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Advance care planning

https://policybase.cma.ca/en/permalink/policy13694
Date
2017-05-27
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Date
2017-05-27
Replaces
Advance care planning (2015)
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
Text
With the advent of technology allowing for the extension of life, and as a result of the increasing importance of personal autonomy, decisional capacity, and informed consent and the growing awareness of issues related to quality of life and dying, Canadians have become increasingly interested in expressing their wishes regarding their health care and having more input into decisions about their care should they become incapable. Advance care planning (ACP) can help patients to achieve these goals. The CMA supports development of a strategy for ACP1 in all provinces and territories. ACP leads to better concordance between patients' wishes and treatments provided,2,3 decreased anxiety for families,4 decreased moral distress for health care providers,5 decreased hospitalization rates of nursing home residents3 and fewer unnecessary medical treatments.3,6,7 ACP is at the intersection of the provision of health care, ethical values and legal rights and duties. In particular, it involves the acknowledgement of essential aspects of autonomy, informed consent, and respect of patients' care wishes now and in the future, and their intentions if they become incapable.8,9 The balancing of the need to obtain informed consent for a treatment option in the present with the need to respect health care preferences that were stated in the past has been addressed using various clinical, legal and institutional approaches across Canadian jurisdictions." Physicians10 can play a significant role in ACP throughout the course of the patient-physician relationship, including in the pediatric setting. At any time, outcomes of the planning process can be documented and/or the patient can appoint a substitute decision-maker in writing. These documents can be identified as advance directives, personal directives or powers of attorney for personal care11 (hereinafter all will be referred to as advance directives). An advance directive does not remove the need for a physician to obtain consent before providing a treatment to a patient, except in an emergency. As stated in the Canadian Medical Protective Association's consent guide: "[U]nder medical emergency situations, treatments should be limited to those necessary to prevent prolonged suffering or to deal with imminent threats to life, limb or health. Even when unable to communicate in medical emergency situations, the known wishes of the patient must be respected."12 While much of the focus of ACP is on making care decisions and nominating proxy decision-makers in case the patient becomes incapable of making decisions in the future, ACP has much more utility. ACP conversations13 can assist patients in determining treatment trajectories and making decisions about the intensity level of interventions in their current care. Providers can have discussions with patients and their families about proposed treatments in the context of the patient's communicated goals and wishes. The process of ACP also helps patients and their families to become familiar with the language and processes used to make cooperative health care decisions. SCOPE OF POLICY This policy aims to provide guidance on key considerations pertinent to ACP in a way that is consistent with a physician's ethical, professional and legal obligations. This is a complex subject: physicians should be aware of the legislation in the jurisdiction in which they practise, the standards and expectations specified by their respective regulatory authority, as well as the policies and procedures of the setting(s) in which they practise (e.g., regional health authority, hospital). GENERAL PRINCIPLES 1. ACP is a process of (a) respecting patients' wishes through reflection and communication, (b) planning for when the patient cannot make health care decisions and (c) discussion with friends, family and professionals; (d) it may result in a written document.5 It informs the substitute decision-maker and provides information for the clinician to consider in the provision of care within the bounds of the law. 2. Although often associated with the end of life, ACP represents the expression of a patient's wishes for any future health care when the patient is incapable. It expresses the patient's values and beliefs regarding current care decisions and provides information that can inform any decisions that must be made during an emergency when the patient's consent cannot be obtained. For these reasons, ACP should occur throughout a person's lifetime. 3. Respect for patients' dignity and autonomy is a cornerstone of the therapeutic physician-patient relationship. Patients' right to autonomous decision-making has become embedded in ethical frameworks, consent legislation and case law.14 Respect for the wishes of an incapable patient constitutes a preservation of autonomy and promotes trust between the physician and patient.15 4. The way in which the act of obtaining consent is weighed against the patient's stated wishes as outlined during the ACP process varies according to the jurisdiction in which the patient and physician are located. EDUCATION 1. Given the practical, ethical and legal complexities of ACP, physicians, medical learners should be supported in becoming familiar with ACP and comfortable in engaging in the process with their patients. To this end, CMA supports the development of training in ACP and efforts to make it available to all physicians and medical learners.16 For practising physicians and residents, many resources are available, for example: a. Advance Care Planning in Canada: A National Framework b. Facilitating Advance Care Planning: An Interprofessional Educational Program c. Information from the Health Law Institute of Dalhousie University on the regulatory policies and legislation of individual provinces and territories d. A comprehensive collection of Canadian resources compiled by the Speak Up campaign of the Advance Care Planning in Canada initiative e. Pallium Canada's Learning Essential Approaches to Palliative Care module on ACP In the case of medical students, the CMA supports the position of the Canadian Federation of Medical Students that end-of-life training is an essential facet of undergraduate medical education. 