should not provide information about the patient to the patient's employer without the patient's authorization. The following are best practices when obtaining patient consent: * Consent should be specific rather than general; * Written authorization for such disclosure is desirable and may be required in some jurisdictions; * A separate patient consent should be obtained for each request for medical information; and * Patient consent should be considered time-limited. To respect the privacy of the patient, the treating physician should be careful not to provide medical information that is not needed to facilitate the patient's return to work. The patient has the right to examine and copy medical records that pertain to him or her. Patient access to records may be denied only in accordance with the exceptions specified under the relevant privacy legislation, such as reasonable risk of serious harm, solicitor-client privilege or identification of another person. The treating physician should ensure that he/she is familiar with the applicable legislation and rules with respect to a patient's right of access. If access is denied and the patient challenges the treating physician's decision, the onus is on the physician to justify denial of access. Treating physicians should consult appropriate statements from the relevant provincial or territorial licensing body and from the Canadian Medical Protective Association for additional information and guidance. Physicians should also be aware of any relevant legislation or other legal requirements in their jurisdictions. Billing for Return-to-Work Services Many services related to a timely return-to-work program are not covered by public medical insurance. Although often the case, patients should not be required to cover the costs of services related to a timely return-to-work program. The CMA recommends that the requesting party bear these costs.xi Payment should be commensurate with the degree of expertise and the time expended by the physician and office staff. The physician should consult the billing policy of his/her provincial medical association for further guidance. i Ontario Medical Association, The role of the primary care physician in timely return to work. OMA position paper. Ontario Medical Review, March 2009. https://www.oma.org/Resources/Documents/2009PCPandTimelyReturn.pdf (accessed 2013 Jan 07). ii Canadian Medical Association, Short-Term Illness Certificate, 2010. http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-06.pdf (accessed 2013 Jan 07). iii The College of Physicians and Surgeons of Ontario, Third Party Forms, Update 2012. https://www.cpso.on.ca/uploadedFiles/policies/policies/policyitems/ThirdParty.pdf (accessed 2013 Jan 07). iv The College of Physicians and Surgeons of British Columbia, Medical Certificates policy, Update 2009. https://www.cpsbc.ca/files/u6/Medical-Certificates.pdf (accessed 2013 Jan 07). v Canadian Medical Protective Association, Forms and Reports: The Case for Care, Update 2008. http://www.cmpa-acpm.ca/cmpapd04/docs/resource_files/infosheets/2002/com_is0227-e.cfm (accessed 2013 Jan 07). vi Canadian Medical Protective Association, Reasonable Delays for Filling out Insurance Forms, 2007. http://www.cmpa-acpm.ca/cmpapd04/docs/resource_files/infoletters/2007/com_il0720_2-e.cfm (accessed 2013 Jan 07). vii See also Presley Reed, The Medical Disability Advisor: Workplace Guidelines for Disability Duration, Reed Group, As amended. and the American College of Occupational and Environmental Medicine, Guidelines in Preventing Needless Work Disability, 2006. http://www.acoem.org/PreventingNeedlessWorkDisability.aspx. (accessed 2013 Jan 07). viii Ontario Medical Association, The role of the primary care physician in timely return to work. OMA position paper. Ontario Medical Review, March 2009. https://www.oma.org/Resources/Documents/2009PCPandTimelyReturn.pdf (accessed 2013 Jan 07). ix Ontario Medical Association, The role of the primary care physician in timely return to work. OMA position paper. Ontario Medical Review, March 2009. https://www.oma.org/Resources/Documents/2009PCPandTimelyReturn.pdf (accessed 2013 Jan 07). xCanadian Medical Association, Principles for the Protection of Patients' Personal Health Information. 2004, http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-03.pdf (accessed 2013 Jan 07). xi Canadian Medical Association, Third Party Forms: The Physician's Role (Update 2010). http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-04.pdf (accessed 2013 Jan 07).
Documents
Less detail

Joint position statement: The role of health professionals in tobacco cessation

https://policybase.cma.ca/en/permalink/policy10090
Last Reviewed
2019-03-03
Date
2011-03-05
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-03-05
Replaces
Tobacco : the role of the health professional in smoking cessation : joint statement (2001)
Topics
Population health/ health equity/ public health
Text
The Role of Health Professionals in Tobacco Cessation - Joint position statement This statement was developed cooperatively by the Canadian Association of Occupational Therapists, Canadian Counselling and Psychotherapy Association, Canadain Dental Hygienists Association, Canadian Medical Association, Canadian Nurses Association, and Canadian Physiotherapy Association. POSITION There is a role for every Canadian health professional in tobacco-use cessation.1 Tobacco use2 inflicts a heavy burden on Canadians' health and on the Canadian health-care system, and health professionals can advocate effectively for tobacco-use cessation at the clinical and public health levels. As providers of client and patient-centered services, health professionals are involved in tobacco cessation by: * assessing and documenting all forms of tobacco use, willingness to quit and risk of exposure to second-hand smoke; * discussing with clients and patients the negative health effects of tobacco use and exposure to second-hand smoke, and the health and other benefits (e.g., financial) of becoming tobacco free; * offering to help, and helping, tobacco users to quit; * offering a variety of tobacco-cessation strategies (e.g., counselling, behavioural therapy, self-help materials, pharmacotherapy) as appropriate to their knowledge, skills and tools; * providing strategies for non-smokers to help them reduce their exposure to second-hand smoke; * being knowledgeable about and providing referrals to community-based initiatives and resources; * recognizing that relapse occurs frequently, and conducting follow-up assessment and intervention; * tailoring interventions to the needs of specific populations (e.g., age, gender, ethnicity, diagnosis, socio-economic status); and * using a collaborative, multidisciplinary approach. As educators and researchers, health professionals are involved in tobacco cessation by: * including education on tobacco-cessation strategies and strategies for resisting tobacco use in basic education programs for health professionals; * providing professional development programs for health professionals on tobacco cessation; * conducting research to encourage and improve health professionals' knowledge and provision of tobacco cessation; and * communicating research evidence about tobacco-cessation strategies. As administrators of health-care organizations, health professionals are involved in tobacco cessation by: * offering training on tobacco cessation as part of employee orientation; * providing access to professional education on tobacco cessation for employees; * enforcing applicable bans on tobacco wherever health professionals are employed (e.g., health-care facilities, private homes); and * ensuring that tobacco-cessation programs and tobacco-free workplaces are included in accreditation standards. As public health advocates, health professionals are involved in tobacco cessation by: * increasing public awareness that health professionals can help people remain tobacco free or stop using tobacco; and * advocating for federal, provincial and territorial governments' investment in comprehensive tobacco control that includes programs, legislation and policies to prevent the uptake of tobacco and reduce tobacco use (e.g., bans on tobacco advertising). Programs must focus on health promotion and include community-based initiatives. BACKGROUND Tobacco is an addictive and harmful product, and its use is the leading cause of preventable death in Canada.3 Each year in Canada, more than 37,000 people die prematurely due to tobacco use.4 Approximately 17 per cent of the population 15 years of age and older (about 4.8 million Canadians) smoke.5 Strong evidence has revealed that smoking is associated with more than two dozen diseases and conditions.6 The economic costs of tobacco use are estimated at $17 billion annually ($4.4 billion in direct health-care costs and $12.5 billion in indirect costs such as lost productivity).7 Second-hand smoke is also harmful. Each year, more than 1,000 non-smoking Canadians die due to second-hand smoke.8 Exposure to second-hand smoke is the number two cause of lung cancer (smoking is the number one cause).9 Second-hand smoke can also aggravate allergies, bring about asthma attacks and increase the risk of bronchitis and pneumonia.10 Research also suggests that there may be a link between second-hand smoke and the risk of breast cancer.11 Tobacco use is the result of the complex interaction of individual and social factors, such as socio-economic status, having family members who smoke and exposure to marketing tactics of the tobacco industry. Reduction and elimination of tobacco use requires comprehensive, multi-faceted strategies addressing both physical dependence and social context. Such strategies will include: * prevention - helping to keep non-users from starting to use tobacco; * cessation - helping current smokers to quit, and helping prevent relapse; and * protection - protecting all Canadians from the harmful effects of tobacco use and from the influences of tobacco industry marketing. Prevention is the most important strategy of the three; being tobacco-free is a vital element of a healthy active life. Thus, for current tobacco users, quitting is the single most effective action they can take to enhance the quality and length of their lives. Most tobacco users would like to improve their health, and in a Canadian survey 30 per cent of all smokers stated that they intended to quit as means of doing so.12 Indeed, in studies in Canada, the U.K. and Germany, smokers rated health concerns and current health problems as the primary reason for wanting to quit;13 other reasons why smokers quit include the cost of cigarettes14 and persistent advice to quit from family15 and health professionals.16 However, the relapse rate is very high because of the addictive nature of tobacco.17 Most smokers attempt to quit several times before they finally succeed. Smoking cessation counselling is widely recognized as an effective clinical strategy. Even a brief intervention by a health professional significantly increases the cessation rate.18 Furthermore, counselling programs that initiate follow-up calls to smokers as a "proactive" measure have been found to increase smoking-cessation rates by 50 per cent.19 The majority of Canadians consult a health professional at least once a year,20 creating several "teachable moments" when they may be more motivated than usual to change unhealthy behaviours.21 A smoker's likelihood of quitting increases when he or she hears the message from a number of health-care providers from a variety of disciplines.22 However, health professionals encounter barriers that require solutions, notably: - the need for better education for health professionals (e.g., how to identify smokers quickly and easily, which treatments are most effective, how such treatments can be delivered); - the need to allow for sufficient time to provide counselling; - the need to focus on preventive care by * increasing funding for preventive care (e.g., providing reimbursement for smoking cessation interventions, follow-up or support); and * encouraging health-care settings to facilitate preventive care (e.g., access to quick reference guides or tools to identify people with specific risk factors); - the need to increase public awareness of the smoking cessation services a health professional can provide; and - the need to recognize the frustration associated with the high rate of relapse. Because of the powerful nature of tobacco dependence, smokers often go through a long period of reaching readiness before they finally quit. References Bao Y., Duan N., & Fox S. A. (2006). Is some provider advice on smoking cessation better than no advice? An instrument variable analysis of the 2001 National Health Interview Survey. Health Services Research, 41(6), 2114-2135 Breitling, L. P., Rothenbacher, D., Stegmaier, C., Raum, E., & Brenner, H. (2009). Older smokers' motivation and attempts to quit smoking. Deutsches Arzteblatt International, 106(27), 451-455. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment. (2008). Dynamic guidelines for tobacco control in Canada Version 1.0 [Wiki clinical practice guidelines]. Toronto: Author. Canadian Cancer Society. (2010). Second-hand smoke is dangerous. Toronto: Author. Retrieved May 19, 2010, from http://www.cancer.ca/canada-wide/prevention/quit%20smoking/second-hand%20smoke.aspx Canadian Centre on Substance Abuse, (2006). The costs of substance abuse in Canada in 2002. Ottawa: Author. Canadian Lung Association. (2006). Smoking and tobacco: Second-hand smoke. Retrieved June 14, 2010, from http://www.lung.ca/protect-protegez/tobacco-tabagisme/second-secondaire/hurts-nuit_e.php Canadian Dental Hygienists Association. (2004). Tobacco use cessation services and the role of the dental hygienist - a CDHA position paper. Canadian Journal of Dental Hygiene, 38(6), 260-279. Canadian Medical Association. (2008). Tobacco control [Policy statement]. Ottawa: Author. Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., & Curry, S. J. (2008). Treating tobacco use and dependence: 2008 update [Clinical practice guideline]. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Health Canada. (2009). Smoking and your body: Health effects of smoking. Ottawa: Author. Retrieved June 17, 2010, from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/body-corps/index-eng.php Health Canada. (2007). Overview of health risks of smoking. Ottawa: Author. Retrieved June 17, 2010, from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/res/news-nouvelles/risks-risques-eng.php Nabalamba, A, & Millar, W. J. (2007). Going to the doctor [Statistics Canada, catalogue 82-003]. Health Reports, 18(1), 23-35. Retrieved January 26, 2011, from http://www.statcan.gc.ca/pub/82-003-x/2006002/article/doctor-medecin/9569-eng.pdf Physicians for a Smoke-Free Canada. (2005). Smoking in Canada: A statistical snapshot of Canadian smokers. Ottawa: Author. Retrieved May 14, 2010, from http://www.smoke-free.ca/pdf_1/SmokinginCanada-2005.pdf Registered Nurses' Association of Ontario. (2007). Integrating smoking cessation into daily nursing practice [Nursing best practice guideline]. Toronto: Author. Ross, H., Blecher, E., Yan, L., & Hyland, A. (2010) Do cigarette prices motivate smokers to quit? New evidence from the ITC survey. Addiction, November 2010. Shields, M. (2004). A step forward, a step back: Smoking cessation and relapse. National Population Health Survey, Vol. 1, No. 1. Ottawa: Statistics Canada. Statistics Canada. (2009). Canadian tobacco use monitoring survey (CTUMS): CTUMS 2009 wave 1 survey results. Ottawa: Author. Retrieved January 25, 2011, from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/_ctums-esutc_2009/w-p-1_sum-som-eng.php Stead, L. F., Lancaster, T., & Perera, R. (2006). Telephone counselling for smoking cessation (review). Cochrane Database of Systematic Reviews, Issue 3. Vangeli, E., & West, R. (2008). Sociodemographic differences in triggers to quit smoking: findings from a national survey. Tobacco Control, 17(6), 410-415. Young, R.P., Hopkins, R.J., Smith, M., & Hogarth, D.K. (2010). Smoking cessation: The potential role of risk assessment tools as motivational triggers. Post Graduate Medical Journal, 86(1011), 26-33. Replaces: Tobacco: The role of health professionals in smoking cessation [Joint position statement]. (2001) 1 For detailed recommendations and guidelines for tobacco treatment related to health professionals, see Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, (2008); Registered Nurses' Association of Ontario, (2007); and Canadian Dental Hygienists Association, (2004). 2 For the purpose of this position statement, tobacco includes products that can be inhaled, sniffed, sucked or chewed (e.g., flavoured cigarillos, kreteks, chewing tobacco, moist snuff, betel or qat, hookah or shisha, bidis, cigars and pipes). 3 (Health Canada, 2009) 4 (Health Canada, 2007) 5 (Statistics Canada, 2009) 6 (Health Canada, 2007) 7 (Canadian Centre on Substance Abuse, 2006) 8 (Canadian Cancer Society, 2010) 9 (Canadian Lung Association, 2006) 10 (Canadian Cancer Society, 2010) 11 (Canadian Cancer Society, 2010) 12 (Physicians for a Smoke-Free Canada, 2005) 13 (Vangeli & West, 2008; Ontario Tobacco Research Unit - Tobacco Informatics Monitoring System (TIMS), 2008; Breitling, Rothenbacher, Stegmaier, Raum & Brenner, 2009) 14 (Ross, Blecher, Yan & Hyland, 2010) 15 (Young, Hopkins, Smith & Hogarth, 2010) 16 (Bao, Duan & Fox, 2006) 17 (Fiore et al., 2008; Shields, 2004) 18 (Fiore et al., 2008) 19 (Stead, Lancaster & Perera, 2006) 20 (Nabalamba & Millar, 2007) 21 (Canadian Medical Association, 2008) 22 (Fiore et al., 2008)
Documents
Less detail

