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Active Transportation

https://policybase.cma.ca/en/permalink/policy9483
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2009-05-31
Topics
Population health/ health equity/ public health
Text
The major diseases affecting the quality and quantity of life of Canadians, which include obesity, diabetes, coronary artery disease, depression and cancer, are all linked to physical inactivity. In Canada, 69% of women and 68% of men in Canada are considered physically inactive.(1) The cost of this inactivity and obesity was estimated at $4.3 billion in 2001.(2) A 10% increase in physical activity could potentially reduce direct health care expenditures by $150 million a year. This does not include indirect costs such as lost productivity due to illness, premature death or a range of other factors, including mental illness and poor quality of life.(3) Thus far, efforts to increase physical activity by changing the behaviour of individuals have had limited success. One reason is that many people have difficulty sustaining behaviours that involve additional time commitments. That is one reason for the increasing emphasis being placed on active transportation, which is any human-powered form of transportation, such as walking and cycling. Walking and cycling can be efficient alternatives to automobile travel. Cycling is usually the fastest mode of travel door to door for distances under five km, and for up to 10 km in city cores. Walking is simpler and nearly as fast for distances up to two km. When travel times are similar for active and motorized transportation, physical activity is gained with no net time lost, and at much lower cost. The cost of operating a motor vehicle is typically $10,000 per year,(4) while operating costs for a bicycle are much lower. Communities that have sidewalks, enjoyable scenery, street lights and nearby stores have improved levels of active transportation and physical activity. However, in recent decades communities have often been designed around the automobile. Street design, parking space, sidewalks and distance to retail destinations have all been planned assuming motorized transportation, and this often makes it difficult to move around communities by walking or cycling. Although individual decision-making remains important in any strategy for increasing active transportation, there is an essential role for communities and governments to play. Major improvements in the health of Canadians in the past 200 years have been due to improved sanitation, access to clean water and injury prevention. The role of individual decision-making in effecting these changes is dwarfed by the impact of the public health measures and infrastructure involved. Just as potable tap water is a health issue, so are decisions about land use, transportation policy and infrastructure. Community design is a major determinant of whether people use active transportation, whether they are physically active and whether they are obese. Canadians need communities that make it easy to be physically active in their daily living. Communities can create an environment in which the physically active choice is the easy choice. They can do this via sidewalks, trails, bicycle lanes and bicycle paths, and by providing pedestrian-friendly intersections, parks and green spaces, and safe bicycle parking spaces. They can also arrange zoning so that retail destinations are within walking or cycling distance of residential areas. This process also includes dedicating a sufficient portion of their street maintenance budget (including snow clearing) to maintaining active transportation routes as well as routes for motorized vehicles. It may include redesigning intersections, giving up vehicle lanes or parking spaces, or increasing the price of parking. Additional benefits to designing communities for pedestrians and cyclists. * a stronger sense of community with greater civic involvement by citizens * increased property values and retail activity * less noise pollution * lower crime rates * less smog and other air pollution * less greenhouse gas production * decreased risk of injury to pedestrians and cyclists * decreased costs of roadway and parking construction. A role for everyone Other sectors can support communities in making active transportation choices easy choices: * Businesses can create a work environment friendly to active transportation, including a corporate culture friendly to physical activity. They can incorporate active transportation planning into building design and create an environment friendly to physical activity. These steps could include making bicycle parking, showers and lockers available, and providing stairs that are pleasant and easier to access than elevators. They can also incorporate a culture of physical activity in decisions about where and how to hold meetings, and what people are allowed to wear to work. * School boards can develop policies to promote active transportation to and from school. These include building and maintaining secure bicycle parking, ensuring safe walking routes within communities, and assisting parents in walking their children to school. * Citizens can use active transportation themselves and treat with respect those who are already making active transportation choices. They can also lobby governments to make their community safer and easier places for cycling and walking. * Physicians can encourage patients to use active transportation as a way to boost their physical activity levels and improving their health. They can also lead by example and use active transportation themselves. Recommendations The CMA recommends that all sectors (government, business and the public) work together, as a matter of priority, to create a culture in their communities that supports and encourages active transportation. The CMA urges governments to: * Commit to long-term plans for active transportation networks that are in keeping with these goals and that include specific benchmarks to measure progress. * Require that active transportation be part of all infrastructure renewal projects, with investment in active transportation vs. motorized transportation in proportion to targeted active transportation use. (Some cities have achieved active transportation rates of up to 15%.) * Develop an awareness campaign to help Canadians to recognize the value of active transportation in their communities. * Require public health impact assessments for all land-use and transportation decisions, including the impact on the chemical environment and on physical activity. * Assess the impact that changes in the "built" environment can have on public health, and which interventions are most safe and effective. 1 Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in overweight and obesity in Canada, 1981-1996. Int J Obes Relat Metab Disord 2002;26(4):538-43. 2 Katzmarzyk PT, Janssen I. The economic costs associated with physical inactivity and obesity in Canada: an update. Can J App Phys 2004;29(1):104. 3 Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada. CMAJ 2000;163(11): 1435-40. 4 Canadian Automobile Association. Driving Costs: 2005 Edition. Available: www.carpool.ca/pdf/CAA-driving-costs-05.pdf (accessed 2007 Feb. 2).
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Funding the continuum of care

https://policybase.cma.ca/en/permalink/policy9719
Last Reviewed
2018-03-03
Date
2009-12-04
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2009-12-04
Topics
Health systems, system funding and performance
Text
FUNDING THE CONTINUUM OF CARE The continuum of care may be defined as the array of health services that spans the range over the life course from primary care (including prevention and health promotion) through institutionally based secondary and tertiary care to community and home-based services that promote health maintenance, rehabilitation and palliation at the end of life. Given the ever-increasing diversity of service offerings and providers, and aging populations, governments worldwide face the ongoing challenge of what to fund for whom. After a lengthy period of examination that began in the 1930s, Canada arrived at a social consensus on universal, first-dollar coverage provision of hospital (1957)1 and physician (1966)2 services. All provinces bought into "Medicare" by the early 1970s and the 1984 Canada Health Act (CHA)3 was the capstone of the national hospital and medical insurance program, adding the principle of accessibility, which effectively prohibited user charges for insured hospital and physician services. Notwithstanding the more recent legislation, the foundation of Medicare was set in the health and health care reality of 1957. Hospital and medical services accounted for two-thirds of health spending (65%).4 Prescription drugs accounted for just 6% of spending, less than half of their 14.6% share in 2008. Life expectancy was almost a decade shorter than it is today, hence there was less concern about long-term care. The first knee replacement was not done until a decade later. The 1957 Hospital and Diagnostic Services Act specifically excluded tuberculosis hospitals, sanitaria and psychiatric hospitals as well as nursing homes/homes for the aged. These exclusions carried forward to the CHA. By all accounts the CHA has taken on an iconic status, but at the same time it is agreed that it is an impediment to modernizing Medicare through its definitions and program criteria and how they are interpreted by the provinces and territories. The CHA narrowly defines insured health services as "hospital services, physician services and surgical dental services provided to insured persons." While the CHA recognizes "extended" health services such as home care and ambulatory health care services, these are not subject to the program criteria. Over the years, the CHA has been extremely effective in preserving the publicly funded character of physician and hospital services. As of 2008, the Canadian Institute for Health Information (CIHI) has estimated that 98.4% of physician and 90.7% of hospital expenditures are publicly funded.5 The dividing line of the CHA may be seen in virtually all other categories of service. Fewer than one-half of prescription drugs (44.5%) and less than one-tenth (6.9%) of the services of other health professionals (e.g., dentistry and vision care) are publicly covered. Canada is unique among industrialized countries in its approach to Medicare. Countries with social insurance (Bismarck) funded systems tend to provide a similar total level of public expenditure over a wider range of services. Over time, as health care has moved from institutions to the community, the CHA is diminishing with respect to the share of total health spending it covers. At the time the CHA was passed, physician and hospital services represented 57% of total health spending; this has declined to 41% as of 2008. It must be emphasized that there is significant public spending beyond CHA-covered services (in excess of 25% of total spending) for programs such as seniors' drug coverage and home care; however, those programs are not subject to the CHA's program criteria. In addition, they can be subject to arbitrary cutback. While a majority of the working age population and their families are covered by private health insurance, those with lower incomes are less likely to have such benefits. Since the late 1990s, notwithstanding the widely shared concern about the sustainability of Canada's Medicare program, several high profile studies have advocated for its expansion, starting with the 1997 Report of the National Forum on Health6 and latterly with the Kirby7 and Romanow8 reports in 2002, both of which strongly recommended home care and catastrophic drug coverage. There is also growing concern about the availability of so-called "orphan drugs" that treat rare diseases such as Fabry disease, and can cost hundreds of thousands of dollars per patient for a single year of treatment. First Ministers have concluded three health accords in 20009, 200310 and 200411, each of which addresses expanding the boundaries of Medicare. To date there are a series of unfulfilled commitments from these accords, including a national basket of home care services and first-dollar coverage for home care and catastrophic drug coverage. In its 2007 report, the Health Council of Canada summarized progress on catastrophic drug costs as "disappointing."12 There is no appetite among governments in Canada to implement new universal programs with first-dollar coverage. In fact, recently governments have removed services that had previously been publicly insured, as evidenced by recent examples such as physiotherapy and chiropractic services in some jurisdictions. General Principles The CMA puts forward the following principles for funding the continuum of care in a national context, recognizing that there will continue to be a mix of public-private funding. * Canadians should take personal responsibility to plan ahead for the contingency that they may eventually require support with their activities of daily living; * home care and long-term care should be delivered in appropriate and cost-effective settings that respect patient and family preferences; * there should be quality and accreditation standards for both public and private service delivery; * there should be uniform approaches to needs assessment for home care and long-term care; * there should be a uniform means of distinguishing the medically necessary component of home care and long-term care from the accommodation component; * there should be a means of mitigating against open-ended public coverage of pharmaceutical, home care and long-term care coverage; * there should be recognition and financial support for informal care givers; * there should be consideration of risk-pooling, risk adjustment and risk sharing1 between public and private funders/providers of pharmaceutical, home care and long-term care coverage; * there should be a uniform approach to individual/household cost-sharing (e.g., copayments and deductibles); and * provision should be made for pre-funding long-term care from public and private sources. Prevention and Health Promotion The continuum of care begins with prevention and this requires a strong public health foundation that includes the core elements of population health assessment, health surveillance, health promotion, disease and injury prevention and health protection.13 An investment in public health, including health promotion and disease prevention, is critical to the future health of Canadians. One important component of effective prevention is immunization. The National Immunization Strategy was implemented in 2001 with the goal of reducing vaccine preventable diseases and improving vaccine coverage rates. The 2004 federal budget allocated $400 million to support this strategy and in 2007, $300 million was set aside in the federal budget for a Human Papillomavirus Immunization program. However, permanent funding should be allocated towards immunization programs for all illnesses that are preventable through vaccinations. The federal government also has a role to play in establishing and promoting partnerships that will enhance prevention and promotion programming down to the local level. The CMA recommends that: the federal government continue funding of the national immunization strategy consistent with the original three-year funding program; governments fund appropriate additions to the vaccination schedule, as new vaccines are developed, within the context of a national immunization strategy; and the federal government establish a Public Health Infrastructure Renewal Fund ($350 million annually) to build partnerships between all levels of government to build capacity at the local level. Pharmaceuticals Prescription drugs are the fastest growing item in the health envelope. Over the past two decades, prescription drugs as a proportion of total health spending have doubled from 7% in 1986 to an estimated 14.6% in 2008, and they are now the second largest category of health expenditure. It is estimated that less than one-half (44.5%) of prescription drug costs were paid for publicly in 2008; just over one-third (37.1%) were paid by private insurers and almost one-fifth (18.4%) out-of-pocket. The studies reported in 2002 by the Senate Standing Committee on Social Affairs, Science and Technology (Kirby) and by the Commission on the Future of Health Care in Canada (Romanow) have forged a consensus on the need for "catastrophic" pharmaceutical coverage, which may be defined as out-of-pocket prescription drug expenditures that exceed a certain threshold of household income. In the Kirby proposal, in the case of public plans, personal prescription drug expenses for any family would be capped at 3% of total family income. The federal government would then pay 90% of prescription drug expenses in excess of $5,000. In the case of private plans, sponsors would have to agree to limit out-of-pocket costs to $1,500 per year, or 3% of family income (whichever is less). The federal government would then agree to pay 90% of drug costs in excess of $5,000 per year. Both public and private plans would be responsible for the difference between out-of-pocket and $5,000, and private plans would be encouraged to pool their risk. Kirby estimated that this plan would cost approximately $500 million per year. For his part, Romanow recommended a Catastrophic Drug Transfer through which the federal government would reimburse 50% of the costs of provincial and territorial drug insurance plans above a threshold of $1,500 per year. Romanow estimated that this would cost approximately $1 billion. The National Pharmaceuticals Strategy (NPS) has continued to explore cost projections of catastrophic pharmaceutical coverage, leaning toward a variable percentage threshold linked to income but there has been no public reporting on progress since 2006.14 At their September 2008 meeting, provincial/territorial health ministers called for the federal government to be an equal partner (50/50) to support a national standard of pharmacare coverage so that prescription drug costs will not exceed 5% (on average) of the net income base of provincial/territorial populations. The total estimated cost of such a program for 2006 was estimated at $5.03 billion.15 Data from Statistics Canada indicate that there is wide variation in levels of household spending on prescription drugs in Canada. In 2006 almost one in twenty (3.8%) households in Canada spent more than 5% of net income on prescription drugs; there was almost a five-fold variation across the provinces, ranging from 2.2% in Ontario to 10.1% in Prince Edward Island.16 Canada does not have a nationally coordinated policy in the area of very costly drugs that are used to treat rare diseases. Moreover, there is also an issue of expensive drugs that may be used for common diseases (wide variation has been documented across provinces/territories). Thus far the term "catastrophic" has been used by First Ministers and the NPS to describe their vision of national pharmaceutical coverage. As defined by the World Health Organization catastrophic expenditure reflects a level of out-of-pocket health expenditures so high that households have to cut down on necessities such as food and clothing and items related to children's education.17 From the CMA's perspective, this does not go far enough and what must be strived for is "comprehensive" coverage that covers the whole population and effectively pools risk across individuals and public and private plans in various jurisdictions. The CMA recommends that: governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies; such a program should include the following elements: * a mandate for all Canadians to have either private or public coverage for prescription drugs; * a uniform income-based ceiling (between public and private plans and across provinces/territories) on out-of-pocket expenditures on drug plan premiums and/or prescription drugs (e.g., 5% of after-tax income); * FPT cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal share of reimbursement or by scaling the household income ceiling or both; * group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size; and, * a continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs); the federal government establish a program for access to expensive drugs for rare diseases where those drugs have been demonstrated to be effective; the federal government assess the options for risk pooling to cover the inclusion of expensive drugs in public and private drug plan formularies; the federal government provide adequate financial compensation to the provincial and territorial governments that have developed, implemented and funded their own public prescription drug insurance plans; governments provide comprehensive coverage of prescription drugs and immunization for all children in Canada; and the Canadian Institute for Health Information and Statistics Canada conduct a detailed study of the socio-economic profile of Canadians who have out-of-pocket prescription drug expenses to assess barriers to access and to design strategies that could be built into a comprehensive prescription drug coverage program. Home Care Home care began in Canada in the late 19th century as a charitable enterprise delivered by non-profit groups such as the Victorian Order of Nurses. In the expansionary period of the 1960s and 1970s, governments moved increasingly into this area. The New Brunswick Extra-Mural Program, arguably Canada's most successful/ambitious home care program, accepted its first clients in 1981. The Established Programs Financing Act of 1977 recognized home care as one of several extended health services and included a fund initially set at $20 per capita to cover such services. These extended services are also recognized in the CHA but are not subject to the five program criteria (principles). The 1997 Report of the National Forum on Health recommended that home care be added to Medicare (along with pharmacare). The $150 million Health Transition Fund supported several demonstration projects in the home care area. Both the Kirby and Romanow reports recommended expanded home care funding. In February 2003, First Ministers concluded an accord in which they committed to determine a basket of home care services by 30 Sept. 2003, covering short-term acute home care, community mental health and end-of-life care. To date this has not happened. The federal government implemented a Compassionate Care Benefit in 2003 to support family caregivers; however, this only applies to those who are in the paid labour force.18 According to the Canadian Institute for Health Information, there is almost a five-fold variation in the use of home care across provinces/territories.19 The extent of private expenditure on home care services is not presently known. However, Statistics Canada has reported that the proportion of Canadians living in the community who require assistance with their personal activities of eating, bathing and dressing who are receiving government-subsidized home care declined from 46% in 1994-1995 to 35% in 2003; the suggestion is that some of the burden may have shifted to home care agencies or family and friends.20 Statistics Canada has reported that in 2002, over 1.7 million adults aged 45 to 64 provided informal care to almost 2.3 million seniors with long-term disabilities or physical limitations.21 In light of the foregoing, the CMA believes that: optimal management of the continuum of care requires that patients take an active part in developing their care and treatment plan, and in monitoring their health status; the issue of the continuum of care must go beyond the question of financing and address questions related to the organization of the delivery of care and to the shared and joint responsibilities of individuals, communities and governments in matters of health care and promotion, prevention and rehabilitation; support systems should be established to allow elderly and disabled Canadians to optimize their ability to live in the community; strategies should be implemented to reduce wait times for accessing publicly funded home and community care services; integrated service delivery systems should be created for home and community care services; and any request for expanding the public plan coverage of health services, in particular for home care services and the cost of prescription drugs, must include a comprehensive analysis of the projected cost and potential sources of financing for this expansion. The CMA recommends that: governments adopt a policy framework and design principles for access to publicly funded medically necessary services in the home and community setting that can become the basis of a "Canada Extended Health Services Act;" governments initiate a national dialogue on the Canada Health Act in relation to the continuum of care; governments and provincial/territorial medical associations review physician remuneration for home and community-based services; and governments undertake pilot studies to support informal caregivers and long-term care patients, including those that: a) explore tax credits and/or direct compensation to compensate informal caregivers for their work, b) expand relief programs for informal caregivers that provide guaranteed access to respite services in emergency situations, c) expand income and asset testing for residents requiring assisted living and long-term care, and d) promote information on advance directives and representation agreements for patients. Mental Health Care In 2000 mental illness was the fourth-ranking contributor to the total economic burden of illness in Canada.22 The exclusion of psychiatric hospitals from the CHA means that they are not subject to the five principles and were not included in the original basis of the federal transfer payments. While a major Senate Committee report has pointed out that the closure of psychiatric facilities means that this exclusion is no longer pertinent, the Committee also noted that many essential services for persons with mental illness such as psychological services or out-of-hospital drug therapies are not covered under provincial health insurance plans.23 Moreover, there remain 53 psychiatric hospitals in Canada.24 The CMA recommends that: the federal government make the legislative and/or regulatory amendments necessary to ensure that psychiatric hospital services are subject to the five program criteria of the Canada Health Act; in conjunction with legislative and/or regulatory changes, funding to the provinces/territories through the Canada Health Transfer be adjusted to provide for federal cost sharing in both one-time investment and ongoing cost of these additional insured services; and Canadian physicians and their organizations advocate for parity of allocation of resources (relative to other diseases) toward the continuum of mental health care and research. Long-term Care According to Statistics Canada's most recent population projections, the proportion of seniors in the population (65+) is expected to almost double from its present level of 13% to between 23% and 25% by 2031.25 The Organization for Economic Cooperation and Development has projected that the share of Gross Domestic Product devoted to long-term care will at least double from its 2005 level of 1.2% to 2.4% by 2050, and could almost triple to (3.2%) depending on the success of efforts to contain cost.26 The potential need for long-term care is not confined to the senior population. Based on the results of its 2006 Participation and Activity Limitation Survey, Statistics Canada estimated that there were 2 million adults aged 15-64 with disabilities, of whom 40% were severely disabled; in addition there were 202,000 children with disabilities, of whom 42% were severely disabled.27 A lack of appropriate long term care is imposing a bottleneck in the acute care system. The term Alternate Level of Care (ALC) is used to describe a situation when a patient is occupying a bed in a hospital and does not require the acute care provided in this setting. According to a 2009 CIHI report, in 2007-08, there were more than 74,000 ALC patients and more than 1.7 million ALC hospital days in Canada (excluding Manitoba and Quebec), accounting for 5% of hospitalizations and 14% of hospital days. In other words, every day almost 5,200 beds in acute care hospitals were occupied by ALC patients28. This has significant consequences; emergency departments are being used as holding stations while admitted patients wait for a bed to become available, surgeries are being postponed, and the care for ALC patients may not be as good as it might be in an alternate site that is better equipped to suit their specific needs. Insufficient access to long term care at all ages is an obstacle to improving the health care system. Major investment is required in community and institutionally based care. Most of the discussion in Canada since the mid-1990s has focused on the sustainability of the current Medicare program and the prospect for enhancements such as pharmacare. There has been little attention since the early 1980s on the future funding of long-term care. Internationally, in contrast, the United Kingdom has had a Royal Commission on long-term care, and Germany has moved to put in place a contributory social insurance fund. A cursory assessment of the literature would suggest that there is a consensus that long-term care cannot/should not be financed on the same pay-as-you-go basis (i.e., current expenditures funded out of current contributions) as medical/hospital insurance programs. The federal government has several options available to promote the pre-funding of long-term care: Long-term care insurance: Policies are offered in Canada and are of fairly recent origin. There has been little take-up of such policies to date. At the end of 2005, about 52,700 Canadians were covered under long-term care insurance. One option could be to make long-term care insurance premiums deductible through a tax credit, similar to what Australia has done for private health insurance. Tax-deferred savings: The Registered Retirement Savings Plan (RRSP) has been a very popular method for Canadians to save for retirement. As of 2007, an estimated 7 out of 10 (68%) of Canadians reported having an RRSP. However, in 2002, just 27% of all tax returns filed in Canada reported deductions for RRSP contributions. In 1998, Segal proposed a Registered Long-term Care Plan that would allow Canadians to save against the possibility of their need for a lengthy period of care. Another option to consider would be to add a provision to RRSPs similar to the Lifelong Learning Plan and the Home Buyer's Plan. This would be referred to as the Long-term Care Plan and would allow tax-free withdrawals from RRSPs to fund long-term care expenses for either the RRSP investor's own care or their family members' care. Tax-prepaid saving: In Canada, the Registered Education Savings Plan (RESP) is an example of a plan whereby after-tax earnings are invested and allowed to grow tax-free until they are distributed and included in the recipient's income. In the 2007 federal budget, the government announced the introduction of a Registered Disability Savings Plan. Parents and guardians will be able to contribute to a lifetime maximum of $200,000 and similar to the RESP program there will be a related program of disability grants and bonds, scaled to income. This approach could have more general applicability to long-term care. The 2008 federal budget has introduced a tax-free savings account (TFSA) that, starting in 2009, enables those 18 and over to contribute up to $5,000 per year in after-tax income to a TFSA, whose investment growth will not be taxed; however, funds can be withdrawn at any time for any purpose29. Payroll deduction (Social Insurance): A compulsory payroll tax that would accumulate in a separate fund along the lines of the Canada Pension Plan has been recommended in provincial reports in Quebec and Alberta. In summary, whatever vehicle might be chosen, governments need to impress upon younger Canadians the need to exercise personal responsibility in planning for their elder years, given continuing gains in longevity. The CMA recommends that: governments study the options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance; and the federal government review the variability in models of delivery of community and institutionally based long-term care across the provinces and territories as well as the standards against which they are regulated and accredited. End-of-life Care The Senate of Canada, and the Honourable Sharon Carstairs in particular, have provided leadership over the last decade in highlighting both the progress and the persistent variability across Canada in access to quality end-of-life care. In the latest (2005) of three reports issued since 1995, the Senate again calls for the development of and support for a national strategy for palliative and end-of-life care.30 In that report Still Not There it is noted that it is commonly estimated that no more than 15% of Canadians have access to hospice palliative care, and that for children, the figure drops further to just over 3%. To date, palliative care in Canada has primarily centred on services for those dying with cancer. However, cancer accounts for less than one-third (30%) of deaths in Canada. Diseases at the end of life such as dementia and multiple chronic conditions are expected to become much more prevalent in the years ahead. The demand for quality end-of-life care is certain to increase as the baby boom generation ages. By 2020 it is estimated that there will be 40% more deaths per year. While there has been a decreasing proportion of Canadians dying in hospital over the past decade, many more Canadians would prefer to have the option of hospice palliative care at the end of life than current capacity will permit. In its April 2009 report, the Special Senate Committee on Aging recommended a federally funded national partnership with provinces, territories and community organizations to promote integrated quality end-of-life care for all Canadians, the application of gold standards in palliative home care to veterans, First Nations and Inuit and federal inmates, and renewed research funding for palliative care.31 The CMA recommends that: governments work toward a common end-of-life care strategy that will ensure all Canadians have equitable access to and adequate standards of quality end-of-life care. References 1 Risk pooling is defined by the World Health Organization as the practice of bringing several risks together for insurance purposes in order to balance the consequences of the realization of such individual risk. Risk adjustment and risk sharing are means of adjusting or compensating for risk differentials between risk pools. 1 Canada. Hospital Insurance and Diagnostic Services Act. Statutes of Canada 1956-57 Chap 28. Ottawa: Queen's Printer, 1957. 2 Canada. Medical Care Act 1966-67, C. 64, 5.1. Revised Statutes of Canada 1970 Volume V. Ottawa: Queen's Printer, 1970. 3 Canada. Canada Health Act. Chapter C - 6. Ottawa, 1984. 4 Hall, E. Royal Commission on Health Services, Volume 1. Ottawa: Queen's Printer, 1964. 5 Canadian Institute for Health Information. National Health Expenditure Trends 1975-2008. Ottawa, 2008. 6 National Forum on Health. Canada Health Action: Building on the legacy - Volume 1 - the final report. Ottawa: Minister of Public Works and Government Services, 1997. 7 Standing Senate Committee on Social Affairs, Science and Technology. The health of Canadians - the federal role Volume six: recommendations for reform. Ottawa, 2002. 8 Commission on the Future of Health Care in Canada. Building values: the future of health care in Canada. Ottawa, 2002. 9 Canadian Intergovernmental Conference Secretariat. First Ministers' meeting communiqué on health. September 11, 2000. http://www.scics.gc.ca/cinfo00/800038004_e.html. Accessed 09/24/09. 10 Canadian Intergovernmental Conference Secretariat. 2003 First Ministers' Accord on Health Care Renewal. February 5, 2003. http://www.scics.gc.ca/pdf/800039004_e.pdf. Accessed 08/05/08. 11 Canadian Intergovernmental Conference Secretariat. A 10-Year plan to strengthen health care. September 16, 2004. http://www.scics.gc.ca/cinfo04/800042005_e.pdf. Accessed 08/05/08. 12 Health Council of Canada. Health care renewal in Canada: Measuring up? Toronto, 2007. 13 Canadian Institutes of Health Research. The future of public health in Canada: Developing a public health system for the 21st century. Ottawa, 2003. 14 Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceuticals Strategy. National Pharmaceuticals Strategy Progress Report. June 2006. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 08/05/08. 15 Canadian Intergovernmental Conference Secretariat. Backgrounder: National Pharmaceutical Strategy Decision Points. September 24, 2009. http://www.scics.gc.ca/cinfo08/860556005_e.html. Accessed 09/24/09. 16 Statistics Canada. Survey of Household Spending 2006. Detailed table 2, 62FPY0032XDB. 17 Xu K, Evans D, Carrin G, Aguilar-Riviera A. Designing health financing systems to reduce catastrophic health expenditure. Geneva: World Health Organization, 2005. 18 Service Canada. Employment insurance (EI) compassionate care benefits. http://142.236.154.112/eng/ei/types/compassionate_care.shtml. Accessed 09/24/09. 19 Canadian Institute for Health Information. Public sector expenditures and utilization of home care services in Canada: exploring the data. Ottawa, 2007. 20 Wilkins K. Government-subsidized home care. Health Reports 2006;17(4):39-42. 21 Pyper W. Balancing career and care. Perspectives on labour and income 2006;18(4): 5-15. 22 Public Health Agency of Canada. Table 2 Summary - Economic burden of illness in Canada by diagnostic category, 2000. Ottawa, 2000. 23 Standing Committee on Social Affairs, Science and Technology. Out of the shadows at last: transforming mental health, mental illness and addiction services in Canada. Ottawa, 2006. 24 Canadian Healthcare Association. September 2009. 25 Statistics Canada. Population projections. The Daily, Thursday, December 15, 2005. 26 Organization for Economic Co-operation and Development. Projecting OECD health and long-term care expenditures. What are the main drivers? Paris, 2006. 27 Statistics Canada. Participation and Activity Limitation Survey 2006: Tables. Catalogue no. 89-628-XlE-No. 003. Ottawa: Minister of Industry, 2007. 28 Canadian Institute for Health Information. Alternate level of care in Canada. Ottawa, 2009. 29 Canada Revenue Agency. Tax-free savings account (TFSA). http://www.cra-arc.gc.ca/E/pub/tg/rc4466/rc4466-e.html#P44_1114. Accessed 09/24/09. 30 Carstairs S. Still not there. Quality end-of-life care: a status report. http://sen.parl.gc.ca/scarstairs/PalliativeCare/Still%20Not%20There%20June%202005.pdf. Accessed 09/24/09. 31 Special Senate Committee on Aging. Final report: Canada's aging population: Seizing the opportunity. Apr 2009.