Determining the impact of chemical contamination on human health

https://policybase.cma.ca/en/permalink/policy10149
Last Reviewed
2019-03-03
Date
2011-05-28
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-05-28
Topics
Population health/ health equity/ public health
Text
Industrialization and manufacturing have had enormous positive benefits for humankind, but the consequences of hazardous by-products (chemical contamination) to human health and the environment are less well recognized. A major incident such as Bhopal is an unequivocal example of catastrophic poisoning caused by industry. However, more subtle human health impacts can result from low levels of exposure to chemical and industrial by-products from agriculture, consumer products, manufacturing, and even medical sources. Chemicals from industrial sources have been found in the soil, water, air, food and human tissue. Due to improving technology, even minuscule amounts of potentially noxious substances can be detected. Some exposures warrant remedial action, but in others the health impact may be negligible: the toxin, dose, route and duration of exposure must be considered. Of course, there are potentially toxic substances that have been found to pose little or no harm to human health, but there are many more for which the health effects are unknown. A substantial knowledge gap exists in that the effects of many chemical agents have not been fully studied. As a result, rigorous surveillance and assessment to ensure potential health impacts are reduced or avoided is necessary. Chemicals like dichlorodiphenyltrichloroethane (DDT) can persist in the environment or in living beings long after the product was pulled from the market, making it essential that full and rigorous testing of new and existing chemicals is undertaken. Finally, research is needed to determine whether emerging issues, such as the presence of pharmaceuticals in drinking water, pose a legitimate threat to human health. Chemicals, properly managed, can and will continue to provide enormous benefits to society, but caution is warranted because of the potential health consequences. Provided below is a discussion of certain classes of chemicals that need to be regulated, monitored and properly researched. Agriculture Agriculture represents the largest component of the global economy. Rising pressures to meet the needs of a growing population have resulted in the mechanization of farming, and the widespread use of fertilizers and pesticides.1 Fertilizer and pesticide run-off has been found in soil, water and the human food supply.2 Approximately 40 chemicals classified by the International Agency for Research on Cancer (IARC) as known, probable, or possible human carcinogens, are EPA registered pesticides available on the open market.3 Long-term low dose pesticide exposure has been linked to various cancers, immune suppression, hormonal disruption, reproductive abnormalities, birth defects, and developmental and behavioural problems.4 Certain pesticides are also known to be persistent in the human body.5 While many individual pesticides can be safely used, there is a lack of research on the effect of certain pesticides when used in combination. Consumer Products Modern technologies have led to advances with a positive impact on the quality of human life. While newer consumer products have benefits over earlier materials, their use is not without side effects. Both the chemicals used to make these products and those that form key components of the products themselves may be harmful. Bisphenol A (BPA) is an industrial chemical added to many hard plastic bottles and to metal based food and beverage cans since the 1960s.6 In August 2010, Statistics Canada reported that measurable levels of BPA were found in the urine of 91 per cent of Canadians aged six to 79.7 Concerns have been raised about effects on the brain, behaviour, and prostate gland from exposure to this chemical, particularly in fetuses, infants, and children.8 In 2008, Canada banned BPA in infant bottles.9 In October 2010, Canada went a step further by becoming the first jurisdiction in the world to declare BPA toxic.10 Manufacturing With the growing demand for consumer products, there has been a corresponding growth in manufacturing. Manufacturing is one of the biggest contributors to outdoor air pollution, and contributes to soil and water pollution.11 In 2004, US industry released 1.8 billion pounds of potentially toxic chemicals. Exposure to some of these chemicals has been linked to severe health effects, including cancer. 12 One of the released chemicals, dioxin, can be harmful at very low levels. Dioxins accumulate in fats and break down slowly. This leads to contamination of the food supply, and human exposure through the consumption of meat, dairy, fish and shellfish.13 Even in the far north, animals have been found to contain dioxins.14 The EPA estimates that the cancer risk from dioxins already present in the general public is 1-per-1,000.15 In most cases the emissions pose minimal risk to human health. However, chemicals, and chemical combinations which remain unstudied should be properly assessed.16 Medical Practices Advancements in medical science and the use of pharmaceuticals, diagnostic equipment and other medical treatments have prolonged life expectancy. However, these interventions can also contribute to environmental contamination. In 2008, the Associated Press reported pharmaceuticals in the water of 24 major metropolitan areas in the United States, serving 41 million people.17 There is a concern that these pharmaceuticals could negatively impact male fertility, lead to birth defects, cause breast and testicular cancer in humans, and lead to antibiotic resistance.18 For many pharmaceuticals found in water sources, no concerted environmental impact surveys have been carried out.19 Mercury is used in fever thermometers, sphygmomanometers, gastrointestinal tubes, and oesophageal dilators20. Reports indicate that medical waste incinerators are among the largest sources of anthropogenic mercury emissions in both the United States and Canada.21 Medical waste, while not the principle source of mercury poisoning, contributes to the mercury levels present in the environment. In fetuses, infants and children, low-dose exposure to mercury can cause severe and lifelong behavioural and cognitive problems.22 At higher exposure levels, mercury may adversely affect the kidneys, the immune, neurological, respiratory, cardiovascular, gastrointestinal, and haematological systems of adults.23 It has also been linked to cancer.24 These examples highlight the major categories of human exposure to chemicals. As the review suggests, some of these chemicals have been linked to harmful human health impacts. What is important to keep in mind, however, is that the harm is conditional on the level and lengths of exposure. For most people, these chemicals pose no harm because the exposure is so low. In some cases, such as BPA, it has been determined that the potential harm is not worth the risk: the Canadian government has decided to declare BPA toxic and regulate it accordingly. In other cases, such as pharmaceuticals, the evidence simply warrants further study and surveillance. Given the potential harm to human health, surveillance and research are vitally important in all categories. The more information that is available to policy makers and health care professionals, the better the chance of limiting human health impacts. What has been done? International Action Concerns regarding chemical contamination and human health have led to numerous interventions from the international community. These include the International Programme on Chemical Safety (1980), the Inter-Organization Programme for the Sound Management of Chemicals (1995), the Globally Harmonized System of Classification and Labelling (2002), and the Strategic Approach to International Chemicals Management, which was adopted by governments and stakeholders at the first International Conference on Chemicals held in Dubai in 2006. 25 Various conventions have also been passed, including the Stockholm Convention (2004) on persistent organic pollutants such as DDT, and the Rotterdam Convention (2004) which applies to pesticides and industrial chemicals.26 There is some concern about the continued effectiveness of the Rotterdam convention. In 2006, the Canadian government was instrumental in preventing the listing of asbestos as a toxic chemical. Given the persuasive evidence of the harm caused by asbestos, this action undermines the legitimacy of voluntary international conventions.27 Canadian Action In addition to being a signatory to all international agreements listed above, the Canadian government has programs for chemical management domestically. The main tool is the Canadian Environmental Protection Act (CEPA) 1999. Jointly administered by Environment Canada and Health Canada, it is intended to prevent pollution and address the potentially dangerous chemical substances to which Canadians are exposed.28 The plan calls for increased surveillance of certain chemicals to monitor exposure and health effects, and will increase focus on the management of the health and environmental risks of pharmaceuticals, personal care products, and chemical contamination in food.29 There were 23,000 chemical substances on the Domestic Substances List (DSL) in Canada in 1999. To date, only about 1,000 of these chemicals have been fully assessed. Of the remaining 22,000, 85% have been categorized as not requiring any additional action.30The most recent Canadian Chemicals Management Plan states that full assessments will be done on 550 substances identified as potentially harmful. Even with these additional assessments, more than 3,000 chemicals will not have been assessed. Canadian Medical Association In 2009, the Canadian Medical Association and the Canadian Nurses Association released a joint position statement on environmentally responsible activity for the health-care sector. Recommendations included the proper handling and disposal of toxic chemicals and the reduction of products using these substances. An adapted version of this position statement was then endorsed by a coalition of 12 national healthcare organizations and the David Suzuki Foundation. In October 2010, the World Medical Association, of which CMA is a member, adopted a policy statement on environmental degradation and the management of chemicals. The statement calls for mercury-free health care, support for international efforts to restrict chemical pollution and to monitor harmful chemicals in humans and the environment, and mitigation of the health effects of toxic exposure to chemicals. What needs to be done? Research and Surveillance Research on chemicals produced through man-made activities remains insufficient. While some of the more toxic chemicals have been reviewed and are now more closely regulated, thousands remain that have had neither health nor environmental assessments. The Domestic Substances List in Canada has 3,300 chemicals of concern that have not been assessed. There is limited research on the effect of these chemicals in combination or in different mediums. Finally, work must be done to ensure environmental and human surveillance of potential chemical exposure threats. The CMA: 1. Urges the government to complete the health and environmental assessment of the chemicals on the Domestic Substances List. 2. Encourages research on the health impacts of chemical substances, as well as the combinations of these substances in different products (e.g. pesticides), and in different mediums (e.g. pharmaceuticals in drinking water). Long-term research programs are required to determine health impacts from prolonged low-dose exposures. 3. Encourages ongoing surveillance of chemicals in the environment. 4. Encourages ongoing research on the impact of regulations and monitoring of chemicals on human health and the environment. Advocacy Regulations have been developed both internationally and domestically to undertake chemical management. However, gaps remain, largely due to the voluntary nature of the frameworks. Canada can play a lead role by respecting its commitments, seeking continued adherence to these agreements and providing leadership in developing effective domestic programs and legislation. The CMA: 5. Urges the government to continue to support international efforts to manage chemical pollution. In particular CMA urges the government to fully support the principles of the Rotterdam Convention and support the listing of Asbestos as an Annex III toxic chemical. 6. Supports government legislation and regulation which reduces dangerous chemical pollution, detects and monitors harmful chemicals in both humans and the environment, mitigates the health effects of toxic exposures, and requires an environmental and health impact assessment prior to the introduction of a new chemical. Regulatory frameworks should be favoured over voluntary frameworks in order to ensure a level playing field for all manufacturers and to secure rapid and equitable health protection for all Canadians. CMA encourages the government to advocate for similar legislation internationally. Leadership Physicians can participate in the monitoring of patients for potential health effects from chemical exposure. Additionally, physicians can be leaders in encouraging greener health care practices. Finally, physicians can support national medical organizations in developing clinical tools to assess patient risk to chemical exposure. The CMA: 7. Supports the phase out of mercury and other persistent, bio-accumulating and toxic chemicals in health care devices and products. 8. Supports the development of effective and safe systems to collect and dispose of pharmaceuticals that are not consumed. 9. Supports the development of clinical tools for physicians to help assess their patients' risk from chemical exposures. Education and Professional Development Physicians have a role to play in educating their patients, the public, and current and future colleagues about the potential human health consequences of chemical contamination. Medical education and continuing professional development in this area could have a significant impact on human health. The CMA: 10. Should assist in building professional and public awareness of the impact of the environment and global chemical pollutants on personal health. 11. Supports the development of locally appropriate continuing medical education on the clinical signs, diagnosis and treatment of diseases that are introduced into communities as a result of chemical pollution. 12. Encourages physicians to inform patients about the importance of safe disposal of pharmaceuticals that are not consumed. Conclusion National and International initiatives have substantially reduced the incidence of harmful chemical contamination, but more work is needed. Evidence of health effects (or lack thereof) may be strong for certain chemicals, but for others it remains incomplete. Given the dangers of chemicals such as dioxin, which can cause severe effects with small doses, more comprehensive research is warranted. To ensure human health consequences are identified and risks are minimized, improved surveillance is essential. Further policies and regulations are needed to ensure that chemicals utilized are as safe as possible. The Canadian BPA ban demonstrates the use of the precautionary principle in the presence of convincing if not complete evidence. While there are clear benefits associated with the use of chemicals, it is necessary to ensure that potential harmful effects are considered.' Finally, public and health care provider information is sorely lacking. Physicians can play a role in correcting some of these deficiencies through their actions to support research and surveillance, advocacy, leadership, education, and professional development. References 1 Ongley, Edwin D. (1996) Control of water pollution from agriculture- FAO irrigation and drainage paper 55.Chapter 1: Introduction to agricultural water pollution Food and Agriculture Organization of the United Nations. Available at: http://www.fao.org/docrep/w2598e/w2598e00.HTM 2 Peters, Ruud J.B. (2006) Man-Made Chemicals in Food Products. TNO Built Environment and Geosciences. Available at: http://assets.panda.org/downloads/tno_report.pdf 3 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk: What We Can Do Now: 2008-2009 Annual Report. President's Cancer Panel. Available at: http://deainfo.nci.nih.gov/advisory/pcp/annualReports/pcp08-09rpt/PCP_Report_08-09_508.pdf 4 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk...; Shah, Binod P. & Bhupendra Devkota (2009) "Obsolete Pesticides: Their Environmental and Human Health Hazards." The Journal of Agriculture and Environment. Vol:10 June 2009. Available at: http://www.nepjol.info/index.php/AEJ/article/view/2130/1961 ; Kjellstrom, Tord et.al. (2006) Chapter 43: Air and Water Pollution: Burden and Strategies for Control in Disease Control Priorities in Developing Countries. Disease Control Priorities Project. Available at: http://files.dcp2.org/pdf/DCP/DCP43.pdf 5 California Environmental Protection Agency (2002) Environmental Protection Indicators for California: Chapter 3: Environmental Exposure Impacts Upon Human Health. Available at: http://oehha.ca.gov/multimedia/epic/2002reptpdf/Chapter3-7of8-HumanHealth.pdf 6 United States Food and Drug Administration (2010) Update on Bisphenol A for Use in Food Contact Applications. Available at: http://www.fda.gov/newsevents/publichealthfocus/ucm064437.htm 7 CBC News (October 13, 2010) BPA declared toxic by Canada. Available at: http://www.cbc.ca/health/story/2010/10/13/bpa-toxic.html 8 States Food and Drug Administration (2010) Update on Bisphenol A... 9 Health Canada (2008) Government of Canada Protects Families with Bisphenol A Regulations Available at: http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/_2008/2008_167-eng.php 10 CBC News (October 13, 2010) BPA declared toxic by Canada... 11 Kjellstrom, Tord et.al. (2006) Chapter 43: Air and Water Pollution... 12 Cassady, Alison & Alex Fidis (2007) Toxic Pollution and Health: An Analysis of Toxic Chemicals Released in Communities across the United States. U.S. PIRG Education Fund. Available at: http://cdn.publicinterestnetwork.org/assets/KTfes5EXnCLOgG9eWTKU6g/ToxicPollutionandHealth2007.pdf 13 World Health Organization (2010) Dioxins and their effects on human health. Available at: http://www.who.int/mediacentre/factsheets/fs225/en/index.html 14 Woolford, Julian & Noemi Cano Ed. (2006) Killing them softly... 15 Cassady, Alison & Alex Fidis (2007) Toxic Pollution and Health... 16 Ibid 17 Natural Resources Defense Council (2010) Dosed Without Prescription: Preventing Pharmaceutical Contamination of Our Nation's Drinking Water. Available at: http://www.nrdc.org/health/files/dosed4pgr.pdf 18 Wright-Walters, Maxine & Conrad Volz (2009) Municipal Wastewater Concentrations of Pharmaceutical and Xeno-Estrogens: Wildlife and Human Health Implications. Available at: http://www.chec.pitt.edu/Exposure_concentration_of_Xenoestrogen_in_pharmaceutical_and_Municipal_Wastewater__Final8-28-07%5B1%5D.pdf; Daughton, Christian G. (N.D.) Pharmaceuticals and the Environment. Available at: www.epa.gov/osp/regions/emerpoll/daughton.ppt; Nikolaou, Anastasia; Meric, Sureyya & Despo Fatta (2007) "Occurrence patterns of pharmaceuticals in water and wastewater environments." Analytical and Bioanalytical Chemistry. 387: 1225-1234; Natural Resources Defense Council (2010) Dosed Without Prescription... 19 Daughton, Christian G. (N.D.) Pharmaceuticals and the Environment... 20 Environment Canada. (N.D.)Mercury and the Environment. Available at: http://www.ec.gc.ca/MERCURY/SM/EN/sm-mcp.cfm#MD 21 Health Care Without Harm (2007) The Global Movement for Mercury Free Health Care. Available at: http://www.noharm.org/lib/downloads/mercury/Global_Mvmt_Mercury-Free.pdf; World Health Organization (2005) Mercury in Health Care: Policy Paper. Available at: http://www.who.int/water_sanitation_health/medicalwaste/mercurypolpaper.pdf 22 Environmental Working Group (N.D.) Chemical Pollution: The Toll on America's Health. Available at: http://www.ewg.org/files/EWG-kid-safe-toll-on-health.pdf 23 California Environmental Protection Agency (2002) Environmental Protection Indicators... 24 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk... 25 World Health Organization (N.D.) International Programme on Chemical Safety: About us. Available at: http://www.who.int/ipcs/en/; World Health Organization (N.D.) Inter-Organization Programme for the Sound Management of Chemicals. Available at: http://www.who.int/iomc/brochure/brochure_english.pdf; United Nations Economic Commission for Europe (N.D.) Globally Harmonized System of Classification and Labelling of Chemicals (GHS). Available at: http://www.unece.org/trans/danger/publi/ghs/ghs_welcome_e.html; Weinberg, Jack (2008) An NGO Guide to SAICM: The Strategic Approach to International Chemicals Management. Available at: http://www.ipen.org/ipenweb/documents/book/saicm%20introduction%20english.pdf 26 Eskenazi, Brenda et.al. (2009) "The Pine River Statement: Human Health Consequences of DDT Use." Environmental Health Perspectives. 117:1359-1367 Available at: http://www.eoearth.org/article/Human_Health_Consequences_of_DDT_Use#gen4; World Health Organization (N.D.) Rotterdam Convention: Share Responsibility. Available at: http://www.pic.int/home.php?type=t&id=5&sid=16 27 Kazan-Allen, Laurie (2007) Rotterdam Treaty Killed by Chrysotile Asbestos! International Ban Asbestos Secretariat. Available at: http://www.ibasecretariat.org/lka_rott_meet_geneva_oct_06.php 28 Government of Canada (2007) The Canadian Environmental Protection Act, 1999 (CEPA 1999). Available at: http://www.chemicalsubstanceschimiques.gc.ca/about-apropos/cepa-lcpe-eng.php 29 Government of Canada (2010) Chemicals Management Plan. Available at: http://www.chemicalsubstanceschimiques.gc.ca/plan/index-eng.php 30 Ibid.
Documents
Less detail