Documents
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The health of Aboriginal peoples 2002

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

https://policybase.cma.ca/en/permalink/policy11890
Date
2016-05-20
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Date
2016-05-20
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
One in five Canadians suffer from a mental health problem or illness in any given year. Mental illness costs Canada over $50 billion annually in health care costs, lost productivity and reductions in health-related quality of life. The social costs of poor mental health are high; a person with serious mental illness is at high risk of experiencing poverty, homelessness and unemployment. Despite the widespread prevalence of mental health disorders, it is estimated that fewer than one-third of people affected by them will seek treatment. This is due in large part to the stigma society attaches to mental illness, which can lead to discriminatory treatment in the workplace or the health care system. In recent years, awareness of mental health issues has risen considerably in Canada. However, much still needs to be done to ensure that Canadians who require mental health care have timely access to the treatment and support they need. The Canadian Medical Association (CMA) and Canadian Psychiatric Association (CPA) recommend that all stakeholders, and governments at all levels, work together toward developing a mental health care system that incorporates the following elements:
Comprehensive, patient-centred care and evidence-based treatment for mental health disorders. This includes enhancing collaboration and teamwork among health professionals, patients and their families; providing education and resources for health professionals; and supporting ongoing research to identify and disseminate best clinical practices.
Timely access to mental health services. The health care system should ensure an appropriate supply, distribution and mix of accredited mental health professionals, ensure equitable coverage of essential mental health care and treatment, and provide appropriate services for populations with unique needs, such as children and older Canadians.
Adequate supports in the community, for example in schools and workplaces, to promote mental health, identify mental health issues in a timely manner and support people with mental illness as they seek to function optimally.
Reduction of stigma and discrimination faced by Canadians with mental health disorders, in the health care system and in society. Summary of recommendations Comprehensive, patient-centred care and evidence-based treatment Governments and health care systems 1. Develop and support a continuum of evidence-based, patient-centred services for the promotion of mental health and treatment of mental illness, in the community and in hospitals, with smooth transitions and linkages between each level. 2. Develop and implement models of collaborative mental health care in the community, with input from key stakeholders including the public, patients and their families, evaluate their effectiveness and encourage the adoption of those that demonstrate success. 3. Develop and implement a national caregiver strategy and expand the financial and emotional support programs currently offered to informal caregivers. 4. Continue to develop, implement and monitor mental health indicators that reflect both health system performance and population health, regularly report the results to the public and use them to improve the delivery of mental health services in Canada. 5. Increase funding for mental health research so that it is proportionate to the burden of mental illness on Canada’s health care system. Medical faculties, professional associations and the health care systems 6. Continue to develop evidence-based guidelines and professional development programs on mental health treatment and management, for all health care providers. 7. Continue to conduct research into best practices in mental health care and treatment and communicate the results of this research promptly to health care providers and the public. Appropriate provision and funding of mental health services Governments and health care systems Address current gaps in access to mental health services in the following ways: 8. Ensure that mental health services are appropriately funded to effectively meet the needs of Canadians. 9. Make mental health a priority with all levels of government and ensure stable and appropriate funding. 10. Establish standards for access to mental health services, including appropriate maximum wait times, and measure and report them on an ongoing basis. 11. Fund and support primary health care delivery models that include mental health promotion and mental illness treatment among the services they provide and identify and address the barriers to their implementation. 12. Increase funding for access to evidence-based psychotherapies and counselling services for mental disorders. 13. Establish a program of comprehensive prescription drug coverage to ensure that all Canadians have access to medically necessary drug therapies. 14. Continue to develop linkages between remote communities and larger health centres, including telehealth and e-health services, to ensure adequate access to mental health services by people in smaller communities. Health professional associations 15. Work with governments and other stakeholders to develop a mental health human resources plan that optimizes the scope of practice of every health professional, is culturally appropriate and takes into account Canada’s diverse geography. 16. Undertake a national study of ways to optimize the supply, mix and distribution of psychiatrists in Canada and present its findings/recommendations to governments. Adequate community supports outside the health sector Governments 17. Ensure the availability of school-based mental health promotion and mental illness prevention programs, and programs that address school-related problems, such as bullying, that are associated with mental distress. 18. Work with employers and other stakeholders to support mental health programs for workplaces. 19. Provide programs and services to improve the interface between people with mental illnesses and the criminal justice system. 20. Expand programs that provide housing for people with mental illness. Reduction of stigma and discrimination Governments and the health care system 21. Incorporate identification and elimination of stigma as a quality of care indicator in the ongoing monitoring of health system performance at all levels. 22. Implement and evaluate national public awareness and education strategies to counteract the stigma associated with mental illness. 23. Enforce legislation and regulations to guard against discrimination against people with mental illness. Professional education 24. Incorporate effective anti-stigma education into the entire medical education continuum (medical school, residency and continuing professional development) for all physicians and other health professionals. 25. Incorporate effective anti-stigma education into professional development programs at hospitals and other health care facilities. Introduction Mental health disorders impose a heavy burden on Canadians and their health care system. In any given year, one in five Canadians will suffer from a mental health problem or illness. It is estimated that 10% to 20% of Canadian youth are affected by a mental health disorder. By age 40, 50% of Canadians will have had a mental illness. Mental illness can shorten life expectancy; for example, people with schizophrenia die as much as 20 years earlier than the population average. This is due both to higher rates of suicide and substance abuse and to a poorer prognosis for conditions such as heart disease, diabetes and cancer. Suicide is the second leading cause of death (after injuries) for Canadians aged 15 to 34. For people with mental health disorders, the effect on their lives goes beyond their interaction with the health care system; a person with serious mental illness is at high risk of experiencing poverty, homelessness and unemployment. Mental health disorders are costly to Canada’s health care system and to its economy. A third of hospital stays in Canada and 25% of emergency department visits are due to mental health disorders. It is estimated that mental illness costs Canada over $50 billion per year, including health care costs, lost productivity and reductions in health-related quality of life. Despite the widespread prevalence of mental health disorders, it is estimated that only one- quarter to one-third of people affected by them will seek treatment. This could be due in part to the stigma society attaches to mental illness, which deters many people from seeking needed treatment because they fear ostracism by their friends or discriminatory treatment in the workplace or the health care system. Those who do seek treatment may have a difficult time finding it. According to Statistics Canada, in 2012 almost a third of Canadians who sought mental health care reported that their needs were not met or only partially met. Lack of access to family physicians, psychiatrists and other health care providers contributes to this deficit. Though mental illnesses constitute more than 15% of the disease burden in Canada, the country spends only about seven cents of every public health care dollar on mental illness (7%), below the 10% to 11% of spending devoted to mental illness in countries such as New Zealand and the United Kingdom.4 Since 2000, however, Canadians’ awareness of mental health issues has risen considerably. The seminal 2006 report entitled Out of the Shadows at Last by the Standing Senate Committee on Social Affairs, Science and Technology, chaired by Senator Michael Kirby, made a number of recommendations aimed at increasing awareness, improving access to mental health services and reducing the stigma of mental illness. As a result of this report, in 2007 the federal government established the Mental Health Commission of Canada (MHCC) to be a catalyst for improving the mental health system and changing the attitudes and behaviours of Canadians around mental health issues. In 2012, the MHCC released Canada’s first mental health strategy, “Changing Directions, Changing Lives.” As part of her mandate from the prime minister following the 2015 federal election, Canada’s health minister has been asked to “engage provinces and territories in the development of a new multi-year Health Accord [that will] make high quality mental health services more available to Canadians who need them.” Nearly all provincial governments have also developed mental health strategies for their own jurisdictions. Much still needs to be done to translate heightened awareness into improvements in service provision to give Canadians who require mental health care timely access to the evidence-based, patient-centred treatment and support they need. The Canadian Medical Association (CMA) and Canadian Psychiatric Association (CPA) agree it is time to make mental health a high priority in Canada. The CMA and CPA recommend that all stakeholders, and governments at all levels, work together toward developing a mental health care system that is driven by needs-based plans with clear performance measures and that receives an appropriate share of health care funding. This position statement discusses and makes recommendations on issues relating to access to mental health care, with a focus on:
comprehensive, patient-centred care and evidence-based treatment for mental health disorders;
appropriately funded primary, specialty and community mental health treatment and support services;
adequate community supports for people with mental health disorders; and
reduction of the stigma and discrimination faced by Canadians with mental health disorders. Comprehensive, patient-centred care and evidence-based treatment The goal of mental health care in Canada should be to allow patients’ needs to be met in the most appropriate, timely and cost-effective manner possible. Current best practice suggests that care for patients with mental health disorders should be provided using models that incorporate the following principles. Patient-centred care One of the fundamental principles of health care is that it be patient centred. CMA defines patient-centred care as “seamless access to the continuum of care in a timely manner … that takes into consideration the individual needs and preferences of the patient and his/her family and treats the patient with respect and dignity.” For treatment of mental health disorders, it is essential that patients be core members of the health care team, working with health care providers to address their individual needs, preferences and aspirations and to seek their personal paths to well-being. Physicians and other health professionals can help patients make choices about their treatment and can provide information and support to patients and their families as they seek to cope with the effects of their illnesses and live functional lives. A continuum of mental health services Mental health disorders can be complex and can vary in severity. A patient may have short-term coping difficulties that can be resolved with counselling or a severe psychotic illness that requires frequent hospital care and intensive, lifelong support. This range of needs requires that the health care system provide different levels of care, including:
community-based programs to promote and maintain mental health and to facilitate early identification of problems requiring intervention;
community-based primary health care, including collaborative care teams, which focus on providing mental health maintenance programs and on treating high-prevalence conditions such as anxiety disorders, mood disorders and addictions;
specialized services in the community for patients with greater needs, which can be delivered through a variety of means, including community-based psychiatrists, interdisciplinary family health teams that incorporate psychiatric services and specialized interdisciplinary teams such as assertive community treatment (ACT) teams ;
acute-care mental health services including community crisis teams and beds, psychiatric emergency services and inpatient beds in community hospitals, and specialized psychiatric hospitals;
a continuum of residential care services including long-term care facilities;
seamless, integrated transitions from one level of care to another, and across age groups (e.g., from youth to adult to senior mental health services);
appropriate services for special populations, including children and adolescents, and adults with dementia;
specialized psychiatric services for patients with complex mental illnesses such as eating disorders, post-traumatic stress disorder and personality disorders; and
community-based programs that provide housing, vocational support and other services to optimize community integration of people with mental illness. Mental health care should ideally be provided in the context of caring for the patient’s overall health, taking into account any physical conditions for which the patient is receiving or may receive treatment. Collaborative and team-based mental health care Within this continuum, a variety of health care professionals with different skills and education provide mental health services in Canada. They include:
primary care physicians (family physicians and general practitioners);
psychiatrists (hospital and community based);
other specialist physicians (including emergency physicians, paediatricians, geriatricians);
other health professionals (psychologists, nurses, pharmacists, occupational therapists, social workers); and
case managers, peer support workers and system navigators. Collaborative models enable a variety of mental health care providers to work with patients and their families to provide effective, coordinated care according to a mutually agreed plan. Collaborative partnerships in mental health care have demonstrated benefits including symptom and functional improvement, reduced disability days and improved adherence to medication. Elements of a successful collaborative partnership include:
effective linkages among psychiatrists, primary care providers and other mental health professionals, including a seamless process for consultation and referral;
effective communication and information flow;
use of technology, such as electronic health records and telemedicine, to facilitate collaboration among providers in all health care settings;
coordination of care plans and clinical activities to ensure the most effective care and efficient use of resources; and
integration of mental health and primary care providers within a single service or team (in some cases, providers may work in the same practice setting).13 Education and resources for health professionals Since mental health disorders are pervasive and are often associated with other chronic conditions such as heart disease, health care providers of all disciplines and specialties often encounter them while caring for their patients. The Mental Health Core Competencies for Physicians report, prepared collaboratively by the Royal College of Physicians and Surgeons of Canada, the MHCC, the College of Family Physicians of Canada, CMA and CPA, proposes goals, principles and core mental health competencies to provide guidance to physicians of all specialties. The intent is to improve access to mental health services; improve the experience of care, including reducing stigma; recognize and address the interaction between physical and mental health; and provide practice support for physicians. To support physicians and other health care providers in treating mental health disorders, clinical and practice resources should be available to them, including:
early education in medical school and residency on mental health promotion, diagnosis and treatment of mental health conditions, and liaison with other community resources, for all specialties;
clinical practice tools including practice guidelines, clinical pathways and online decision support including prescribing guidelines for the appropriate use of psychiatric drugs;
online continuing professional development (CPD) programs ;
enhanced interprofessional education for all providers (psychiatrists, family physicians, nurses, social workers, occupational therapists, peer support workers, patients, their family members and others as relevant) ; and
evidence-based, user-friendly education and support tools for patients, which physicians can recommend to help them manage their conditions. Support for informal caregivers Often the burden of caring for a person with mental illness falls heavily on family or friends, and the role of the informal caregiver can be demanding financially, physically and/or emotionally. Though governments have instituted tax credits and other forms of support for caregivers, more help is required. A national caregiver strategy, developed by governments and other key stakeholders, could define a national standard of support for informal caregivers and expand the financial and emotional support programs that are currently offered. Research and evaluation Thanks to ongoing research, our knowledge of how to treat and manage mental health disorders is constantly growing and developing. However, there are still gaps in this knowledge, and research needs in the area remain substantial. CMA and CPA encourage a continued commitment to research into best practices in early identification, care and treatment of mental health disorders and to funding this research so that it is proportionate to the burden of mental illness on Canada’s health care system. Results of this research should be communicated to health professionals and the public as quickly and widely as possible, so that it can be rapidly incorporated into clinical practice. Mental health care interventions should also be routinely evaluated for their effectiveness in improving patient care, enhancing the sustainability of the health care system and increasing the overall health and well-being of Canadians. The MHCC has developed a set of 63 mental health indicators that focus on 13 specific areas, including access and treatment, the economy and workplace, and special populations such as seniors, children and youth. Other projects are underway to develop indicators to monitor and report more specifically on mental health system performance, such as use of emergency departments for mental health care, and physician follow-up after hospital treatment. Such indicators should be used on an ongoing basis to monitor the performance of the mental health care system and provide mental health professionals, planners and governments with reliable information that they can use to better meet the needs of Canadians. Recommendations Governments and health care systems 1. Develop and support a continuum of evidence-based, patient-centred services for the promotion of mental health and treatment of mental illness, in the community and in hospitals, with smooth transitions and linkages between each level. 2. Develop and implement models of collaborative mental health care in the community, with input from key stakeholders including the public, patients and their families, evaluate their effectiveness and encourage the adoption of those that demonstrate success. 3. Develop and implement a national caregiver strategy and expand the financial and emotional support programs currently offered to informal caregivers. 4. Continue to develop, implement and monitor mental health indicators that reflect both health system performance and population health, regularly report the results to the public and use them to improve the delivery of mental health services in Canada. 5. Increase funding for mental health research so that it is proportionate to the burden of mental illness on Canada’s health care system. Medical faculties, professional associations and health care systems 6. Continue to develop evidence-based guidelines and professional development programs on mental health treatment and management, for all health care providers. 7. Continue to conduct research into best practices in mental health care and treatment and communicate the results of this research promptly to health care providers and the public. Appropriate provision and funding of mental health services Appropriate provision of mental health services requires that people be able to access the right care in the right place at the right time, in both hospital and community settings. Unfortunately, because of the underfunding of the mental health care system, limited resources are available to accommodate all of those who need such services. The exact extent of lack of access to hospital and community mental health services is not well documented; for instance, provinces do not report wait times for psychiatric services. According to the 2015 Wait Time Alliance Report Card, no jurisdiction is measuring what proportion of patients is being seen within the benchmark time periods. In December 2015 the CPA expressed disappointment that “no visible progress has been made in measuring how well the health system meets the psychiatric needs of Canadians.” In the absence of community-based services, patients may have their discharge from hospital delayed. Once they are back in the community, they may be unable to find appropriate assistance, or assistance may be available but beyond their financial means. They may abandon treatment or rely on emergency departments for episodic crisis care.4 Canada should work to remedy the current deficiencies in access to mental health services so that people with mental health disorders have timely access to seamless, comprehensive care in the most appropriate setting. This includes ensuring an appropriate supply, distribution and mix of accredited mental health professionals, ensuring equitable coverage of essential health services and making appropriate services and supports available to populations with unique needs. Access to physician services Primary care For the majority of patients who seek treatment for a mental health problem, the first (often the only) point of contact is their primary care physician. As part of the comprehensive care they provide to patients, family physicians and general practitioners can provide mental health promotion and wellness counselling, detect and treat mental health disorders in their early stages and monitor the patient’s progress in the context of his or her overall health and well-being, referring to psychiatrists and other mental health professionals as needed.13 CMA has long recommended that every Canadian have an established professional relationship with a family physician who is familiar with his or her condition, needs and preferences. However, some Canadians may have difficulty finding primary medical care, since the proportion of family physicians and general practitioners to the population is not consistent across Canada. All stakeholders should continue working to ensure that every Canadian has access to comprehensive first-point-of-contact medical care. Psychiatric services Psychiatrists are physicians who complete five to seven years of specialty and subspecialty training to diagnose, treat and provide ongoing care for mental illnesses, particularly to people with complex illnesses that cannot be managed within a primary care setting alone. In addition to providing specialty treatment, psychiatrists are also active in the areas of education, research and advocacy about the importance of mental health promotion and mental illness prevention. They provide care across the lifespan, in both hospital and community settings. Patient access to psychiatrists is often limited by long wait times. It has been suggested that this is due to a shortage of psychiatrists, which is more severe in some parts of Canada than others. Recent surveys report that a number of specialists, including psychiatrists, are in the latter half of their careers, and there are concerns that the number of psychiatrists per Canadian population is declining. Though the Royal College notes that the number of psychiatric residency positions has increased in recent years, it is unclear if this is sufficient to meet current and future population needs. The CPA recommends the development of strategies to attract, train and retain practitioners in clinical psychiatry. Access to services not funded by provincial and territorial health systems Though Canada’s public health care system covers many mental health services and treatments, including physician consultations and hospital care, it does not cover all aspects of optimal treatment and care, and access to some therapies may be limited by the patient’s ability to pay. Psychiatric drugs, especially those that must be taken over many years, can pose a heavy financial burden for patients who do not have drug coverage through employer-provided benefit programs or provincial or territorial drug plans. Psychotherapies delivered by non-physician health care practitioners are generally not covered by government health plans and must, therefore, in most cases be paid for out of pocket or through private insurance plans, to which many Canadians do not have access. Federal, provincial and territorial governments should work to increase access to accredited psychological and counselling services that are evidence based and to provide comprehensive coverage of medically necessary prescription drugs for all Canadians. Some primary health care practices, such as family health teams in Ontario, have funding envelopes that they can use to contract with skilled mental health professionals to provide psychotherapy, stress management programs and other services that are not ordinarily funded through provincial health budgets. Models such as these help to make publicly funded mental health care available to patients who might otherwise have been unable to afford it. Access to mental health services for special populations For some populations, access to mental health services may be particularly problematic. For example, stakeholders should consider the needs of the following populations:
Children and youth: As up to 70% of mental health conditions first appear in adolescence or young adulthood, it is important that young people have access to mental health promotion and to appropriate assessment and treatment of mental health disorders. At present only one out of four children who need mental health services receives them.1,3 CMA and CPA particularly recommend increased supports for children in high-risk situations, such as those in foster care. The transition from the youth to the adult mental health service sectors should be smooth and well organized.
Remote areas: People in the North and other remote parts of Canada may have to travel many miles to access mental health and other health care services. This gap should be remedied by using technologies such as telehealth and e-mental health services and by strengthening communication and coordination between small communities and the larger health centres to which their residents travel for care.
Immigrants and refugees: New arrivals to Canada may have problems understanding our language and culture and may also face mental health problems as a result of traumatic experiences in their countries of origin or the stress of relocation.
Indigenous Peoples. Rates of mental health disorders, addictions and suicide are high among Canada’s First Nations, Inuit and Métis. Much of this is linked to past experience of forcible separation from their traditional languages and culture. Health service providers should work with Indigenous communities to address their distinct mental health needs appropriately.
Seniors: An estimated 10% to 15% of seniors report depression, and the rate is higher among those with concomitant physical illness and those living in long-term care facilities. Depression among older people may be under-recognized and under-treated or dismissed as a normal consequence of aging. Poor mental health is often associated with social isolation, a common problem among seniors. The majority of older adults in long-term care settings have dementia or another mental health condition. Recommendations Governments and health care systems Address current gaps in access to mental health services in the following ways: 8. Ensure that mental health services are appropriately funded to effectively meet the needs of Canadians. 9. Make mental health a priority with all levels of government and ensure stable and appropriate funding. 10. Establish standards for access to mental health services, including appropriate maximum wait times, and measure and report them on an ongoing basis. 11. Fund and support primary health care delivery models that include mental health promotion and mental illness treatment among the services they provide and identify and address the barriers to their implementation. 12. Increase funding for access to evidence-based psychotherapies and counselling services for mental disorders. 13. Establish a program of comprehensive prescription drug coverage to ensure that all Canadians have access to medically necessary drug therapies. 14. Continue to develop linkages between remote communities and larger health centres, including telehealth and e-health services, to ensure adequate access to mental health services by people in smaller communities. Health professional associations 15. Work with governments and other stakeholders to develop a mental health human resources plan that optimizes the scope of practice of every health professional, is culturally appropriate and takes into account Canada’s diverse geography. 16. Undertake a national study of ways to optimize the supply, mix and distribution of psychiatrists in Canada and present its findings/recommendations to governments. Adequate community supports outside the health sector People with mental health disorders often require not only treatment and care from the health sector but also support from the community at large to function optimally. Ideally, the community should provide an environment that supports patients as they work toward recovery and well-being. In addition, schools, workplaces and other community agencies can play an important role in promoting mental health and identifying problems that require attention. Schools Education and information should be made available to parents, teachers and health professionals to help them identify signs of mental illness or distress in children and adolescents, so they can intervene early and appropriately. School health education programs should include the promotion of mental health and incorporate self-management techniques such as mindfulness training to help young people develop resilience. Schools should also ensure that they minimize possible threats to children’s mental health, such as bullying, that may occur on their premises. Workplaces Unlike many other chronic conditions, mental illness frequently affects younger people and those in their most productive years, so the burden it imposes on Canada’s economy is high. Mental health disorders account for 30% of short-term workplace disability claims,1 and the Conference Board of Canada has estimated that six common mental health disorders cost the country’s economy more than $21 billion a year and predicts that this cost will increase to $30 billion by 2030. However, often employees do not disclose mental health problems to their employers for fear of losing their jobs, being ostracized by colleagues, or other negative consequences. Workplaces can support the mental health of their employees by:
offering mental health promotion assistance through stress management seminars, employee assistance and other programs;
training managers to identify potential mental health issues in their staff and to intervene early and appropriately;
eliminating stigma and discrimination and providing an environment in which employees feel safe disclosing their mental health issues; and
offering adequate benefits, including supplementary health insurance and supportive leave-of-absence programs. The MHCC’s Standard for Psychological Health and Safety in the Workplace, released in 2013, provides guidance to employers on how to promote the mental health of their staff and intervene in cases of mental distress. Correctional services People with mental illnesses are overrepresented in the criminal justice system. Estimates suggest that rates of serious mental illness among federal offenders upon admission have increased by 60% to 70% cent since 1997.4 This places a heavy burden on corrections and law enforcement staff, who are often inadequately trained to deal with mental illness. Programs and services are needed to ensure that people with mental health disorders who run afoul of the law are identified early, given appropriate treatment throughout their incarceration and followed up on release. These could include:
training for police and other frontline criminal justice and corrections workers in how to interact with people with mental illnesses;
diversion programs, such as mental health courts, to redirect people with mental illnesses who are about to enter the criminal justice system;
comprehensive psychiatric screening, assessment and treatment for incarcerated patients with mental illnesses and common co-occurring conditions such as addiction; and
Careful handover of clinical care at the point of release from custody with engagement by mental health services in the community. Housing Mental illness increases a patient’s risk for poverty and homelessness. It is estimated that two- thirds of Canada’s homeless population have a serious mental illness. Homelessness and poverty can exacerbate existing mental health and addiction problems, hinder access to treatment and reduce life expectancy. Programs such as the MHCC’s Housing First research demonstration project can improve the social and economic circumstances of people with mental illness. The MHCC project provided no-strings-attached supportive housing for people with chronic mental health problems, giving them a secure base from which they could pursue their treatment and recovery goals. Evaluation showed that this approach reduced the rate of homelessness, improved access to treatment and support services and led to cost savings, particularly for the program participants who had the highest service-use costs. Recommendations Governments 17. Ensure the availability of school-based mental health promotion and mental illness prevention programs, and programs that address school-related problems, such as bullying, that are associated with mental distress. 18. Work with employers and other stakeholders to support mental health programs for workplaces. 19. Provide programs and services to improve the interface between people with mental illnesses and the criminal justice system. 20. Expand programs that provide housing for people with mental illness. Reduction of stigma and discrimination Many believe that the primary reason for the underfunding of the mental health care system and for the reluctance of people with mental health disorders to seek treatment is the stigma attached to their conditions. Mental illness is the most stigmatized disease state in Canada, and discriminatory behaviour toward people with mental health disorders is widespread. This can include ostracism and lack of support from peers, discrimination in the workplace and distorted public perceptions, such as the tendency to equate mental illness with violent behaviour. Discriminatory behaviour can also occur in the health care system. Experts acknowledge that stigma affects health care providers’ attitude toward patients with mental health problems.29 Though many health care providers are unaware that their language or actions can be harmful, their attitude may have negative effects on the treatment their patients receive. For example, if a patient who has been treated for a psychiatric condition reports physical symptoms, these symptoms might be attributed to the mental illness rather than to a physical condition, and as a result the patient may not receive necessary treatment. This is known as diagnostic overshadowing. , CMA and CPA recommend comprehensive efforts to change the culture of stigmatization of mental illness, in the health care system and in society. A number of interventions are underway to help reduce stigma and discrimination related to mental illness. These include public awareness programs such as the Bell Let’s Talk campaign, Mental Illness Awareness Week, sponsored by the Canadian Alliance on Mental Illness and Mental Health, and the Opening Minds program of the MHCC, which focuses on specific populations including youth and health care providers. The current consensus among experts is that the most effective interventions are those that:
are aimed at changing behaviour rather than modifying attitudes;
are ongoing rather than time limited;
are targeted to specific groups rather than to the general population; and
involve direct contact with people with mental illness. Within the health care system, professional education is a potentially important means of addressing stigma and discrimination. It has been recommended that anti-stigma education be incorporated into the medical education continuum at all levels (including residency and CPD) and for all specialties and that this education incorporate direct contact with people with mental illness, to share their stories of recovery.27 All health professionals and their associations should be encouraged to address the elimination of stigma in their educational programs. CMA and CPA have worked with partners to provide education to physicians, through workshops, online materials and other means. Recommendations Governments and the health care system 21. Incorporate identification and elimination of stigma as a quality of care indicator in the ongoing monitoring of health system performance at all levels. 22. Implement and evaluate national public awareness and education strategies to counteract the stigma associated with mental illness. 23. Enforce legislation and regulations to guard against discrimination against people with mental illness. Professional education 24. Incorporate effective anti-stigma education into the entire medical education continuum (medical school, residency and CPD) for all physicians and other health professionals. 25. Incorporate effective anti-stigma education into professional development programs at hospitals and other health care facilities. Conclusion Despite increased public awareness about mental illness, ensuring access to effective mental health services and supports remains a challenge in Canada, and the stigma and discrimination associated with mental illness remain high. CMA and CPA believe that change is possible. In an ideal future, all Canadians would feel safe acknowledging their mental health problems and seeking help for them, a range of effective, evidence-based treatments would be available for every Canadian who needs them, and communities would support Canadians as they work to promote and maintain their mental health or to recover from mental illness. It is our hope that health care providers, governments, communities, patients and their families will work together toward realizing this future. References Mental Health Commission of Canada. The Facts. Calgary (AB): The Commission; 2012. Available: http://strategy.mentalhealthcommission.ca/the-facts/ (accessed 2015 May 05). Mental Health Commission of Canada. Making the case for investing in mental health in Canada. Calgary (AB): The Commission; 2013. Chesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry 2014; 13 (2):53–60. Mental Health Commission of Canada. Changing directions, changing lives: the Mental Health Strategy for Canada. Calgary (AB): The Commission; 2012. Available: https://strategy.mentalhealthcommission.ca/download (accessed 2014 Sep 07). Centre for Addiction and Mental Health. Mental illnesses and addictions: facts and statistics. Toronto (ON): The Centre; 2016. Available: www.camh.ca/en/hospital/about_camh/newsroom/for_reporters/Pages/addictionmentalhealthstatistics.aspx (accessed 2016 Mar 9). Mental Health Commission of Canada. Opening minds. Ottawa (ON): The Commission; 2016. Available: http://www.mentalhealthcommission.ca/English/initiatives/11874/opening-minds (accessed 2016 Mar 9). Statistics Canada. Canadian Community Health Survey: mental health, 2012 [media release]. Ottawa (ON): Statistics Canada; 2013 Sep 18. Available: www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.htm?HPA (accessed 2015 Sep 08). Mental Health Commission of Canada. About MHCC. Ottawa (ON): The Commission; 2016. Available: www.mentalhealthcommission.ca/English/who-we-are (accessed 2016 Mar 10). 9 Prime Minister of Canada. Minister of Health Mandate letter to the Hon. Jane Philpott, Minister of Health, November 2015. Ottawa (ON): Office of the Prime Minister of Canada; 2015. Available: http://pm.gc.ca/eng/minister-health-mandate-letter (accessed 2016 Apr 14). Canadian Medical Association. Health care transformation in Canada: change that works. Care that lasts. Ottawa (ON): The Association; 2010. Available: http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD10-05.PDF (accessed 2015 Sep 14). Neilson G, Chaimowitz G. Informed consent to treatment in psychiatry. A position paper of the Canadian Psychiatric Association. Can J Psychiatry. 60 (4):1-12. Available: http://publications.cpa-apc.org/media.php?mid=1889 (accessed 2016 Mar 9). Ontario ACT Association. ACT model: the team approach. [Place unknown]: The Association; 2015. Available: http://ontarioacttassociation.com/act-model/ (accessed 2015 Mar 25). Kates N, Mazowita G, Lemire F, et al. The evolution of collaborative mental health care in Canada: a shared vision for the future. A position paper developed by the Canadian Psychiatric Association and the College of Family Physicians of Canada. Can J Psychiatry. 2011; 56(5): 1-10. Available: http://www.cfpc.ca/uploadedFiles/Directories/Committees_List/Collaborative%20mental%20health%20care-2011-49-web-FIN-EN.pdf (accessed 2014 Oct 16). Whiteman H. Mental illness linked to increased risk of heart disease, stroke. Medical News Today. 2014, Oct 27. Available: www.medicalnewstoday.com/articles/284461.php (accessed 2015 Mar 25). Mental Health Core Competencies Steering Committee. Mental health core competencies for physicians. Ottawa (ON): Royal College of Physicians and Surgeons of Canada, Mental Health Commission of Canada, College of Family Physicians of Canada, Canadian Psychiatric Association and Canadian Medical Association; 2014. Available: www.royalcollege.ca/portal/page/portal/rc/common/documents/policy/mhcc_june2014_e.pdf (accessed 2016 Mar 9). Canadian Collaborative Mental Health Initiative. Toolkits. Mississauga (ON): The Initiative; n.d.. Available: www.shared-care.ca/page.aspx?menu=69&app=266&cat1=745&tp=2&lk=no (accessed 2014 Oct 16) Curran V, Ungar T, Pauzé E. Strengthening collaboration through interprofessional education: a resource for collaborative mental health care educators. Mississauga (ON): Canadian Collaborative Mental Health Initiative; 2006 Feb. Available: www.shared-care.ca/files/EN_Strengtheningcollaborationthroughinterprofessionaleducation.pdf (accessed 2016 Mar 9). Canadian Medical Association. Health and health care for an aging population: policy summary of the Canadian Medical Association. Ottawa (ON): The Association; 2013 Feb. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD14-03.pdf (accessed 2014 Sep 14). Mental Health Commission of Canada. Informing the future: mental health indicators for Canada. Ottawa (ON): The Commission; 2015 Jan. Available: www.mentalhealthcommission.ca/English/document/68796/informing-future-mental-health-indicators-canada (accessed 2016 Mar 09). Wait Time Alliance. Time to close the gap: report card on wait times in Canada. Ottawa (ON): The Alliance; 2014 June. Available: www.waittimealliance.ca/wta-reports/2014-wta-report-card/ Canadian Psychiatric Association. Tracking access to psychiatric care needed to chart a way forward say psychiatrists [media release]. Ottawa (ON): The Association; 2015 Dec 8. Available: www.cpa-apc.org/media.php?mid=2385 (accessed 2016 Mar 09). CMA Physician Data Centre. Canadian physician statistics: general practitioners/family physicians per 100,000 population by province/territory, 1986-2014. Ottawa (ON): Canadian Medical Association; 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/14-FP_per_pop.pdf (accessed 2016 Mar 09). Canadian Collaborative Centre for Physician Resources. Psychiatry: a recent profile of the profession [bulletin]. Ottawa (ON): Canadian Medical Association; 2012 Apr. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/25-Psychiatry.pdf#search=psychiatry%20a%20recent%20profile (accessed 2016 Mar 09). Sargeant JK, Adey T, McGregor F, et al. Psychiatric human resources planning in Canada: a position paper of the Canadian Psychiatric Association. Can J Psychiatry 2010; 55 (9): 1-20. Available: http://publications.cpa-apc.org/media.php?mid=1015 (accessed 2015 Sep 14). Conference Board of Canada. Mental health issues in the labour force: reducing the economic impact on Canada. Ottawa (ON): The Board; 2012 Jul. Mental Health Commission of Canada, Canadian Standards Association. CAN/CSA-Z1003-13/BNQ 9700-803/2013 - Psychological health and safety in the workplace — prevention, promotion, and guidance to staged implementation. Toronto (ON): CSA Group; 2013. Available: http://shop.csa.ca/en/canada/occupational-health-and-safety-management/cancsa-z1003-13bnq-9700-8032013/invt/z10032013 (accessed 2014 Oct 10). Mental Health Commission of Canada. Turning the key: Assessing housing and related supports for persons living with mental health problems and illnesses. Ottawa (ON): The Commission; 2012. Available: www.mentalhealthcommission.ca/English/media/3055 (accessed 2014 Oct 10). Mental Health Commission of Canada. National final report: Cross-Site At Home/Chez Soi Project. Ottawa (ON): The Commission; 2014. Available: www.mentalhealthcommission.ca/English/document/24376/national-homechez-soi-final-report (accessed 2015 May 15). Hawthorne D; Major S; Jaworski M; et al. Combatting stigma for physicians and other health professionals. Ottawa (ON): MDcme.ca; 2011. Available https://www.mdcme.ca/courseinfo.asp?id=143 (accessed 2015 May 15). Abbey SE, Charbonneau M, Tranulis C, et al. Stigma and discrimination. Can J Psychiatry 2011; 56(10): 1-9. Available: http://publications.cpa-apc.org/media.php?mid=1221 (accessed 2015 Aug 4). Pietrus M. Opening Minds interim report. Calgary (AB): Mental Health Commission of Canada; 2013. Available: www.mentalhealthcommission.ca/English/document/17491/opening-minds-interim-report (accessed 2015 Aug 4). Mental Health Commission of Canada. Together against stigma: changing how we see mental illness: a report on the 5th International Stigma Conference, Ottawa (ON), 2012 Jun 4–6. Ottawa (ON): The Commission; 2013. Available: www.mentalhealthcommission.ca/English/media/3347 (accessed 2014 Oct 14).