Medication use and seniors (Update 2017)

https://policybase.cma.ca/en/permalink/policy10151
Last Reviewed
2019-03-03
Date
2011-05-28
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-05-28
Replaces
Medication use and seniors
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Older Canadians represent the fastest-growing segment of our population and are the largest users of prescription drugs. Seniors take more drugs than younger Canadians because, on average, they have a higher number of chronic conditions. According to the Canadian Institute for Health Information, in 2012, nearly two-thirds of seniors had claims for 5 or more drug classes, and more than one-quarter of seniors had claims for 10 or more drug classes. The number of drugs used by seniors increased with age. The use of multiple medications, or polypharmacy, is of concern in the senior population. The risk of drug interactions and adverse drug reactions is several-fold higher for seniors than for younger people. This phenomenon is associated with pharmacokinetic and pharmacodynamics factors in seniors, including changes in renal and hepatic function, increased sensitivity to drugs and, potentially, multiple medical problems. In older persons, adverse drug reactions are often complex and may be the direct cause of hospital admissions for acute care. Cognitive and affective disorders, for example, may be due to adverse reactions to sedatives or hypnotic drugs. Chronic pain is a common issue, and it is important to carry out research into and education for health care providers concerning the unique challenges of managing pain in older adults. The CMA supports the development of a coordinated national approach to reduce polypharmacy and prevent adverse drug reactions. Prescribers must be vigilant to optimize pharmacotherapy and in reconciling medications, taking into consideration physiological changes as a person ages. Deprescribing should be considered, reducing or stopping medications that may be harmful or no longer be of benefit, seeking to improve quality of life. There has been considerable interest in determining which factors affect prescribing behavior and how best to influence these factors. Strategies that improve prescribing practices include evidence-based drug information provided through academic detailing; objective continuing medical education; accessible, user-friendly decision support tools available at point of care; and electronic prescribing systems that allow physicians access to their patient's treatment and medication profiles. The following principles define the basic steps to appropriate prescribing for seniors.
Know the patient.
Know the diagnosis.
Know the drug history. Keep a medication list for each patient and review, update, reconcile and evaluate adherence at each visit. Instruct the patient to bring all prescription and over-the-counter medications, including medications prescribed by other physicians, and natural health products, to each appointment. In some provinces, pharmacists conduct medication use reviews for patients on public drug benefit programs.
Know the history of use of other substances such as alcohol, tobacco, cannabis, opioids and caffeine.
Consider non-pharmacologic therapy, including diet, exercise, psychotherapy or community resources. Continuing medical education in specific non-pharmacologic therapies is valuable. For example, evaluation and management of behavioural and psychological symptoms of dementia should be considered before anti-psychotic therapy. As well, Canadian standardized non-pharmacologic order sets should be developed for the treatment of delirium.
Know the drugs. Critically evaluate all sources of drug information and use multiple sources such as clinical practice guidelines, medical journals and databases, continuing medical education and regional drug information centres. Monitor patients continually for adverse drug reactions. Appropriate drug dosage depends on factors such as age, sex, body size, general health, concurrent illnesses and medications, and hepatic, renal and cognitive function (for example, older people are particularly sensitive to drugs that affect the central nervous system).
Keep drug regimens simple. Avoid mixed-frequency schedules when possible. Try to keep the number of drugs used for long-term therapy under five to minimize the chance of drug interactions and improve adherence.
Establish treatment goals. Determine how the achievement of goals will be assessed. Regularly re-evaluate goals, adequacy of response and justification for continuing therapy. Time to benefit of prescribed medications should be a key consideration when providing care to seniors at end of life.
Encourage patients to be responsible medication users. Verify that the patient and, if necessary, the caregiver, understands the methods and need for medication. Recommend the use of daily or weekly medication containers, calendars, diaries or other reminders, as appropriate, and monitor regularly for compliance. Encourage the use of one dispensary. The Institute for Safe Medication Practices Canada has developed a program, Knowledge is the best medicine (https://www.knowledgeisthebestmedicine.org), that can be helpful to seniors and their healthcare team manage medicines safely and appropriately. Approved by the Board on May 28, 2011 Update approved by the Board on March 02, 2019
Documents
Less detail

Principles for health system governance

https://policybase.cma.ca/en/permalink/policy10320
Last Reviewed
2019-03-03
Date
2011-10-23
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-10-23
Replaces
Regionalization (Update 2001)
Topics
Health systems, system funding and performance
Text
Principles for Health System Governance This policy provides principles and recommendations for developing, implementing and evaluating health system governance models such as regionalized health care for the purposes of delivering high quality care to patients. Since the 1990s, health care systems in many countries including Canada have been searching for more effective health system governance models to accomplish a variety of health policy objectives. These objectives include funding health care based on population health needs and improving service delivery integration. In Canada, most provinces and territories moved to a regionalized model of health system governance during the 1990s. This "regionalization" approach involved both decentralizing and centralizing specific elements of the health care system. Decentralizing involved moving planning, budgeting and decision making authority from the provincial or territorial level to certain regional bodies. Centralizing involved moving the planning and governance of health care and medical services from individual institutions or agencies to a regional body. In terms of the delivery of health care services, centralization often occurred through the consolidation of several programs into a single program for a region and through the merger and closure of individual institutions. Since 2003, several provincial governments initiated new changes to their approach to health system governance ranging from vertical integration involving a range of health agencies under a single board (e.g., Quebec) to the creation of boards that oversee the delivery of care for larger portions of a jurisdiction or even the entire jurisdiction itself (e.g., Alberta Health Services). Many of these new models involve an arm's length authority governed by an appointed board that is mandated to manage and integrate the operations of the health system across the province/territory while leaving the ministry of health to set the overall plan and priorities for the health system as well as set standards and monitor outcomes. No doubt, governments will continue to search for an ideal health system governance and delivery model as part of an effort to develop "high performing health systems". Examples of high performing health systems exist at all levels such as at regional levels within countries (e.g., Jonkoping, Sweden) or at the client group level (e.g., US Veterans Health Administration). Health system governance models, such as health regions or health agencies, must have an overall goal of ensuring the delivery of high quality, timely and accessible care to its citizens. The Institute for Healthcare Improvement's (IHI) Triple Aim concept identifies three objectives for health systems: improve the health of the population; improve the health care experience for patients; and improve the value for money spent on health and health care. Many previous health system reforms have not resulted in improved care for patients. The CMA's 2010 action plan, Health Care Transformation in Canada: Change that Works. Care that Lasts, calls for patient-centred health care that puts the patients and their families' interests first. From the health provider perspective, previous regionalization efforts have raised several issues of concern, including whether these models translate into improved delivery of care for patients. There is also concern with the prospect that new models will limit provider involvement in health system governance and that health human resource planning will be localized when mobility of labour transcends local borders. The CMA is committed to playing a positive role in the debate on the future of health care reform in Canada. It recognizes that health system governance models are subject to change. However, this CMA policy on health system governance identifies fundamental principles that should guide any model under consideration. These guiding principles draw upon previous CMA work starting in 1991 with its Working Group on Regionalization, leading to its Language of Health System Reform report. Guiding principles Patient-centred: Any consideration of governance models must begin with an overall goal of providing patient-centred care-seamless access to the continuum of care in a timely manner, based on need and not the ability to pay, that takes into consideration the individual needs and preferences of the patient and his/her family, and treats the patient with respect and dignity. Defined objectives: The development and implementation of health system governance models/strategies must begin with a clear statement of objectives. The objectives should reflect the changes that need to be made to the health care system to address specific problems and, whenever possible, must be defined in measurable terms so that health system governance policies can be evaluated. Accountability/authority: Aligning accountability and authority is essential to effective and sustainable high performing health systems. Accountability is affected by the degree of authority and the scope of responsibilities (i.e., planning, administration, organization and funding of health care services) transferred to the governing units (e.g., regions). Who is accountable, and for what, need to be defined. There needs to be a clear statement of the roles of government, governing boards, physicians and all health care stakeholders. Physicians have a unique contribution to make and their views should be taken into account in any restructuring of the health care delivery system. Needs based planning/Responsive to regional needs: The definition of the region(s) or sub-regions should reflect the natural, socio-political and geographic divisions of the population. Once regions are defined, the health care needs of the population served by regional units should be determined through epidemiological studies, input from communities and other needs assessment. In addition to local planning, there is also the need for broader based planning to address medical and scientific research, new technologies and procedures. Regional health needs can vary requiring flexible delivery models. Credentialing that meets jurisdictional standards should be maintained at the regional level in order to effectively respond to regional needs and issues. Informed choice: Any form of health system governance should not restrict patients' mobility between providers or regions, physicians' mobility between and within regions, or physicians' choice of practice setting by limiting employment to community health centres or other forms of group practice. Participatory democracy Both patients/public and providers should be involved in determining governance models and participating in the ongoing governance of health systems. If providers are to be encouraged to get involved, they need to have ready access to the planning and administrative skills needed to participate effectively and make a valuable contribution to management and leadership. Three key areas in which providers must become knowledgeable and involved include governance and credentialing, health care needs assessment and health economics. Clinical autonomy: Physicians have a responsibility to advocate on behalf of their patients to ensure the availability of needed care. This responsibility should not be hindered by a physician's practice setting, mode of remuneration or paying agency. Evaluation: Evaluation protocols must be built into health system governance models at the outset, and the results of evaluation must be used to "fine tune" and improve the strategies. These protocols should address cost effectiveness, population health status, patient access to health care services and the interests of government, the profession and the public. Standards for reasonable access: Certain areas and cultural groups do not have the same level of access to health care services as the national norm. All health system governance models should address these shortcomings to ensure that the entire population of any given region has reasonable access to primary, secondary and tertiary care. Balancing access and affordability: One of the implicit objectives of new models of health system governance appears to be achieving both control over health care costs and redirecting expenditures from health care to community and social services. Governing authorities must be careful to maintain a balance between access to health care services and affordability allowing for a variety of methods to achieve this (e.g., internal markets). They must also maintain a comprehensive accounting of the cost of implementing any new model. Balancing curative with preventive and sustaining care: All health system governance models must support not only the system's ability to provide curative care but also an ability to provide effective preventive and sustaining care. Governance models should ensure funds can be allocated toward a comprehensive approach to care as well as allow for models of care that support all three functions. Support for medical education and research: Policies and structures of health system governance models need to acknowledge and foster the role of medical education and research in the health care system. Governance of medical teaching and research should reside within the academic health sciences centres. These centres should be assured of adequate financial and human resources and of access to cross regional patient populations and to community teaching sites in order to provide adequate learning and research opportunities. Recommendations With regard to the development, implementation and evaluation of health system governance models, the CMA recommends that: * advocacy on behalf of patients and physicians be maintained irrespective of any regional administrative boundaries; * governments ensure that the introduction of new models of health system governance do not interfere with clinical autonomy and professional freedom in the context of the physician/patient relationship; * governments, health governing authorities and institutions ensure that physicians, through their professional associations, are included in the development and revision of practitioner/medical staff bylaws and appointment policies; * family physicians, on the basis of their education, training and skills, are reaffirmed as the preferred point of entry into Canada's health care system; * governments ensure that catchment area under the governing authority be defined in a way that is sensitive to the political, cultural and geographic circumstances of the population and recognizes established patterns of the demand for, and the provision of, health care; * governments ensure that the introduction of new governance models does not interfere with reasonable access by the population to medical services at the primary, secondary and tertiary levels; * leadership be provided to help ensure that the development, implementation and evaluation of health system governance models are based on clear, measurable objectives; * governments develop and maintain national standards for access to high quality health care, medical education and research, irrespective of regional boundaries; * governments ensure that programs and policies under any form of health system governance be designed and implemented in a manner that supports key principles of medical education and research, including: - the governance and resources required for medical teaching, both in the academic health sciences centres and in appropriate community based sites throughout the province or territory, - academic health sciences centres' responsibilities for providing secondary and tertiary care to catchment populations that cut across regional boundaries, and - the need for academic physician resource plans to ensure a critical mass for teaching and research; * governments give priority to mechanisms to protect the mobility of patients and physicians when developing and implementing programs under any new health system governance model; and * the medical profession work with governments to develop: - clear role, responsibility and accountability statements for government, health system governing boards, health care providers and consumers, - mechanisms to ensure that governing boards have broad representation and meaningful input from the community, including physicians, and that regional boards be recruited through a clearly specified appointment or electoral process, - guidelines for use by communities to assess their health care needs and to provide assistance, as required, with the conduct of such assessments, - protocols and procedures for evaluating health system governance initiatives, - mechanisms to ensure adequate and appropriate physician input into operational aspects of regional planning and coordination of health care services, and - processes under any health system governance model ensure adequate opportunities for research, education (including continuing medical education) and training of physicians consistent with national standards.
Documents
Less detail

Operational principles for the measurement and management of wait lists (Update 2011)

https://policybase.cma.ca/en/permalink/policy10322
Last Reviewed
2019-03-03
Date
2011-10-23
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-10-23
Replaces
Operational principles for the measurement and management of waiting lists
Topics
Health systems, system funding and performance
Text
This policy statement provides operational principles for the measurement and management of wait list systems that support timely access to necessary care for patients. This statement is based on the understanding that in order for wait list systems to be effective in improving timely access to medically necessary care for patients, physicians and other providers must be centrally involved and appropriately supported to assist in their development, measurement and management. Since the late 1990s, Canadians have become increasingly concerned over lengthening wait times to access medically necessary care. As a result, a major focus of the 2004 Health Care Accord (10-Year Agreement to Strengthen Health Care) was to improve timely access to necessary medical care. Since then, provinces and territories have taken steps to measure, monitor and manage patient wait times. However, most efforts thus far to improve wait times have been focused on the wait between the specialist consultation and the scheduled date for treatment. Patients may also experience waits in accessing a family physician (many Canadians do not have a family physician) and waiting to see a specialist following a referral by a family physician. Canadians deserve timely access to medically necessary care. Governments must ensure that patients are treated within established wait-time benchmarks for all major diagnostic, therapeutic, and surgical services. Physicians recognize that it is desirable to minimize waits and to properly prioritize and manage patients' wait for care by accurately capturing and utilizing wait-time data. However, there remain serious concerns over the quality of wait-time data and who has the primary responsibility for capturing the data. Physicians and other providers are increasingly being requested to input wait-time data (e.g., length of wait for consultation or for start of treatment). Yet, in many instances, they are expected to do so without the necessary resources and supports. Outlined below are Operational Principles for the Measurement and Management of Wait Lists developed originally through CMA's Access to Quality Health Care Project(1) with input from public opinion research as well as stakeholder groups, including CMA Core Committees, Provincial-Territorial Medical Associations and CMA Affiliates. Goals 1. To maintain or enhance patients' quality of life and health status through effective development, measurement and management of wait lists. 2. To ensure that the development, measurement and management of wait lists are based on the best available evidence of clinical appropriateness, clinical effectiveness, rational use of resources, clinical need and patient quality of life. Principles A. Stakeholder Involvement 1. Physicians in clinical practice must have a leadership role: - in identifying clinically relevant data elements through consensus; - in developing standard definitions and measures for prioritization for wait lists; and - in developing wait-time benchmarks. 2. Health care providers and other stakeholders should be involved in the development, measurement, maintenance, monitoring, management and evaluation of wait list systems, and should be appropriately compensated for their time and effort. B. Database Development and Management Systems 1. Systems for developing and managing wait lists must require and provide reliable, current, useful and valid data and information. 2. Database development and wait list management requires involvement of multidisciplinary panels. 3. Systems for managing wait lists should: - provide accurate, reliable, timely, publicly accessible and real-time information in a cost-effective manner. Deadlines for inputting data should be reasonable and implemented without the use of threats or penalties; - collect and assess data on need, quality of life and health outcomes; be flexible and dynamic so that they can adapt over time with the development of new technologies and approaches to treatment; and - require policies and procedures on confidentiality, so that patients' and providers' privacy are protected. C. Investment 1. Systems for managing wait lists require initial and sustained investment in dedicated human resources, sophisticated information systems and information technology infrastructure at all levels (e.g., medical offices, hospitals, health regions). D. Accountability 1. The parties involved in managing wait lists must accept their responsibilities and obligations to each other and to the public. 2. Privacy and confidentiality of patient and provider information must be respected. 3. The systems, processes and results for managing wait lists should be widely communicated to obtain stakeholder involvement and support. E. Evaluation 1. Systems for managing wait lists must: - be continually monitored and evaluated to identify opportunities for improvement; and - regularly undergo independent data audits and evaluations of process and outcome. F. Governance 1. An independent, stakeholder-based, non-governmental organization with an advisory committee should be responsible for overseeing and administering systems for managing wait lists. (1) Canadian Medical Association, Access to Quality Health Care Project, January 1998. Ottawa.
Documents
Less detail

The evolving professional relationship between Canadian physicians and our health care system: Where do we stand?