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Multi-stakeholder Position Statement: Toward an Environmentally Responsible Canadian Health Sector

https://policybase.cma.ca/en/permalink/policy9580
Last Reviewed
2017-03-04
Date
2009-05-31
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2017-03-04
Date
2009-05-31
Topics
Population health/ health equity/ public health
Text
Health, health care and the environment are linked inextricably. Environmental contaminants have been associated with compromised health status, including cancer, birth defects, respiratory and cardiovascular illness, gastrointestinal ailments and death - and an increased demand for a range of health care services. The health sector is a significant part of Canada's economy, contributing approximately 10% of gross domestic product (GDP). Thus, the sector uses considerable energy, consumes large quantities of plastics, paper and other resources, and produces significant solid, liquid and gaseous waste. With the improvement of health care technologies and a growing awareness of environmentally responsible practices, there is an increased opportunity for reducing the health sector's environmental footprint. Although there are important health, financial and ethical reasons for adopting such practices in the health sector, a number of challenges exist, including financial, technical and administrative challenges. Vision We envision the health sector as a leader in integrating environmentally responsible practices into the delivery of health care. We also see it as an advocate in sharing information on best practices and encouraging Canadians and Canadian organizations to limit their environmental footprint. In a green health sector, minimizing negative impact on the environment would be a priority for all organizations and individuals in their day-to-day practices and at all levels of decision-making. A collaborative approach Achieving our vision requires a collaborative approach to delivering environmentally responsible health care. For example:1 Greener health infrastructure * support investment in renewing physical plant infrastructure that allows for the retrofit of facilities that function more efficiently, use cleaner technologies and meet new environmental standards for energy efficiency, water management and waste management Best practices * educate staff and the public on the link between health and the environment and on the health impact of environmental degradation, and help in the development, dissemination and implementation of knowledge and best practices * support and encourage research on health and the environment, and on environmentally responsible practices in a variety of health care settings * implement energy-conserving techniques and products * request rationalized packaging and other environmentally responsible actions from vendors of health care products * promote safer substitutes to reduce exposure to toxic substances * reduce waste by reusing and recycling when possible * practise safe disposal practices for biomedical and infectious waste, outdated medications, and polyvinyl plastics, mercury and other toxic substances * establish green teams to support the practice of ecologic stewardship We recognize that our efforts to achieve a greener health sector must fit into broader societal and global actions to improve the environment. The health sector plays a role in supporting the efforts of all Canadians to find environmentally responsible ways to perform their daily activities by contributing to the management of global environmental issues, such as greenhouse gas emissions and toxic waste disposal. Calls to Action We call on governments and policymakers at all levels to understand and address links between health and the environment and to incorporate these links into policy decisions through legislative and budgetary actions. We call on all health care organizations to pledge to minimize the negative impact of their activity on the environment and to seek solutions to existing barriers. We call on individuals working in the health sector to both model and advocate for environmentally responsible approaches to delivering health care without compromising patient safety and care. Association of Canadian Academic Healthcare Organizations Canadian Coalition for Green Health Care Canadian College of Health Service Executives Canadian Dental Association Canadian Healthcare Association Canadian Medical Association Canadian Nurses Association Canadian Pharmacists Association Canadian Public Health Association David Suzuki Foundation Developed by a working group of the above organizations 1 Canadian Nurses Association/Canadian Medical Association. Joint position statement: Environmentally responsible activity in the health care sector. Ottawa. 2009
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The Wait Starts Here: Final Report of the Primary Care Wait Time Partnership

https://policybase.cma.ca/en/permalink/policy9705
Last Reviewed
2018-03-03
Date
2009-10-03
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2009-10-03
Topics
Health systems, system funding and performance
Text
In 2007, The College of Family Physicians of Canada (CFPC) and The Canadian Medical Association (CMA) established a partnership to explore wait times in primary medical care - the CFPC-CMA Primary Care Wait Time Partnership (PCWTP). The goal of the Partnership is to advocate for timely access to health care for all Canadians. The first part of the wait time continuum that can be measured is when the patient schedules his or her first visit ith a family physician. A family physician may then refer the patient to specialty care. Both of these stages in the continuum have not been addressed in wait time discussions thus far. The available evidence suggests that one-half of the total waiting time for family physician referral to treatment is from family physician referral to when the patient is seen by the consulting specialist. Thus, there are three main issues around our focus on primary care wait times: Access to primary care for those without a family physician; Access to primary care for those with a family physician; and Referral from primary to more highly specialized care. The CFPC has proposed a target that 95% of Canadians in each community have a family physician by 2012. There are two ways to achieve this goal: 1. increase the number of family physicians practicing in Canada and 2. increase the capacity of existing family physicians. To help address the supply issue, medical schools must find innovative ways to encourage more medical students to choose family medicine. A second approach to increasing the supply of family physicians is to provide more training opportunities so that qualified International Medical Graduates can be integrated into the family physician workforce. In terms of capacity, there are a number of approaches that have been taken to help improve family physicians' ability to take on additional patients. For example, financial incentives geared towards this objective have been included in some physician contracts. However, much more can be done in this regard, such as improving patient flow with more efficient practice management procedures There are several models for primary care delivery operating in Canada, including various collaborative practice arrangements with different care providers working together. However, thus far there is no conclusive evidence that any one particular model is better than all of the others in terms of providing timely access to care. Many studies have compared various models in a variety of ways; each with different conclusions. While there is no definitive research on best models for primary care delivery, there is a range of innovative approaches to enhancing timely access to quality primary medical care. More research is necessary to help determine which model or models of primary care, if broadly implemented, will make considerable improvements to patient access. Aside from collaborative care practice models, we must look for solutions that increase patient access to care through enhanced practice efficiency and not by expecting family physicians to work harder and longer. Physicians should be educated on how to run a practice from a patient flow point of view as well as a financial one. To address this, enhanced practice management training should be provided during medical school education and residency levels and Continuing Medical Education programs should be created. One method of improving practice efficiency is through a process known as Clinical Practice Redesign (CPR). The main objective CPR is to improve patient flow through a medical practice. This involves the use of effective scheduling management techniques that allow appropriate prioritizing of patient visits. This undertaking requires commitment from physicians as well as effective information management and measurement tools, additional practice support and assistance from change management experts. These efforts can go a long way to help improve patient access and increase capacity to accommodate patient appointments. One of the key challenges of primary care wait times is to establish guidelines for timely access to specialty care. This is potentially an enormous undertaking given that there are some 60 recognized specialties and sub-specialties in Canada and each of them is responsible for treating a number of conditions presenting to the family physician. Due to the varying degree of complexity of a patient's medical problem, an appropriate wait time would be difficult to define by a particular disease or illness. Given the wide spectrum of illnesses that are assessed in a primary care setting, any approach to developing wait time targets must be done in consultation with family physicians and with clinical guidelines in mind. When a patient is referred to more highly specialized care, a concerted effort must be made to keep the lines of communication as open as is feasible between family physicians and consulting specialists, in both directions. Improved communication between providers is essential to improving the wait time at this point in the continuum. While timely access to family physicians and the referral time to other specialists is a nationwide concern, access to health care can be a greater challenge in rural locations. Any guidelines regarding wait times to specialty care must also account for the geographic factors that affect access. When considering the concept of target-setting, a significant investment in information infrastructure is required to facilitate the measurement and monitoring of access to primary care physicians and referrals to other specialists. Furthermore, it must be acknowledged that regardless of how targets are determined, even if they are met, not everyone will receive care within the most appropriate period of time for their particular situation. Introduction In 2007, The College of Family Physicians of Canada (CFPC) and The Canadian Medical Association (CMA) established a partnership to explore wait times in primary medical care - the CFPC-CMAPrimary Care Wait Time Partnership (PCWTP). The goal of the Partnership is to advocate for timely access to primary care for Canadians. The Partnership released its interim report, ... And Still Waiting: Exploring Primary Care Wait Times in Canada, in April 2008 to stimulate discussion and agreement about ways to improve timely access to primary care and from primary to more highly specialized care. It reviewed a broad range of issues faced by family doctors in a health system that has largely ignored the wait time challenges their patients face and was very well received by members of the CMA, CFPC and other stakeholders. This final report is a focused approach to some of the recommendations and solutions, especially of relevance in primary medical care. The difficulty in measuring primary care wait times for myriad illnesses and conditions was identified in the first report as one that may impede progress in finding solutions to the wait time challenges that family doctors experience. The PCWTP believes that the initial requirement is the ability to measure and track wait times along the continuum of the patient's care but that this capacity in primary as well as more highly specialized levels of care is still very limited. There is also the need to prioritize which benchmarks or targets should be attained along the patient's wait time continuum: 1) to find a family physician; 2) to be seen by a family physician; and 3) to have a diagnostic intervention or to be seen by a consulting specialist. The difficulty in measuring primary care wait times for myriad illnesses and conditions...may impede progress in finding solutions to the wait time challenges that family doctors experience. Methodology and Scope of Report Methodology This paper is an opportunity to draw attention to issues of relevance to family physicians and their patients waiting for care - either to find a family doctor, or to be seen by their family doctor or to be seen by another specialist. The paper is a reflection of several data sources, including: Expert opinion from family physician leaders in practice and research The National Physician Survey (NPS) results from 2004 and 2007 Stakeholder consultation Given the available expertise within the PCWTP representing two national medical organizations that advocate for patients in primary care and for the resources that support high quality care, the authors of this paper are in a unique position to use their knowledge and understanding to contribute to the proposed solutions and recommendations. Scope It is easier to define what is in than what is out of scope for this paper. There is a variety of important influences coming to bear on primary care wait times. Some are beyond the scope of this discussion. For example, the health system is promoting more collaborative care and while this is an increasingly important part of practice, its influence on primary care wait times has yet to be determined. There are also enablers and impediments to improved access to care, some of these still poorly defined. For example, where a physician practices and the influence of location, e.g. suburban in contrast to rural communities, makes a difference to access. The location of resources based on criteria such as cost-effectiveness and skill maintenance requires more attention. Likewise, new models of primary care are encouraging incentives to practice differently. But it is still uncertain how these new models of care are affecting access to timely care. Finally, there are many personal factors that affect patient choice and physician decision in determining when access is acceptable or when it is intolerable. Risk plays an important part in these decisions but not all risk is measurable. Some experts have also suggested not every waiting list is a bad list. These issues require much more analysis than this paper allows. In short, recommendations for further research will be reinforced as much by what we know as by what we still do not know. What Does It Mean? Primary Care In the first report by the PCWTP, primary care was defined as first-contact medical care and services provided by family physicians and general practitioners. In contrast, primary health care was defined as the broader determinants of health, including health services delivered by other professional providers. Likewise, in that report it was acknowledged that "primary care is the foundation and family physicians are the backbone of the health system as the first points of contact for most patients." Patients have access to a continuum of medical services by first presenting to their family physician at the primary care level. Individuals may require specialty care at various points in their lives. Patients may see several specialists for a variety of problems; however, patients' family physicians play an important role during interaction with specialty care throughout the continuum of lifelong care. (Figure 1) [SEE PDF FOR CORRECT DISPLAY] What does it mean to have a family physician? As set out in the CFPC's Four Principles of Family Medicine, a person may be said to have a family physician when they have established a patient-physician relationship that provides for continuing care through repeated contacts across the life cycle and in which the physician becomes an advocate for the patient by referring to other specialists and other health care resources as appropriate. While in the past this relationship has often been established through an unwritten contract, in some of the new practice models patients are formally "rostered", that is to say they sign a commitment to seek all of their non-emergent care from the particular physician or clinic. Patients may see several specialists for a variety of problems; however, patients' family physicians play an important role during interaction with specialty care throughout the continuum of lifelong care. What does it mean to not have a family physician? Persons without a family physician are those without an established relationship with a primary care physician who maintains a continuous medical record for them. The largest population-based surveys that collect data on health care use among the general population have been conducted by Statistics Canada. They have not asked specifically about "family physicians" but rather about "regular doctors" or "regular medical doctor". In its 2007 Canadian Community Health Survey (CCHS), Statistics Canada asked the simple question, Do you have a regular medical doctor?1 Nationally, 85% of the population aged 12 or older reported that they did. In 2008, the CFPC commissioned a Harris/Decima survey and found that 86% of respondents had a family physician. 2 The CFPC proposed a target that 95% of Canadians in each community have a family physician by 2012. Some regions of the country may be close to attaining this target while others have far to go. Persons with a regular doctor are more likely to report greater continuity of care. According to Statistics Canada's 2007 Survey of Experiences with Primary Health Care, among the 86% of the population reported to have a regular medical doctor, 95% said that they would either definitely or probably be taken care of by the same physician or nurse each time they visited their physician's office. In contrast, among the 10% of the population with no regular doctor but some regular place of care, just 31% said they would definitely or probably see the same physician or nurse with each visit. 