https://policybase.cma.ca/en/permalink/policy10389
Last Reviewed
2019-03-03
Date
2012-05-26
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2012-05-26
Topics
Ethics and medical professionalism
Text
This paper discusses the current state of the professional relationship between physicians and the health care system. A review of the concept of medical professionalism, and the tensions that can arise between the care of individual patients and a consideration of the broader needs of society, provides some basic groundwork. Our understanding of what it means to be a physician has evolved significantly over the years, and the medical profession is now being challenged to clarify the role it is willing to play in order to achieve transformation of our health care system. We have arrived at this point due to a convergence of several factors. Regionalization of health care has led to a change in the leadership roles played by practising physicians and to the opportunities they have for meaningful input into system change. Physicians are now also less likely to be involved in hospital-based care, which has resulted in a loss of collegiality and interactions with peers. Changing models of physician engagement status and changing physician demographics have also presented new and unique issues and challenges over the past few years. The Canadian Medical Association (CMA) suggests that its physician members and other stakeholders employ a "AAA" lens to examine the challenges and opportunities currently facing Canadian physicians as they attempt to engage with the health care system: Autonomy, Advocacy and Accountability. These important concepts are all underpinned by strong physician leadership. Leadership skills are fundamentally necessary to allow physicians to be able to participate actively in conversations aimed at meaningful system transformation. KEY CMA RECOMMENDATIONS ARE AS FOLLOWS: Physicians should be provided with the leadership tools they need, and the support required, to enable them to participate individually and collectively in discussions on the transformation of Canada's health care system. Physicians need to be provided with meaningful opportunities for input at all levels of decision-making, with committed and reliable partners, and must be included as valued collaborators in the decision-making process. Physicians have to recognize and acknowledge their individual and collective obligations (as one member of the health care team and as members of a profession) and accountabilities to their patients, to their colleagues and to the health care system and society. Physicians must be able to freely advocate when necessary on behalf of their patients in a way that respects the views of others and is likely to bring about meaningful change that will benefit their patients and the health care system. Physicians should participate on a regular and ongoing basis in well-designed and validated quality improvement initiatives that are educational in nature and will provide them with the feedback and skills they need to optimize patient care and outcomes. Patient care should be team based and interdisciplinary with smooth transition from one care setting to the next and funding and other models need to be in place to allow physicians and other health care providers to practise within the full scope of their professional activities. INTRODUCTION The concept of medical professionalism, at its core, has always been defined by the nature and primacy of the individual doctor-patient relationship, and the fiduciary obligation of physicians within this relationship. The central obligation of the physician is succinctly stated in the first tenet of the CMA Code of Ethics: Consider first the well-being of the patient.1 Since the latter half of the 20th century, however, there has been a growing emphasis on the need for physicians to also consider the collective needs of society, in addition to those of their individual patients. As stated in the CMA Code of Ethics: Consider the well-being of society in matters affecting health. This shift in thinking has happened for at least two reasons. First, there have been tremendous advances in medical science that now enable physicians to do much more to extend the length and quality of life of their patients, but these advances inevitably come at a cost which is ultimately borne by society as a whole. Second, since World War II, Canadian governments have been increasingly involved in the financing of health care through taxation revenues. As a result, there have been growing calls for physicians to be prudent in their use of health care resources, and to be increasingly accountable in the way these resources are employed. The 2002 American Board of Internal Medicine (ABIM) Foundation Charter on Medical Professionalism calls for physician commitment to a just distribution of finite resources: "While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources."2 This has also been described as civic professionalism. Lesser et al have put forward a systems view of professionalism that radiates out from the patient-physician relationship to broader interactions with members of the health care team, the training environment and to the external environment, dealing with payers and regulators and also addressing the socio-economic determinants of health.3 Understandably, given that the resources available for health care are finite, tensions will arise between the care of individual patients and the collective needs of society, and these tensions can at times be very difficult to resolve for individual medical practitioners. As stated in the CMA policy Medical Professionalism (Update 2005): Medical professionalism includes both the relationship between a physician and a patient and a social contract between physicians and society. Society grants the profession privileges, including exclusive or primary responsibility for the provision of certain services and a high degree of self-regulation. In return, the profession agrees to use these privileges primarily for the benefit of others and only secondarily for its own benefit. 4 Over time the delivery, management and governance of health care have become more complex, and as a result the health care sector now accounts for roughly one in 10 jobs in Canada. There are more than two dozen regulated health professions across Canada, as well as numerous professional managers employed in various capacities, many of whom have had little or no exposure to the everyday realities of the practice of clinical medicine. Notwithstanding the acknowledgement of the very real and important need for inter-professional collaboration and teamwork, inevitably this creates competition for influence in the health care system. The CMA 2005 update of its policy on medical professionalism acknowledges the need for change. While maintaining responsibility for care of the patient as a whole, physicians must be able to interact constructively with other health care providers within an interdisciplinary team setting. The relationship of physicians with their colleagues must be strengthened and reinforced. Patient care benefits when all health care practitioners work together towards a common goal, in an atmosphere of support and collegiality. Now, physicians are being challenged to clarify exactly what it is that they are prepared to do in order to advance the much-needed transformation of our health care system, and how they will partner with patients, other care providers and the system in order to achieve this common goal. This provides a significant opportunity for physicians to continue their leadership role in the health care transformation initiative in the interests of their patients, while at the same time redefining their relationship with the system (understood in this context as health care administrators, governments and their representatives, health districts, health care facilities and similar organizations) in order to ensure that they have a meaningful and valued seat at the decision-making table, now and in the future. BACKGROUND The common refrain among health administrators, health ministry officials and health policy analysts for the past decade and longer has been that physicians are "not part of the health care system", that they are independent contractors and not employees, and that they are too often part of the problem and not the solution. Over this period of time, several developments have resulted in a diminished role of physicians in clinical governance in Canada and have, to varying degrees, transformed the professional and collegial relationship between physicians and their health regions, health care facilities and communities to one that is increasingly governed by legislative fiat or regulation. Regionalization Beginning with New Brunswick in 1992, all jurisdictions except Ontario, the Yukon Territory and Nunavut have adopted a regional governance model. This change has eliminated all hospital and community services boards within a geographic region and replaced them with a single regional board. Clinical governance is now administered through a regional medical advisory committee (MAC). Some provinces such as Saskatchewan recognize the role of the district (regional) medical staff association. This has had a profound impact in reducing the number of physicians engaged in the clinical governance of health care institutions. Another by-product of regionalization is that in virtually all jurisdictions, physicians no longer sit on governing boards. While physicians continue to serve as department heads and section chiefs within regions and/or individual hospital facilities, the level of support and financial compensation to do so varies greatly, particularly outside major regions and institutions, and there has been a lack of physician interest in such positions in some places. Practice environment In addition to a diminished presence in clinical governance, physicians are less likely to be actively involved in hospitals than they were previously. Anecdotally, many physicians, particularly in larger urban communities, describe having been "pushed out" of the hospital setting, and of feeling increasingly marginalized from the decision-making process in these institutions. Another result of the diminished engagement with hospitals has been the loss of the professional collegiality that used to be fostered through interaction in the medical staff lounge or through informal corridor consultations. In the community setting, there have been some positive developments in terms of physician leadership and clinical governance. Ontario and Alberta have implemented new primary care funding and delivery models that promote physician leadership of multidisciplinary teams, and at least two-thirds of the family physicians in each of these jurisdictions have signed on. British Columbia has established Divisions of Family Practice, an initiative of the General Practice Services Committee (a joint committee of the BC Ministry of Health and the BC Medical Association), in which groups of family physicians organize at the local and regional levels and work in partnership with the Health Authority and the Ministry of Health to address common health care goals. Looking ahead, regionalization is also likely to affect physicians in community-based practice. There is a clear trend across Canada to require all physicians within a region to have an appointment with the health region if they want to access public resources such as laboratory and radiology services. In the future this may also result in actions such as mandated quality improvement activities which may be of variable effectiveness and will not necessarily be aligned with the learning needs of physicians. Physician engagement status Traditionally physicians have interfaced with hospitals through a privileges model. This model, which has generally worked well, aims to provide the physician with the freedom to reasonably advocate for the interests of the patient.5 In this model, legislation and regulations also require that there are minimum procedures in place for renewing, restricting, and terminating privileges, and that procedures are set out to ensure that this takes place within a fair and structured framework. The hospital's MAC generally reviews physician privileges applications and recommends appointment and reappointment. The MAC thus plays an integral role in ensuring the safety of care within the region or hospital.5 There has been increasing attention recently on engaging in other types of physician-hospital relationships, including employment or contractual arrangements. This type of arrangement can vary from an employment contract, similar to that used by other professional staff such as nurses and therapists, to a services agreement whereby the physician provides medical services to the hospital as an independent contractor.5 However, there are concerns, expressed by the Canadian Medical Protective Association (CMPA) and others, that many of the procedural frameworks and safeguards found in hospital bylaws pertaining to the privileges model may not necessarily extend to other arrangements, and that physicians entering into these contractual agreements may, in some cases, find their appointment at the hospital or facility terminated without recourse. Under such arrangements the procedural fairness and the right of appeal available under the privilege model may not be available to physicians. One relatively new approach is the appointment model, which aims to combine many of the protections associated with the privileges model with the advantages of predictability and specificity of the employment model. It generally applies the processes used to grant or renew privileges to the resolution of physician performance-related issues.5 It has been argued that changes in appointment status and relationship models can have a detrimental impact on the relationship between practitioners and health care facilities.6 While this has been reported specifically within the context of Diagnostic Imaging, the same may hold true for other specialties as well. It should also be noted that the issues raised in this paper are applicable to all members of the profession, regardless of their current or future practice arrangements or locations. Changing physician demographics and practice patterns It is well recognized that physician demographics and practice patterns have changed significantly over the past several years. Much has been written about the potential impact of these changes on