3 What does it mean to not have a family physician? Persons without a family physician are those without an established relationship with a primary care physician who maintains a continuous medical record for them. These are referred to as unattached (or orphaned) patients. They obtain episodic care from places like walk-in clinics and hospital emergency rooms (ERs). A recent report by the Institute for Clinical Evaluative Sciences (ICES) found that there are significant excess visits to ERs among people with chronic conditions who do not have a regular family physician. 4 Reducing the number of unattached patients could therefore have a substantial impact on the problem of overcrowded ERs. Of the estimated 4.1 million Canadians aged 12 and over who indicated that they did not have a regular doctor in the 2007 CCHS, 78% reported that they had some other usual source of care. Among these individuals, the most frequently cited source of care was walk-in clinics (64%), followed by hospital emergency rooms (12%), community health centres (10%) and "other" (14%). 5 The Concept of the Medical Home For those with a family physician there has been an increase in the literature in the United States on the concept of a "medical home". In 2007 the American Academy of Family Physicians and three other medical associations adopted "joint principles of the patient-centered medical home" that include: -each patient having a personal physician -physician directed medical practice -whole person orientation -coordinated care across all elements of the health system -quality and safety (e.g. support for optimal patient-centered outcomes) -enhanced access to care (e.g. open appointment scheduling); and -appropriate payment incentives. 6 The Commonwealth Fund attempted to assess the proportion of patients with a medical home in their 2007 International Health Policy Survey. Their definition included patients that have "a regular doctor or place that is very/somewhat easy to contact by phone, always/often knows medical history, and always/often helps coordinate care (yes)." While 84% of Canadian respondents on the survey reported that they had a doctor that they usually see (consistent with all other survey estimates), just under one out of two (48%) were considered to have a medical home according to the Commonwealth Fund definition. Of the seven countries surveyed, respondents in New Zealand and Australia were the most likely to be considered as having a medical home (61% and 59% respectively). 7 Primary Care Models There are several models for primary care delivery and thus far there is no conclusive evidence that any one particular model is better than all of the others. Many studies have compared various models in a variety of ways; each with different conclusions. For example, a comprehensive comparative study on the productive efficiencies of four models of primary care delivery in Ontario concluded that no one type of model dominates and that further research is required. 8 Furthermore, another study comparing various primary health care models with regard to a number of variables including access and quality came to the same conclusion. It found that the fee-for-service physician practice model ranked highest in terms of patient access and responsiveness, while community health centres ranked highest in effectiveness, productivity, continuity and quality. 9 Finally, another study that compared patient satisfaction in walk-in clinics, ERs and family practices came to the conclusion that in terms of waiting time, patients were most satisfied with family practices. 10 While there is no definitive research on best models for primary care delivery, this report shows there is a range of innovative approaches to enhancing timely access to quality primary medical care. Timely Access The issue of wait times has dominated the health policy agenda in Canada, particularly since the First Ministers Accord in 2004. Prior to that however, in their February 2003 Accord, which they considered to be a "covenant", governments agreed to develop and report on common indicators. Among the 40 indicators listed in the 2003 Accord, in addition to access to primary care (measured as a percentage of the population with a regular family doctor and a percentage of doctors accepting new patients), the list included seven wait-time/volume indicators, of which the following were pertinent to primary care: -referral to specialists for cancers (lung, prostate, breast, colo-rectal), heart and stroke; -diagnostic tests (MRI, CT); and -proportion of services/facilities linked to a centralized (provincial/regional) wait list management system for selected cancers and surgeries, referral to specialists, emergency rooms and diagnostic tests. (11) These commitments were overtaken, however, by the 2004 Accord which called for evidence-based benchmarks for five procedures including cancer, heart, diagnostic imaging, joint replacements and sight restoration. (12) National benchmarks were achieved in December 2005, but they begin from the point where the decision has been reached on treatment between the consulting specialist and patient. (13) A. To Family Medicine In discussions regarding the total time patients wait for care, what is often overlooked is the fact that the wait time continuum starts when a patient has a medical problem. However, the first part of the continuum that can be measured is when the patient schedules his or her first visit with a family physician. Figure 2 below illustrates the full wait time continuum. [figure 2. SEE PDF] Access to a family physician is a major concern in this country. In a series of focus groups conducted by Ipsos-Reid across Canada in 2007 on behalf of the CMA, the following concerns/issues were raised by some patients: -people had been searching for a family physician for several years without success; -people with a family physician were frightened about the prospect of their doctor retiring; and -people with a family physician reporting waits of three or four weeks to get an appointment.(14) According to the Commonwealth Fund survey in 2007, Canada had the lowest rate of same-day physician appointments by a wide margin. 22% of respondents said they could see their physician on the same day, versus 30% in the US and 41% and higher for the remaining five countries. Canada also had the highest rate of respondents noting it took six or more days to see their physician, at 30%, as opposed to 20% for Germany and the US and lower for the other four countries surveyed (7). However, in the 2007 National Physician Survey (NPS), 65% of family physicians stated that their patients with urgent needs are able to see them within one day. For non-urgent cases, 41% are able to see their patients within one week and 66% are able to see their non-urgent patients within four weeks.(15) In the 2007 Health Council of Canada survey, of the 26% of respondents who stated they require routine or ongoing care, 45% noted that they had to wait too long for an appointment and 29% said it was difficult to get an appointment. 16 Furthermore, according to the 2007 NPS, when other specialists were asked to rate their patients' access to family physicians, only 13% gave it a very good or excellent rating, while over half (55%) gave it a fair or poor rating. This survey also found that 86% of family physicians stated they had made arrangements for care for their patients outside of their normal office hours. When asked to list the arrangements they have in place, one third (33%) said they extend their office hours, over one third (37%) operate an after-hours clinic that is staffed by members of their practice and 41% included calling a 24/7 telehealth phone line as an option. However, over half (52%) included going to an ER as one of these arrangements.(15) The aforementioned surveys have shown there is evidence of a disparity between patients' and physicians' perspectives regarding access to primary care. Moreover, Canada lags behind other countries in access to primary care. B. To Specialty Care The next stage of the wait time continuum is also often overlooked. This is when a family physician refers the patient to specialty care. The Fraser Institute's research on patient wait times does take this into account, however. According to their most recent survey, the average wait time between referral by a family physician and a consulting specialist fell from 9.2 weeks in 2007 to 8.5 weeks in 2008.(17) It is encouraging to see some movement in the right direction, but there is much more room for improvement. According to the 2007 NPS, only one quarter (24%) of family physicians rated patient access to other specialists as very good or excellent, while over one third (36%) of family physicians rated patient access to other specialists as fair or poor. 15 Some specialists will not take phone calls from family physicians - the only method of communication is by fax, which makes it difficult for the family physician to confirm whether the consulting specialist has received the referral and acted on it. Efforts must be made to keep the lines of both communication and access as open as is feasible between family physicians and consulting specialists, in both directions. Other specialists have noted having some difficulty scheduling appointments for their patients with their family physicians after consultation and/or treatment. The Canadian Medical Protective Association (CMPA) has identified a specific process for referring physicians to follow and includes the following guidance: When a patient is referred to a consulting specialist, the family physician should provide sufficient clinical information so that the consultant can appropriately prioritize his or her referrals. The consultant should notify the family physician of the patient's scheduled appointment. If the timing of this appointment does not seem reasonable to the family physician, he or she should then attempt to schedule an earlier appointment. If this is not possible, the family physician should consider alternative options to seek specialty care and discuss these with the patient. The patient should also be informed of what to expect if his or her condition changes while waiting for specialty care, and what to do and who to consult if this occurs. 18 The Collaborative Action Committee on Intra-professionalism (CACI) was established in 2006 by the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada to discuss enhancing intra-professionalism and exploring ways to encourage desired behaviours that will improve physicians' intra-professional relationships. This work is vital to ensure a seamless continuum of care for patients between family physicians and other specialists. Working groups have been established to focus on improving relations through medical education, training and accreditation and in practice by developing enhancements to the referral-consultation process. (19) Should a timely referral not be available, the CMPA's latest guidance on wait times in a September 2007 information sheet addresses the issue of liability when health-care resources such as specialty care are limited. The sheet notes that physicians may be requested to provide care outside their area of expertise when resources are scarce. While noting that the courts have yet to address this issue, it suggests the "courts will not evaluate your decisions against a standard of perfection. Rather, your decisions will be evaluated in light of what a reasonable and prudent physician like you would have decided in similar circumstances". 20 Nonetheless, given that the decision to refer implies that a physician has determined that a problem is beyond his or her scope of practice, the issue of support for the physician managing what might be long waits for specialty care will need to be addressed. An additional barrier to timely patient access to specialty care is the inconsistency in family physicians' abilities to order advanced diagnostic tests. The Canadian Association of Radiologists (CAR) has guidelines for all physicians to follow when ordering diagnostic tests. C. Rural Versus Urban Access While timely access to family physicians and the referral time to other specialists is a nationwide concern, access to health care is often considered a greater challenge in rural locations. The 2007 NPS survey found that this is not the case. In fact, the opposite is true. There is very little difference in same-day family physician access rates between urban and rural locations and with regard to other specialties, the difference between urban and rural physicians is notable, with 51% of rural physicians stating that urgent appointments can be made on the same day as opposed to only 37% of urban physicians. However, there is a difference between rural and urban settings with regard to factors that increase demand on a physician's time. For example, the 2007 NPS found a lack of availability of other specialists locally was a more significant factor for rural physicians (65%) than for urban (55%), as was the lack of other health care professionals, which was a concern for 66% of rural physicians in contrast to 54% for urban physicians. This survey shows that health human resources is a concern for all physicians, especially in rural settings. (15) It should be pointed out that rural and urban physicians' differing perceptions about access for their patients may have an effect on survey findings; the weather and distance to travel to obtain specialty care, for example, affect a rural family physician's view of the quality of access. The 2007 NPS found that access to Routine andAdvanced Diagnostics was rated very similarly by rural and urban physicians of all specialties, with access to routine services rated higher than access to advanced services in all respects. When the physician's specialty is taken into account, both rural and urban family physicians rated access to routine diagnostics higher than other specialists (very good or excellent - 48% versus 37%). The reverse is true for access to advanced diagnostics, with 15% of family physicians rating it very good or excellent, whereas 21% of other specialists gave it these rankings. (15) Any guidelines regarding wait times to specialty care must also account for the geographic factors that affect access. The most commonly regarded solution to the problem of access to specialty care in rural regions is to increase the number of specialty services in that area; for many specialties, however, this may not be feasible due to insufficient numbers of patients residing in the area to support an effective workload. Next Steps - Finding Solutions For the purposes of this paper, "target" is defined as a time-based standard for accessing care. A. Measuring Primary Care Wait Times What primary care wait times should be measured? How can they be measured? While the selection of the five priority areas noted earlier has stimulated progress in the measurement of waiting for treatment once the consulting specialist has been seen, as the Fraser Institute has reported for the past two years, nationally one-half of the total waiting time for family physician referral to treatment is from family physician referral to when the patient is seen by the consulting specialist. In 2008 the Institute estimated the average total wait from referral to treatment at 17.3 weeks; of this the wait from referral to specialty consultation was estimated at 8.5 weeks - 49% of the total (17). Among the recent provincial/territorial initiatives there has been no systematic effort to capture the time from family physician referral to specialty consultation. For its part, the Wait Time Alliance is launching a project in spring 2009 that will record the actual total waiting time from initial referral to treatment among a sample of consulting specialists and their patients. B. Setting Targets For the purposes of this paper, "target" is defined as a time-based standard for accessing care. This may be further graduated by the urgency for which the care is needed, and it may also be qualified by a percentage threshold of attainment. For example, "90% of patients with the least urgent requirement for care will be seen within one month of referral". When considering the concept of target-setting, two important points must be stressed: - before any reasonable wait time targets can be established, a significant investment in information infrastructure is required to facilitate the measurement and monitoring of access to primary care physicians, appointments and referral to other specialists; and - regardless of how the targets are determined, even if the targets are met, not everyone will receive care within the most appropriate period of time for their particular situation. Targets to Accessing Primary Care There are two key considerations in this paper with regard to targeting wait times in access to primary care. While other jurisdictions and researchers have considered other approaches, e.g. wait times to access a primary care setting, this paper is focused on ways to improve timely access to primary medical care for those Canadians who have their own family physician and for those who do not - as well as timely access to specialty care services from their family physician. Finding a Family Physician What would it take to reach the target of 95% of Canadians in each community having a family physician by 2012? An estimated 4.1 million Canadians aged 12 or older do not have a family physician. Statistics Canada further subdivides the 4.1 million into those who have not looked for a family physician (2.4 million) and those who have looked but cannot find one (1.7 million) (1). A telephone survey conducted by Harris/Decima in October and November 2008 found that of the 14% of respondents who do not have a family physician, 61% were not looking for a family physician for themselves or a family member. 45% of these stated they are not looking for one because they go to a walk-in clinic or an ER instead, whereas the other half were not looking because they presumed no family physicians were available.(2) It would seem reasonable that the population who has looked for but cannot find a family physician should be a priority target to advancing toward the 2012 goal. As advocated and explored by the CFPC, this may entail establishing registries for unattached patients in communities across Canada. Several provinces and territories have included incentives in their physician contracts for taking on unattached patients and it would be useful to assess their effectiveness. One way to increase the number of family physicians practicing in Canada is to encourage more medical students to choose family medicine by exposing them to family practices early on and to obtain placements in practices that are keenly interested in demonstrating the benefits of family practice to medical students. Support for family practice preceptors and teachers is also important. Incentives to attract more preceptors are required and facilities should be created to improve medical students' awareness of these opportunities across the country. Ontario has set a target of finding a family physician for 500,000 unattached patients over the next three years. 