medicine, and their impact on patient care, on waiting lists and on the ability of patients to access clinical services.7 It is also acknowledged that "lifestyle factors," that is to say the attempt by many physicians to achieve a healthier work-life balance, may play a role in determining the type and nature of clinical practice chosen by new medical graduates, the hours they will work and the number of patients they will see. All of these changes mean that clinical practices may have smaller numbers of patients and may be open shorter hours than in the past. Physicians are being increasingly challenged to outline their understanding of their commitment to ensuring that all patients have timely access to high quality health care within the Canadian public system, while balancing this with their ability to make personal choices that are in their best interests. Put another way, how can we assist physicians in adjusting their clinical practices, at least to some extent, based on the needs of the population? DISCUSSION While there are clearly challenges and barriers to physician participation in meaningful transformation of the health care system, there are also opportunities for engagement and dialogue, particularly when the doctors of Canada show themselves to be willing and committed partners in the process. Health care transformation cannot be deferred just because it involves difficult decisions and changes to the status quo. Regardless of how we have reached the current situation, relationships between physicians and other parties must evolve to meet future needs. Physicians need to be assisted in their efforts in this regard, both by local health boards and facilities, and by organizations such as the CMA and its provincial and territorial counterparts. Physicians, individually and collectively, need to demonstrate what they are willing to do to assist in the process and what they are willing to contribute as we move forward, and they need to commit to having the medical profession be an important part of the solution to the challenges currently facing the Canadian system. We examine some of these challenges through the "AAA" lens of Autonomy, Advocacy and Accountability, which are underpinned by the concept of Physician Leadership. Autonomy To a large extent, physicians continue to enjoy a significant degree of what is commonly termed clinical or professional autonomy, meaning that they are able to make decisions for their individual patients based on the specific facts of the clinical encounter. In order to ensure that this autonomy is maintained, physicians need to continue to embrace the concept of clinical standards and minimization of inter-practice variations, where appropriate, while also recognizing the absolute need to allow for individual differences in care based on the requirements of specific patients. Professional autonomy plays a vital role in clinical decision-making, and it is at the heart of the physician-patient relationship. Patients need to feel that physicians are making decisions that are in the best interest of the patient, and that physicians are not unduly limited by external or system constraints. As part of this decision-making, physicians may also need to consider carefully the appropriate balance between individual patient needs and the broader societal good. In recent years, governments have sometimes made use of the "legislative hammer" to force physicians to conform to the needs of the health system, thus undermining physicians' individual or personal autonomy. Historically, physicians have organized themselves to provide 24-hour coverage of the emergency room and other critical hospital services. This has proven increasingly challenging in recent years, particularly in the case of small hospitals that serve sparsely populated areas where there are few physicians. Physicians need to continue to make sure that they do not confuse personal with professional autonomy and that they continue to ensure that health care is truly patient-centred. Physicians have rights but also obligations in this regard and they need to make sure that they continue to use a collaborative approach to leadership and decision-making. This includes an ongoing commitment to the concept of professionally-led regulation and meaningful physician engagement and participation in this system. While physicians will continue to value and protect their clinical and professional autonomy, and rightly so as it is also in the best interests of their patients, they may need to consider which aspects of personal and individual autonomy they may be willing to concede for the greater good. For example, physicians may need to work together and collaboratively with administrators and with the system to ensure that call coverage is arranged and maintained so that it need not be legislatively mandated, or imposed by regions or institutions. They may need to consider changing the way they practice in order to serve a larger patient population so that patients in need of a primary care physician do not go wanting, and so that the overall patient care load is more evenly balanced amongst colleagues. New primary care models established in Ontario and Alberta over the past decade that provide greater out-of-hours coverage are one example of such an initiative. By working collaboratively, both individually and collectively, physicians are finding creative ways to balance their very important personal autonomy with the needs of the system and of their patients. These efforts provide a solid foundation upon which to build as the profession demonstrates its willingness to substantively engage with others to transform the system. To paraphrase from the discussion at the CMA's General Council meeting in August 2011: Physicians need to carefully examine their individual and collective consciences and show governments and other partners that we are willing to play our part in system reform and that we are credible partners in the process. All parties in the discussion, not only physicians, must be able to agree upon an appropriate understanding of professional autonomy if the health care system is to meet the current and future needs of Canadians. Advocacy Physician advocacy has been defined as follows: Action by a physician to promote those social, economic, educational and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.8 This can consist of advocacy for a single patient to assist them in accessing needed funding for medications, or lobbying the government for changes at a system level. How and when individual physicians choose to undertake advocacy initiatives depends entirely on that individual practitioner, but physicians as a collective have long recognized their obligation to advocate on behalf of their individual patients, on behalf of groups of patients, and at a societal level for changes such as fairer distribution of resources and adequate pandemic planning. Traditionally, physicians have served as advocates for their patients in a number of arenas; however, various factors such as provincial/territorial legislation, regulatory authorities, and hospital contracts have combined to make them more reluctant to take on this important role and as a result overall patient care may suffer and the patient-physician relationship may be threatened. Increasingly, hospital bylaws urge or require physicians to consult with their institution or health region before going public with any advocacy statements, and in at least one health region physicians are required to sign a confidentiality agreement. Because of this, many physicians fear reprisal when they decide to act as an advocate. The ability to undertake advocacy initiatives is a fundamental concept and principle for Canadian physicians. Indeed, the CMA Code of Ethics encourages physicians to advocate on behalf of the profession and the public. Patients need to feel that their concerns are heard, and physicians need to feel safe from retribution in bringing those concerns forward. A well-functioning and respectful advocacy environment is essential to health care planning. Health care is about making choices every day. Governments struggling to balance budgets should be aware that the public can accept that hard choices must and will get made - but they are less likely to be supportive if physicians and their patients do not feel that their opinions are sought and considered as part of the process. Frontline health care providers, many of whom work in relative isolation in an office or community setting, also need to feel that they have a voice. The CMA supports the need for a forum where primary care physicians can speak with one voice (and make sure that this voice is heard and respected) in a community setting. In addition to advocating for issues related directly to patient care, physicians, as community leaders, may also be called upon to advocate for other issues of societal importance, such as protection of the environment or social determinants of health. These advocacy undertakings can also be of great importance. There can be a fine line between advocacy that is appropriate and is likely to affect important and meaningful change, and advocacy that others will perceive as being obstructive or counterproductive in nature. To further complicate matters, what might be seen as appropriate advocacy in one circumstance might not be in a different setting. Physicians should be clear on whose behalf they are speaking and whether they have been authorized to do so. If they have any questions about the possible medicolegal implications of their advocacy activities, they may also wish to contact their professional liability protection provider (e.g., CMPA) for advice in these instances. Depending on the facts of the individual circumstances, physicians may need to consider other factors as well when deciding if, when and how to undertake advocacy activities. They should also be aware that their representative medical organizations, such as national specialty societies, provincial and territorial medical associations and the CMA, may be able to assist them with their initiatives in certain situations. Physicians should not feel alone when advocating for their patients, particularly when this is done in a reasonable manner and in a way that is likely to effect meaningful and important change. Accountability Physician accountability can be seen to occur at three levels: accountability to the patients they serve, to society and the health care system and to colleagues and peers. Accountability to patients The physician-patient relationship is a unique one. Based on, optimally, absolute trust and openness, this relationship allows for a free exchange of information from patient to physician and back again. Physicians often see patients at their most vulnerable, when they are struggling with illness and disease. While other health care providers make essential contributions to patient care, none maintain the unique fiduciary relationships that are at the heart of the physician's role and which are recognized by law. Physicians are accountable to their individual patients in a number of important ways. They provide clinical services to their patients and optimize their availability so that patients can be seen and their needs addressed in a timely fashion. They follow up on test results. They facilitate consultations with other physicians and care providers and follow up on the results of these consultations when needed. They ensure that patients have access to after hours and emergency care when they are not personally available. Physicians can also fulfill their obligation to be accountable to patients in other ways. They can participate in accreditation undertakings to ensure that their practices meet accepted standards. They can ensure, through lifelong learning and maintenance of competency activities, that they are making clinical decisions based on the best available evidence. They can undertake reviews of their prescribing profiles to ensure that they are consistent with best current standards. All of these activities can also be used to maximize consistencies within and between practices and minimize inter-practice variability where appropriate. Accountability to society and the health care system Physician accountability at this level is understandably more complex. In general, society and the health care system in Canada provide physicians with financial compensation, with a significant degree of clinical autonomy as reflected by professionally-led regulation, and with a high level of trust. In some cases, physicians are also provided with a facility in which to practice and with access to necessary resources such as MRIs and operating rooms. In return, physicians agree to make their own individual interests secondary in order to focus on those of their patients, and they agree to provide necessary medical services. Accountability then can be examined based on the extent that these necessary services are provided (i.e. patients have reasonable access to these services) and also the level of quality of those services. Clearly, neither access nor quality can be considered in isolation of the system as a whole, but for the purposes of this paper the focus will be on the role of the physician. The issue of level and comprehensiveness of service provision has been considered to some extent above under the concept of physician autonomy. Physicians as individuals and as a collective need to ensure that patients have access to timely medical care and follow up. They also need to make sure that the transition from one type of care to another (for example, from the hospital to the community setting) is as seamless as possible, within the current limitations of the system. Collectively and individually, physicians also have an obligation to make sure that the quality of the care they provide is of the highest standard possible. They should strive for a "just culture of safety", which encourages learning from adverse events and close calls to strengthen the system, and where appropriate, supports and educates health care providers and patients to help prevent similar events in the future.9 Thousands of articles and hundreds of books have been published on the subjects of quality assurance and quality improvement. From a physician perspective, we want to be able to have access to processes and resources that will provide us with timely feedback on the level of quality of our clinical care in a way that will help us optimize patient outcomes and will be seen as educational in nature rather than punitive. As a self-regulated profession, medicine already has strong accountability mechanisms in place to ensure the appropriate standards of care are maintained. To ensure that physicians are able to meet their obligation to be accountable to the health care system for high quality care, the CMA has developed a series of recommendations for Continuous Quality Improvement (CQI) activities (see box below). Physicians need to take ownership of the quality agenda. New medical graduates are entering practice having come from training systems where they have access to constant feedback on their performance, only to find themselves in a situation where feedback is non-existent or of insufficient quality to assist them in caring for their patients. While regulators and health care facilities have a legitimate interest in measuring and improving physician performance, ultimately physicians themselves must take responsibility for ensuring that they are providing their patients with the highest possible standard of care, and that mechanisms are in place to ensure that this is in fact the case. Accountability to colleagues Physicians are also accountable to their physician peers and to other health care providers. While much of this accountability is captured by the concept of "collegiality," or the cooperative relationship of colleagues, there are other aspects as well. Anecdotal evidence suggests strongly that many physician leaders find themselves marginalized by their peers. They describe being seen as having "gone over to the other side" when they decide to curtail or forego their clinical practices in order to participate in administrative and leadership activities. Physicians should instead value, encourage and support their peers who are dedicating their time to important undertakings such as these. As well, physicians should actively engage with their administrative colleagues when they have concerns or suggestions for improvement. Collaboration is absolutely vital to the delivery of safe and quality care. Physicians also need to make sure that they do everything they can to contribute to a "safe" environment where advocacy and CQI activities can be undertaken. This can mean encouraging physician colleagues to participate in these initiatives, as well as serving as a role model to peers by participating voluntarily in CQI undertakings. Physicians are also accountable to ensure that transition of care from one physician to another occurs in as seamless a manner as possible. This includes participating in initiatives to improve the quality and timeliness of both consultation requests and results, as well as ensuring professional and collegial communications with other physicians and with all team members. Finally, physicians need to support each other in matters of individual health and well-being. This can include support and care for colleagues suffering from physical or psychological illness, as well as assisting with accommodation and coverage for duty hours and professional responsibilities for physicians who are no longer able to meet the demands of full-time practice for whatever reason. Physician Leadership "You will not find a high performing health system anywhere in the world that does not have strong physician leadership." Dan Florizone, Deputy Minister of Saskatchewan Health As we can see from the discussion above, having strong physician leaders is absolutely critical to ensuring that the relationship between physicians and the health care system is one of mutual benefit. Physicians as a collective have an obligation to make sure that they support both the training required to produce strong physician leaders, as well as providing support for their colleagues who elect to undertake this increasingly important role. Physicians are well-positioned to assume leadership positions within the health care system. They have a unique expertise and experience with both the individual care of patients, as well as with the system as a whole. As a profession, they have committed to placing the needs of their patients above those of their own, and this enhances the credibility of physicians at the leadership level as long as they stay committed to this important value. Leadership is not just about enhancing the working life of physicians, but is about helping to ensure the highest possible standard of patient care within an efficient and well-functioning system. As part of their leadership activities, physicians need to ensure that they are consistently engaged with high quality and reliable partners, who will deliver on their promises and commitments, and that their input is carefully considered and used in the decision-making process. These partners can include those at the highest level of government, and must also include others such as medical regulators and senior managers. Without ensuring that they are speaking with the right people, physicians cannot optimize their leadership initiatives. Physician leadership activities must be properly supported and encouraged. Many physicians feel increasingly marginalized when important meetings or training opportunities are scheduled when they are engaged in direct patient care activities. Non-clinician administrators have time set aside for these activities and are paid to participate, but physicians must either miss these discussions in order to attend to the needs of their patients, or cancel clinics or operating room times. This means that patient care is negatively impacted, and it presents a (sometimes significant) financial disincentive for physicians to participate. Some jurisdictions have recognized this as a concern and are ensuring that physicians are compensated for their participation. Patients want their physicians to be more involved in policy-making decisions and this must be enabled through the use of proper funding mechanisms, reflective learning activities, continuing professional development credits for administrative training and participation, assisting in the appropriate selection of spokespersons including guidelines on how to select them, and guidelines for spokespersons on how to provide meaningful representation of the profession's views. Physician leadership training must take place throughout the continuum of medical education, from the early days of medical school through to continuing professional development activities for those in clinical practice. Physicians with an interest in and aptitude for leadership positions should ideally be identified early on in their careers and encouraged to pursue leadership activities and training through means such as mentorship programs and support from their institutions to attend training courses and meetings where they will be able to enhance and refine their leadership skills. There has been action on several fronts to support the organized professional development of physicians in leadership roles. Since the 1990s the Royal College of Physicians and Surgeons of Canada (RCPSC) has been implementing its CanMEDs framework of roles and competencies in the postgraduate medical training programs across Canada, and this has also been adopted by the College of Family Physicians of Canada (CFPC). The CanMEDs framework sets out seven core roles for physicians. Two that are most pertinent to the relationship between physicians and the health care system are those of manager and health advocate.10 These roles highlight the importance of physician involvement in leadership and system engagement activities, and are relevant for physicians in training as well as those in practice. As managers, physicians are integral participants in health care organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the health care system. As health advocates, physicians responsibly use their expertise and influence to advance the health of individual patients, communities and populations. A number of key enabling competencies have been identified for each role, and the RCPSC has developed a variety of resource materials to support the framework. For almost 30 years, the CMA has been offering the Physician Manager Institute (PMI) program in order to provide training for physicians pursuing leadership and management positions. PMI is offered in "open enrolment" format in major cities across Canada, and also "in house" through longstanding associations with hospitals and health regions (e.g., Calgary zone of Alberta Health Services [AHS]). In 2010 the CMA and the Canadian Society of Physician Executives introduced the Canadian Certified Physician Executive (CCPE) Program. The CCPE is a peer-assessed credential that can be attained either through an academic route that is based on completion of PMI courses or through a practice-eligibility route based on formal leadership experience.11 The CMA also partners with several provincial and territorial medical associations to provide leadership training. Currently CMA has agreements with the Saskatchewan, Ontario and Quebec medical associations and this will extend to the four Atlantic medical associations and the Alberta Medical Association/AHS in 2012. In addition, a number of university business schools have developed executive program offerings for health leaders. During the past decade, a number of physicians have taken up CEO positions in Canada's major academic health organizations. Internationally, it has been recognized that physician leadership is critical to the success of efforts to improve health services.12, 13 Having well trained and qualified physicians in leadership roles is critical in making sure that physicians continue to play a central role in the transformation of the Canadian health care system. The CMA and its membership unreservedly support our physician colleagues who dedicate their time and energies to these leadership activities and the CMA will continue to play an integral part in supporting and training the physician leaders of the future. CONCLUSION: THE CMA'S VISION OF THE NEW PROFESSIONAL RELATIONSHIP BETWEEN CANADIAN PHYSICIANS AND OUR HEALTH CARE SYSTEM We have explored the factors that have brought us to this point, as well as the issues that must be examined and addressed to enable us to move forward. It is now time for the physicians of Canada to commit to meaningful participation in the process of transforming our health care system. This can only be achieved through the concerted efforts of all parties, including governments, health authorities, health care facilities, physicians and other health care providers. It will not be easy, and it is not likely that this transformation will take place without commitment and sacrifice on our part. However, now is the time for physicians to demonstrate to their patients, to their colleagues and to society that they are willing to do their share and play their role in this critically important process, at this critically important time. Doing so will help them to achieve the CMA's vision of the new professional relationship between Canadian physicians and the health care system. In this vision: Physicians are provided with the leadership tools they need, and the support required, to enable them to participate individually and collectively in discussions on the transformation of Canada's health care system. Physicians are provided with meaningful opportunities for input at all levels of decision-making, with committed and reliable partners, and are included as valued collaborators in the decision-making process. Physicians recognize and acknowledge their individual and collective obligations (as one member of the health care team and as members of a profession) and accountabilities to their patients, to their colleagues and to the health care system and society. Physicians are able to freely advocate when necessary on behalf of their patients in a way that respects the views of others and is likely to bring about meaningful change that will benefit their patients and the health care system. Physicians participate on a regular and ongoing basis in well-designed and validated quality improvement initiatives that are educational in nature and will provide them with the feedback and skills they need to optimize patient care and outcomes. Patient care is team based and interdisciplinary with seamless transition from one care setting to the next and funding and other models are in place to allow physicians and other health care providers to practise within the full scope of their professional activities. REFERENCES __________________________ 1. Canadian Medical Association. CMA Code of Ethics. http://policybase.cma.ca/PolicyPDF/PD04-06.pdf. Accessed 05/20/11. 2. ABIM Foundation. Medical professionalism in the new millennium: a physician charter. Annals of Internal Medicine 2002; 136(3): 243-6. 3. Lesser C, Lucey C, Egener B, Braddock C, Linas S, Levinson W. A behavioral and systems view of professionalism. JAMA 2010; 304(24): 2732-7. 4. Canadian Medical Association. Medical professionalism 2005 update. http://policybase.cma.ca/dbtw-wpd/Policypdf/PD06-02.pdf. Accessed 06/03/11. 5. Canadian Medical Protective Association. Changing physician : hospital relationships. Managing the medico-legal implications of change. 2011. https://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/com_2011_changing_physician-e.cfm. Accessed 02/07/12. 6. Thrall JH. Changing relationship between radiologists and hospitals Part 1: Background and major issues. Radiology 2007; 245: 633-637. 7. Reichenbach L, Brown H. Gender and academic medicine: impact on the health workforce. BMJ. 2004; 329: 792-795. 8. Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: what is it and how do we do it? Acad Med 2010 Jan; 85(1): 63-7. 9. Canadian Medical Protective Association. Learning from adverse events: Fostering a just culture of safety in Canadian hospitals and health care institutions. 2009. http://www.cmpa-acpm.ca/cmpapd04/docs/submissions_papers/com_learning_from_adverse_events-e.cfm. Accessed 02/07/12. 10. Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 Framework. http://rcpsc.medical.org/canmeds/bestpractices/framework_e.pdf. Accessed 05/20/11. 11. Canadian Society of Physician Executives and Canadian Medical Association. Canadian Certifies Physician Executive. Candidate Handbook. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Leadership/CCPE/2012CCPE-Handbook_en.pdf. Accessed 05/20/11. 12. Ham C. Improving the performance of health services: the role of clinical leadership. Lancet 2003; 361: 1978-80. 13. Imison C, Giordano R. Doctors as leaders. BMJ 2009; 338: 979-80.
Documents
Less detail