21 Ontario already has in place an incentive schedule for patients in its primary care models to take on new patients. The most common of these models (i.e. with the largest number of physicians participating) is the Family Health Group, which provides a payment of $100 each for up to 50 newly enrolled patients without a family physician per year with a premium of 10% for patients aged 65-74 and 20% for those aged 75 and over. There is also a payment of $150 for rostering unattached patients discharged from an inpatient hospital stay. Effective April 1, 2009 a complex/vulnerable new patient fee of $350 will also be introduced, with criteria still under development. New Brunswick has a pilot project in place that is based on a $150 premium, payable in addition to fee-for-service (FFS) billings in installments of $50 per visit up to the maximum. In the Yukon, family physicians who accept unattached patients are paid $200 over and above the initial visit fee. 95% of Canadians in each community should have their own family physician by 2012 Another option currently being discussed in a number of jurisdictions is to allow faster integration of qualified International Medical Graduates (IMGs) by evaluating the equivalency of family medicine training and qualification programs done in other countries. In order to increase the number of family physicians who are trained to provide high-quality care, the CFPC recently approved the following initiatives: -Expansion of the Alternative Route to Certification for practicing FPs interested in Certification in Family Medicine (practice eligible) to those who have been practicing for at least five years in Canada. -Granting Certification to family physicians who hold Certification with the American Board of Family Medicine (ABFM), are in good standing with the American Academy of Family Physicians and are moving to Canada. -Evaluate other postgraduate family medicine training and certification programs in jurisdictions outside Canada in order to consider granting reciprocity for family physicians with training and certification equivalent to family medicine programs in Canada. Access to Family Physicians In terms of targeting approaches to the time to get an appointment to see the family physician, it would appear that the "evidence-based" approaches of urgency scoring will be impractical because they require an assessment of the patient. It may be worth investigating the methodology used by the provincial health phone lines to triage patients based on the use of structured algorithms and exploring whether this can be used in a primary care physician office to better gauge the level of each patient's need to see their physician and to organize the physician's patient schedule in a more effective manner. This would require additional resources (both staff and technology) be made available to the family physician's practice. Want to learn more? Capital Health in Halifax is exploring "a program of supports for family physicians and family practice nurses working in fee-for-service practices in Nova Scotia: www.cfpc.ca/nursinginfamilypracticeTQVI When considering approaches to address the issue of increasing access for patients with a family physician, we must look for solutions that do so through enhanced practice efficiency and not by expecting family physicians to work longer. Improving practice efficiencies can be accomplished through enhanced practice management training during medical school education and residency levels. Continuing Medical Education programs on this topic will also be beneficial. Physicians should be educated on how to run a practice from a patient flow point of view as well as a financial one. To encourage interest in this aspect of running a medical practice it is important that they are made aware of all of the benefits of a well-managed office (e.g. more time spent doing direct patient care, the ability to increase patient load and attain a better work-life balance). New Approaches to Practice Management Some progress is being made to enhance Canadians' access to primary care. A variety of projects are underway that have already shown improvements in this area, including a number of successful efforts occurring in British Columbia, Alberta and Saskatchewan that include the implementation of a innovative practice management system known as Advanced Access. The term Clinical Practice Redesign (CPR) is becoming a more popular description of the process involved. "Advanced Access is about reengineering clinic practices so that patients can see a physician or other primary care practitioner at a time and date that is convenient for them. The advanced access model is often considered to be another scheduling system; however, it is in fact a comprehensive approach to effective patient care delivery."(22) The main objective of CPR is to improve patient flow through a medical practice. This involves the use of effective scheduling management techniques that allow appropriate prioritizing of patient visits. The main premise is that if patient demand for appointments is overall in balance with the physician capacity to schedule appointments, it should be possible to offer patients an appointment on the same day that they telephone for one. The challenge is to work down the backlog and achieve that balance. Once this is accomplished, the wait time to see the physician can be dramatically reduced. The originators of this concept have identified six steps in implementing CPR: 1. Measure and balance supply and demand 2. Eliminate the accumulated backlog 3. Reduce the number of appointment types 4. Develop contingency plans (e.g., flu season) 5. Reduce and shape demand (e.g., phone and e-mail for answering questions) 6. Increase effective supply by delegating tasks 23 Want to learn more? Family Physician Dr. Ernst Schuster presents advanced access in family practices through the Alberta Access Improvement Measures (AIM): www.cfpc.ca/advancedaccessTQVI The sentinel indicator that is used to monitor CPR is what is termed "third next available appointment" and is defined as the average length of time in days between the day a patient makes a request for an appointment with a physician and the third available appointment. Another common patient scheduling technique, often misinterpreted as Advanced Access, is more accurately referred to as the "carve out" model. It involves keeping a block of time open each day for patients who call that day for an urgent appointment. While it allows patients with an urgent problem to see their family physician the same day, it could potentially make the wait time for non-urgent problems longer as there are fewer appointment times that can be used for those cases. It is nonetheless a step in the right direction and shows that family physicians are making efforts to alleviate the primary care access problem. CPR is gaining momentum as a popular method of improving practice efficiency. The first group practice to adopt this system in Saskatchewan was able to reduce its average wait time from 17 days to just two. (24) In addition to reducing wait times, many practices in British Columbia, Alberta and Saskatchewan have been able to increase their patient load due to efficiency improvements. This is therefore also addressing the concern about the large number of Canadians who do not have a family physician. The United Kingdom Experience The UK has adopted fixed targets for primary care, irrespective of the patient's presenting condition. The 2004 National Health Service (NHS) Improvement Plan set out a 24/48 hour access target, by which UK patients would be guaranteed the opportunity of seeing a primary care provider within 24 hours and a GP within 48 hours. (25) The UK has since adopted an incentive approach to achieving this target through an Improved Access Scheme. First implemented on a voluntary basis in 2007, some 5 million surveys were sent to GPs' patients across England about their recent experience with access to their GP. The survey results are linked to a reward payment that has four elements: - 48 hour target reward element; - advance booking target reward element; - ease of telephone access target reward element; and - preferred health care professional target reward element. The level of payment for each element is linked to the satisfaction level reported by the patients. (26) The survey has now been successfully administered twice. In 2008, almost two million responses were received - a 41% response rate. Key findings from the 2008 survey include the following: - 87% of patients reported that they were satisfied with their ability to get through to their doctor's surgery on the phone. - 87% of patients who tried to get a quick appointment with a GP said they were able to do so within 48 hours. - 77% of patients who wanted to book ahead for an appointment with a doctor reported that they were able to do so. - 88% of patients who wanted an appointment with a particular doctor at their GP surgery reported that they could do this. (27) Any kind of patient-based reporting on access requires an up-to-date electronic roster of patients. The survey tool used in the UK is very simple and can be completed online. It should be noted however that the cost of the 2007 survey was estimated at £11 million although this also includes the patient choice survey. (28) No doubt less complex approaches could be developed for applying an incentive approach to reach targets in Canada. However, this would involve the types of supports and resources available to general practitioners in the UK. In addition, the views of the public and patients should be sought before adopting any targeting approaches in primary care. This was emphasized by Berta et al in a Canadian public opinion study of the importance of ten measures of primary care performance. They found that the most important factors for patients were related to the family physicians' knowledge and skills, while the access indicators were least important. (29) Targets to Accessing Specialty Care One of the key challenges of primary care wait times is to establish guidelines for timely access to specialty care. This is potentially an enormous challenge given that there are some 60 recognized specialties and sub-specialties in Canada and each of them is responsible for treating a number of conditions presenting to the family physician. Due to the varying degree of complexity of a patient's medical problem, an appropriate wait time would be difficult to define by a particular disease or illness. National and international experience would suggest that there have been two broad approaches: - the development of "condition-specific" approaches to target-setting linked to a clinical assessment of urgency; and - the adoption of targets that apply to all conditions that are progressively shortened as they are achieved. Since the early 1990s, the NHS has made remarkable progress in tackling wait times through the adoption of targets that have been gradually shortened. This began with the first UK patient charter that was adopted in 1991. Reflecting the long waiting lists at that time, it included the right, "to be guaranteed admission for treatment by a specific date within two years". (30) In 1995 a second version of the Patient Charter lowered this period to 18 months, and to one year for coronary artery bypass grafts. (31) In the late 1990s the NHS moved from the Charter to a series of national service frameworks for conditions such as heart disease and cancer. These frameworks evolved into shortened targets. For example in 2001 the target was a maximum one month wait from diagnosis to first treatment for breast cancer by the end of 2001, in 2005 this was extended to all cancers by December 2005. 32 The most recent development has been the 2004 commitment that by the end of 2008 no patient will have to wait longer than 18 weeks from GP referral to hospital treatment.(33) The UK is on track to meet this target, but it must be emphasized that this has been achieved through a combination of a large infusion of resources, plus policy changes such as the shift from block funding to Payment by Results that reimburses hospitals on the basis of the number of patients treated. It should also be emphasized that the NHS is a much more integrated system than Canada's health care system, and it would be more challenging to define accountability for reaching wait time targets. Past Work on Improving Specialty Care Access In Canada, the "gold standard" of target-setting is considered to be the work done by Naylor and colleagues in developing the urgency rankings for coronary revascularization procedures that underpin the Cardiac Care Network (CCN) of Ontario. This was done using a modified version of the techniques developed by the RAND Corporation in the 1980s to establish appropriateness guidelines for various procedures. In this work a panel of cardiologists and cardiac surgeons rated 438 fictitious case-histories on a seven-point scale of maximum acceptable waiting time for surgery. A regression model was then used to derive a scoring system based on the regression coefficients attached to the major determinants of urgency. (34) This system was implemented to prioritize waitlists by CCN which now works with 18 cardiac care centres in Ontario. A group urology practice in Saskatchewan has initiated a process whereby referring family physicians are provided with a standard form listing the necessary tests. The Diagnostic Imaging Program Standards Committee of the Winnipeg Regional Health Authority in Manitoba found that when physicians requesting a diagnostic test provided a time frame for the test to be completed as well as information about the patient's condition, the process of prioritizing requests became more manageable for radiologists. In Alberta and British Columbia, some family physicians have signed service agreements with other specialists. Such an agreement defines the scope of the work of family physicians and other specialists. It formally encourages all specialties to work collaboratively and to this end regular meetings are held to discuss all relevant matters. Manitoba has recently launched a pilot project called Bridging Generalist and Specialist Care - The Right Door, The First Time that will focus on reducing the wait time between family physician referral and specialty consultation. In the late 1990s a similar approach was used by the Western Canada Waiting List (WCWL) Project to develop priority scoring tools for cataract surgery, general surgery, hip and knee replacement, MRIs and children's mental health. (35) The tool for hip and knee replacement has been adapted for use by family physicians to determine priority of referral to orthopaedic surgeons,although to date it has only been tested on simulated paper cases.(36) The Saskatchewan Surgical network has applied the WCWL approach to develop scoring tools in 12 procedural areas. (37) Clearly it would be a large undertaking to adopt all these tools for use in primary care and to develop tools for the numerous areas that have yet to be tackled. Thus far, governments have concentrated, for the most part, on their initial five priorities. In the Fall of 2007 the Wait Time Alliance added five new benchmark areas, including emergency care, psychiatric care, plastic surgery, gastroenterology and anesthesiology (pain management) and it has challenged governments to adopt them. (38) Recent Efforts to Improve Specialty Care Access How can we work to achieve these targets? There are a variety of initiatives underway to expedite the referral and consultation process. In 2006, the CFPC and the Royal College of Physicians and Surgeons of Canada said that three steps could improve the referral and consultation process: - a defined single access point within local referral/consultation systems; - templates for referrals and consultations advice; - an agreement amoung key players (relevant GP/FP and other specialty organizations) on referral/consultation criteria."(39) As an example, a group urology practice in Saskatchewan has initiated a process whereby referring family physicians are provided with a standard form listing the necessary tests. This process has been very successful in reducing the need for repeat appointments. This practice also implemented a policy that the patient is referred to the first available urologist rather than to a specific physician. This new pooled referral system has reduced patient wait times remarkably and has been very well received by all parties. (40) In addition, other specialties in that province have shown interest in introducing a similar system in their practices. As an additional example of simple ways to gain efficiencies, the Diagnostic Imaging Program Standards Committee of the Winnipeg Regional Health Authority in Manitoba found that when physicians requesting a diagnostic test provided a time frame for the test to be completed as well as information about the patient's condition, the process of prioritizing requests became more manageable for radiologists. (41) In Alberta and British Columbia, some family physicians have signed service agreements with other specialists. Such an agreement defines the scope of the work of family physicians and other specialists. It formally encourages all specialties to work collaboratively and to this end regular meetings are held to discuss all relevant matters. Manitoba has recently launched a pilot project called Bridging Generalist and Specialist Care (BGSC) - The Right Door, The First Time that will focus on reducing the wait time between family physician referral and specialty consultation. This pilot project is intended to address priority areas, including: - mental health: anxiety and depression - lower back pain management - lower gi endoscopy - orthopaedics: arthroplasty - plastic surgery: carpal tunnel, breast reconstruction, breast reduction and skin lesions - lung cancer (42) One of the objectives of this pilot project is to establish guaranteed time frames from referral to consulting specialist in the specific practice areas and to offer alternative options to patients who may exceed these time lines. The BGSC software includes primary care pathways and an electronic referral process, allowing family physicians to send all necessary referral information, such as primary care workups, treatments and testing results, to the other specialist offices electronically. These specialists can then respond to the referrals electronically, advising family physician offices of referral acceptance, appointment dates and times and any additional information within days of receiving the referral request. Want to learn more? Ms. Brie DeMone offers an overview of the government of Manitoba's project to improve communication and coordination between family physicians and other specialists. "Bridging General and Specialist Care" and "the Catalogue of Specialized Services". www.cfpc.ca/BGSCTQVI In January 2009, the web-based Catalogue of Specialized Services (CSS) was launched, which, is, according to provincial director of patient access Dr. Luis Oppenheimer, "like a catalogue order entry system. If you're a GP/FP looking for a service, you will get a catalogue of who provides that service, [...] some idea of the waiting time or capacity for that service [...] and have immediate confirmation of whether [your request] is accepted." By clearly providing family physicians and their offices with information on "who does what", referrals can be accurately directed to the right specialist at the right time, saving