Vision for e-Prescribing: a joint statement by the Canadian Medical Association and the Canadian Pharmacists Association

https://policybase.cma.ca/en/permalink/policy10670
Last Reviewed
2019-03-03
Date
2012-12-08
Topics
Health information and e-health
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2012-12-08
Topics
Health information and e-health
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Vision for e-Prescribing: a joint statement by the Canadian Medical Association and the Canadian Pharmacists Association By 2015, e-prescribing will be the means by which prescriptions are generated for Canadians. Definition e-Prescribing is the secure electronic creation and transmission of a prescription between an authorized prescriber and a patient's pharmacy of choice, using clinical Electronic Medical Record (EMR) and pharmacy management software. Background Health Information Technology (HIT) is an enabler to support clinicians in the delivery of health care services to patients. The Canadian Medical Association (CMA) and the Canadian Pharmacists Association (CPhA) each have identified e-prescribing as a key tool to deliver better value to patients. The integration of HIT into clinics and health care facilities where physicians and pharmacists provide care is a priority for both associations1. As part of its Health Care Transformation initiative, the CMA highlighted the need to accelerate the introduction of e-prescribing in Canada to make it the main method of prescribing. In its policy on optimal prescribing the CMA noted that one of the key elements was the introduction of electronic prescribing. The CPhA, as part of its Blueprint for Pharmacy Implementation Plan, highlights information and communication technology, which includes e-prescribing, as one of five priority areas. We applaud the ongoing efforts of Canada Health Infoway, provinces and territories to establish Drug Information Systems (DIS) and the supporting infrastructure to enable e-prescribing. We urge governments to maintain e-prescribing as a priority and take additional measures to accelerate their investments in this area. It is our joint position that e-prescribing will improve patient care and safety. e-Prescribing, when integrated with DIS, supports enhanced clinical decision-making, prescribing and medication management, and integrates additional information available at the point of care into the clinical workflow. Principles The following principles should guide our collective efforts to build e-prescribing capability in all jurisdictions: * Patient confidentiality and security must be maintained * Patient choice must be protected * Clinicians must have access to best practice information and drug cost and formulary data * Work processes must be streamlined and e-prescribing systems must be able to integrate with clinical and practice management software and DIS * Guidelines must be in place for data sharing among health professionals and for any other use or disclosure of data * The authenticity and accuracy of the prescription must be verifiable * The process must prevent prescription forgeries and diversion * Pan-Canadian standards must be set for electronic signatures Benefits of e-Prescribing A number of these benefits will be realized when e-prescribing is integrated with jurisdictional Drug Information Systems (DIS). * Patients: o Improves patient safety and overall quality of care o Increases convenience for dispensing of new and refill prescriptions o Supports collaborative, team-based care * Providers: o Supports a safer and more efficient method of prescribing and authorizing refills by replacing outdated phone, fax and paper-based prescriptions o Eliminates re-transcription and decreases risk of errors and liability, as a prescription is written only once at the point-of-care o Supports electronic communications between providers and reduces phone calls and call-backs to/from pharmacies for clarification o Provides Warning and Alert systems at the point of prescribing, supporting clinician response to potential contraindications, drug interactions and allergies o Facilitates informed decision-making by making medication history, drug, therapeutic, formulary and cost information available at the point of prescribing * Health Care System: o Improves efficiency and safety of prescribing, dispensing and monitoring of medication therapy o Supports access to a common, comprehensive medication profile, enhancing clinical decision-making and patient adherence o Increases cost-effective medication use, through improved evidence-based prescribing, formulary adherence, awareness of drug costs and medication management o Improves reporting and drug use evaluation Challenges While evidence of the value of e-prescribing is established in the literature, its existence has not fostered broad implementation and adoption. In Canada, there are a number of common and inter-related challenges to e-prescribing's implementation and adoption. These include: * Improving access to relevant and complete information to support decision-making * Increasing the level of the adoption of technology at the point of care * Focusing on systems-based planning to ensure continuum-wide value * Integrating e-prescribing into work processes to gain support from physicians, pharmacists and other prescribers * Increasing leadership commitment to communicate the need for change, remove barriers and ensure progress * Updating legislation and regulation to support e-prescribing Enabling e-Prescribing in Canada CMA and CPhA believe that we can achieve the vision that is set out in this document and address the aforementioned challenges by working collectively on five fronts: * Health care leadership in all jurisdictions and clinical organizations must commit to make e-prescribing a reality by 2015 * Provinces and territories, with Canada Health Infoway, must complete the building blocks to support e-prescribing by increasing Electronic Medical Record (EMR) adoption at the point of care, finishing the work on the Drug Information Systems (DIS) in all jurisdictions and building the connectivity among the points of care and the DIS systems * Pharmacist and medical organizations in conjunction with provinces, territories and Canada Health Infoway must identify clear benefits for clinicians (enhancing the effectiveness of care delivery and in efficiencies in changing workflows) to adopt e-prescribing and focus their efforts on achieving these benefits in the next three years * Provinces, territories and regulatory organizations must create a policy/regulatory environment that supports e-prescribing which facilitates the role of clinicians in providing health care to their patients * Provinces and territories must harmonize the business rules and e-health standards to simplify implementation and conformance by software vendors and allow more investment in innovation. 1 Health Care Transformation in Canada, Canadian Medical Association, June 2010; Blueprint for Pharmacy Implementation Plan, Canadian Pharmacists Association, September 2009
Documents
Less detail

17 records – page 1 of 2.