time and effort for the family physician, other specialist and patient (42),(43). A third new initiative currently underway in Manitoba, the Patient Access Registry Tool (PART), will provide other specialists with the clinical information they need to manage patient demand. Patient demographics and provider information as well as a diagnosis and planned interventions will be available through this tool and it will also document several key wait time dates, including when a referral was first received, the date of the first specialist consultation and when a patient is ready for treatment. Once it is fully operational, PART will capture information on all patients needing a medical consultation or surgery in Manitoba. (44) British Columbia offers a Full Service Family Practice Program with a broad range of incentives The Nova Scotia agreement includes new Chronic Disease Management Incentives that will be linked to guideline-based care for chronic diseases such as diabetes, chronic heart failure and hypertension Given the wide spectrum of illnesses that are assessed in a primary care setting, any approach to developing wait time targets must be done in consultation with family physicians and with clinical guidelines in mind. Currently there is simply not enough information available to establish reasonable wait time targets. The ability to accurately measure and monitor access at all points along the care continuum will require a significant investment in information infrastructure and this system must be in place and used effectively before targets are developed. More importantly, this cannot be effectively implemented without coordinated support from all governments. The Manitoba Government is a pioneer with this particular effort and their pilot projects will be closely monitored for effectiveness. C. Remuneration Models Since the early 1990s there has been a steadily declining trend in fee-forservice (FFS) as the sole mode of payment for family physicians. In 1990, the CMA's Physician Resource Questionnaire (PRQ) survey results showed that 71% of family physicians received 90% or more of their professional income from FFS.45 Subsequent PRQ surveys showed successive decreases and on the 2007 NPS, fewer than one out of two (48%) family physicians reported receiving 90% or more of their income from FFS. 15 While the majority of physicians continue to receive some income from FFS, increasingly it is being blended with other remuneration methods. A blended payment model known as the Family Health Network is now available in Ontario. In this model, capitation accounts for about 65% of a family physician's remuneration. The remainder consists of fee-for-service and other incentive payments and premiums. Over the past decade there has been an international trend towards the adoption of "pay-for-performance" (P4P), in which a variety of payment incentives are used to promote certain physician behaviours. To date, these incentives have been used mainly to encourage process improvements in the delivery of care. The earliest forms of P4P focused on prevention screening, but more recently they have expanded to address chronic disease management. P4P generally works by linking a bonus payment to the achievement of a specific performance target in the patient population. In its new primary care models, Ontario provides bonus payments for cancer prevention screening and diabetes management, as well as other incentives for activities including palliative care and care for patients with serious mental illness. (46) Similarly, British Columbia offers a Full Service Family Practice Program with a broad range of incentives. (47) The recently concluded Nova Scotia agreement includes new Chronic Disease Management Incentives that will be linked to guideline-based care for chronic diseases such as diabetes, chronic heart failure and hypertension.(48) As previously noted, several jurisdictions also provide incentives to acquire new patients. Internationally the UK has gone further by providing a bonus to the attainment of timely access targets as reported by patients. However, the UK also has a long-established rostering system and it has a much less geographically dispersed population than does Canada. Nonetheless it might be interesting to assess the potential for incentives to enhance access to primary and specialty care in Canada. D. Electronic Medical Records Regardless of how a wait time management strategy might be implemented (e.g., at the level of the province, health region, hospital) it will be critical to be able to capture and monitor referral data electronically, starting with the family physician. It may be seen in Table 1 below that according to the 2007 National Physician Survey, there remains a large gap in this regard. Nationally almost two out of three family physicians (63%) continue to use paper charts as their method of record keeping. One out of five (19%) uses a combination of electronic and paper charts while just over one out of 10 (12%) report using electronic charts instead of paper charts.Across the country there is more than two-fold variation of those using paper charts ranging from a low of 36% inAlberta to a high of 81% in PEI and Quebec. [TABLE 1. SEE PDF] Internationally, the Commonwealth Fund has shown that Canada lags far behind comparator countries in the uptake of electronic medical records (EMRs). On its 2006 survey of primary care physicians in seven countries, fewer than one out of four (23%) Canadian respondents reported that they used EMRs in their offices compared to nine out of ten in the UK, New Zealand and the Netherlands.(49) Aside from the issues of wait times for those patients with a family physician there is also the challenge of capturing information about access to primary medical care for those without their own family physician. E. Practice Support Improvements in access to family physicians can also be accomplished through the addition of staff support, of which there are two types: 1 clinical practice support(ie nurse or MOA for patient care),and 2 change management practice support (those with knowledge of clinical practice redesign to support physicians in making, monitoring and sustaining change). The Practice Support Program in British Columbia offers training and financial incentives for family physicians working with medical office assistants and in one district health authority in Nova Scotia, a project is underway where family physicians can obtain financial support to employ family practice nurses through enhanced fee-for-service billings. At present, however, widespread deployment of practice support personnel is constrained by rules of fee-for-service payment that require the physician to have direct contact with each patient for whom a service is billed to the provincial or territorial medicare plan. In terms of change management practice support, thus far CPR has had limited uptake in the rest of the country, primarily due to a lack of awareness. However, stories of the successes with this program are now being heard in the rest of the country and it is increasing in popularity. For example, a new Advanced Access initiative has been recently introduced in Manitoba through their Ministry of Health. In Nova Scotia, one practice that has had great success with Advanced Access is managed by the 2008 recipients of the Health Care Provider of the Year Award in Cape Breton, Elaine Rankin and Steven MacDougall. They worked together on an Advanced Access research project beginning in 2006. Once Dr. MacDougall cleared his patient wait list, he began to operate a same day access practice where his patients can call in the morning for an appointment that day. Now, the number of non-urgent patients from his practice who go to the emergency department has dropped by 28%. 50 By all accounts, those who have implemented CPR indicate they would never return to the traditional model where the appointment schedule is full before the work day starts. CPR is not a tool to be used exclusively in family practices. The group urology practice in Saskatchewan that introduced the notion of pooled referrals with much success has also been engaged in the process of CPR since early 2007. Their practice is now beginning to enjoy the fruits of their labour through reduced wait times for patients who are referred to their practice. The "champion" of this undertaking, Dr. Visvanathan, noted that Clinical Practice Redesign involves improving practice work flow, the introduction of Electronic Medical Records and getting the right staff to do the right jobs. (40) The implementation of a more efficient practice management system such as CPR requires commitment from physicians as well as effective information management and measurement tools, additional practice support and assistance from change management experts. Experience to date suggests that these efforts pay off in terms of improved patient access and increased capacity to accommodate patient appointments. Recommendations There are three main issues that should concern our focus on primary care wait times: - Access to primary care for those without a family physician; - Access to primary care for those with a family physician; and - Referral from primary to more highly specialized care. There are general recommendations that would help address these issues and other recommendations that are more specific to each. This paper has provided valuable information that supports the following recommendations. General Recommendations As noted in the introduction to this paper, it is difficult to measure primary care wait times for myriad illnesses and conditions, and this difficulty may impede progress in finding solutions to the wait time challenges that family doctors experience. The Primary Care Wait Time Partnership (PCWTP) believes that the ability to measure and track wait times along the full continuum of the patient's care is of utmost importance, but that this capacity in primary as well as more highly specialized levels of care is still very limited. 1) Primary care wait time tracking, analysis and improvements should be patient-centred, taking into account the whole wait time continuum that patients experience, starting from the time they first seek medical care. 2) More research and evaluation is needed to analyze primary care wait times so that the inequities and inconsistencies in access to care can be addressed for patients from region to region across Canada. 3) More study on collaborative care is necessary. The PCWTP recognizes that collaboration has the potential to enhance access to primary care. But before we can state with certainty that access to primary care is improved through particular models of care delivery, we need to continue to collect data and analyze results. It makes little sense to invest tremendous resources into any model if patient access to primary care is not improved. 4) Primary care wait time measurement should be a priority for Canadian governments, health authorities and other stakeholders, (e.g. Canadian Institute for Healthcare Information). Reliable data that represents the patient's total wait time experience will need to be collected to support the development of primary care wait time targets in the future. This data must be validated and tracked for the purpose of continuous evaluation. 5) Before reasonable wait time targets can be established and effectively used in primary care, information infrastructures, (e.g. electronic medical records and communication tools) , must be adequately supported and in place. Enhancements in information technology and learning in family practice will be necessary to facilitate the adoption and widespread use of electronic medical records. No measuring or tracking of primary care wait times can be effectively accomplished without financial support from government for electronic communication systems in and between medical practices. 6) There are a number of jurisdictions pursuing important and different ways to improve timely access to care for patients, (e.g. Manitoba's catalogue system and registry tool, Alberta's formal service agreements between referring and consulting physicians). These worthwhile endeavours should be monitored at a national level for opportunities to implement more universal improvements to wait times in our Canadian health care system. Recommendations for Patients without a Family Physician The CFPC and CMA have recommended and supported several strategies to increase the supply of family physicians through education and training (e.g. promotion of family medicine to medical students and residents, better support for preceptors and teachers), to address changing patterns of family practice (e.g. supports for inter-professional collaboration), and to develop models of care that would attract and retain family physicians (e.g. blended remuneration methods). While these recommendations will not be repeated here, they should be given full consideration in seeking to achieve an adequate family physician workforce that can support timely access to care for all Canadians. 1) The PCWTP believes that every Canadian should have a family doctor and supports the CFPC position that all stakeholders, (e.g. governments, medical schools and professional organizations), should work together to achieve a target of 95% of the population in every Canadian community with a family doctor by 2012. 2) Patient registries should be developed and maintained to track patients who do not have a family doctor and are actively looking for one. 3) Other strategies should be more fully developed and supported to find family doctors for patients without a family doctor , (e.g. physician incentives to accept new patients and the use of tools for workload management and patient flow in family practice). 4) Efforts currently underway to integrate appropriately trained and certified international medical graduates as family physicians into our health care system are welcome, should be supported and enhanced. Recommendations for Patients who have a Family Physician 1) Family physicians who see a need to improve timely access to care for their patients could consider Clinical Practice Redesign tools such as Advanced Access . System support should be in place for family physicians who want to adopt these tools. The training and ongoing learning of new and practicing family physicians should include education in practice flow and design. To further assist physicians in the use of these tools, websites should be established with lists of those who have been successful at improving patient flow through their practices and who are willing to assist others attempting to do the same. 2) Practice management education and training should be enhanced in residency in order to teach new family physicians about effective office processes and practice flow efficiencies that improve timely access to care for patients, (e.g. electronic tracking tools). 3) Financial incentives should be available to support the valuable roles of office assistants as well as other health professionals in family practice, (e.g. family practice nurses), for better patient flow and more efficient use of the physician's time. In addition, family physician remuneration should compensate for patient encounters beyond just face-to-face in order to support increasingly important opportunities for electronic encounters with patients and members of the care team. Recommendations for Referral from Primary to Specialty Care 1) All recommendations to address timely access to more highly specialized care must include the wait time from the first visit with the family physician to referral and specialty consultation. 2) Based on four years' experience with benchmarks for the five procedural areas established in 2004, we do not believe it is possible to develop a broad array of condition-specific, evidence-based benchmarks for access to consultations in the near future. However, where they are or do become available and are supported by sufficient infrastructure, wait time targets should be used as guides to drive improvements in timely access to care. Nonetheless, family physicians must continue to be free to use their clinical judgment in the patient's best interests. 3) Good intra-professional relationships between family physicians and other specialists should be promoted and supported in the health care system to improve communications and the continuity of care for patients. Strategies to support good relationships should consider recommendations that have been developed by the Canadian Medical Protective Association as well as the Collaborative Action Committee on Intra-professionalism that is supported by the CFPC and Royal College of Physicians and Surgeons of Canada with CMA participation. 4) Tools that will improve the timeliness of the referral-consultation process between physicians should also be enhanced; however, any development of referral-consultation process tools must be undertaken collaboratively with family physicians, (e.g. referral-consultation frameworks that identify and support the availability of appropriate and timely information to and from referring and consulting physicians, electronic communication of patient information between physicians, and better system supports for electronic communication between physicians and patients). 5) Family physicians should have access to routine and advanced diagnostic tests for their patients in all clinical settings, equal to that of other specialists. There should be no difference in the criteria for access to advanced diagnostic testing from region to region. All physicians should be expected to follow appropriate clinical guidelines in the use of diagnostic tests. These guidelines should be readily available and easily understood by physicians and other health care professionals with whom they work. 6) Guidelines or targets for timely access from primary to specialty care must account for differences in geographic settings and proximity to care that are characteristic of rural and remote locations in contrast to urban and suburban locations. Concluding Remarks While the Canadian Medical Association (CMA) and The College of Family Physicians of Canada (CFPC) are proud to represent doctors across Canada, at the centre of everything we do stands the patient. We know that many Canadians are concerned about timely access to see their own family doctor while others continue a sometimes fruitless search for a family doctor of their own. In this paper we have presented many problems but also a number of solutions to addressing wait times in primary care. We've acknowledged that there are obstacles, but we do not think these obstacles are insurmountable. Canadians exercised considerable political courage, often in the face of adversity, to pioneer a health care system based on the principles of fairness, equality and social justice. Through political will, we are certain we can make the changes necessary to ensure timely access to primary care. The PCWTP hopes that governments, health care providers and the public will read this report and consider the recommendations. We know that these recommendations do not represent an exhaustive list and indeed we may have inadvertently omitted something you think is critical. We encourage you to let us know what you think and how we can work together to improve access to primary care. 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