2. The issue of the supervision of medical learners practising ACP should be clarified, as considerable ambiguity currently exists.17 Medical learners would benefit from unified national guidelines concerning the nature of their participation in ACP, especially regarding end-of-life care. In the case of medical students, the CMA agrees with the recommendation of the Canadian Federation of Medical Students that supervision be mandatory during conversations about end-of-life care. 3. The CMA calls for more research on the outcomes associated with the provision of ACP training to physicians and medical learners. 4. The CMA recommends that governments and institutions promote information and education on ACP to patients and their substitute decision-makers. PROFESSIONAL AND LEGAL RESPONSIBILITY 1. While respecting patients' values, all physicians are expected to encourage their patients to engage in ACP with them. ACP is not a one-time event. The nature of the conversation between the physician and the patient and the regularity with which they discuss the subject will depend on the patient's health status. Family physicians and physicians have ongoing care relationships with chronically ill patients are particularly well placed to have regular discussions with their patients about their beliefs, values and wishes. An effective exchange of information between family physicians (and other physicians who work in the community with outpatients) and acute or tertiary care physicians would assist in ensuring patient's wishes are considered. 2. ACP, in particular advance directives, are at the intersection of medicine and the law. Physicians should recognize this and ask patients whether they have an advance directive or have done any ACP. 3. There is wide variation across jurisdictions in terms of the requirements and procedures for ACP; therefore, physicians should inform themselves about any relevant legislation and the scope of the requirement to obtain consent within that jurisdiction when carrying out ACP. INSTITUTIONS 1. The CMA supports institutional processes that recognize and support ACP. Support for ACP includes developing a consistent process for the exchange of information about patients' wishes and advance directives among health care providers, as patients traverse sectors and locations of care. Patients with a written advance directive must be identified and the advance directive integrated fully within the patient's records18 so that it is available across the institution (and ideally the health care system). The CMA advocates for the inclusion of advance care directive functionality as a conformance and usability requirement for electronic medical record vendors.19 Provinces and territories should be encouraged to establish robust organizational processes and resources for patients in all locations of care and strong province- or territory-wide policy, such as in Alberta.20 2. Institutions and other organizations should encourage health care providers to ask patients to bring their advance directive to appointments at the same time they ask them to bring a list of their medications or other medical information. 3. The CMA supports institutional/organizational audits of structures, processes and outcomes related to ACP as an important step in improving the quality and frequency of ACP activities. ROLE FOR GOVERNMENTS 1. The CMA supports infrastructures enabling ACP, including funding that will support ACP and other end-of-life discussions. 2. The CMA promotes the incorporation of ACP into future federal and provincial/territorial senior strategies and dementia and/or frailty strategies. 3. The CMA supports the development of ACP metrics and their future inclusion in Accreditation Canada standards. GLOSSARY Advance care planning (ACP) Advance care planning is a term used to describe a process of reflection, communication, conversation and planning by a capable individual with family, friends and professionals about their beliefs, values and wishes for a time when they no longer have the mental capacity to make decisions about their health care. ACP can also involve the naming of a substitute decision-maker.8 Advance directive The legislated term "advance directive" has different names, definitions and legal authority across the country. For example, in British Columbia an advance directive is a written legal document that provides a mechanism for capable patients to give directions about their future health care once they are no longer capable. 21 As such, in BC an advance directive may, under certain circumstances, be considered "equivalent to consent to treatment and may be acted upon directly by a health care provider without consultation with an SDM [substitute decision-maker]." 8 In Alberta it is called a personal directive. In Ontario, "advance directive" is a generic non-legal term and refers to communications that may be oral, written or in other forms.8 In Quebec, advance care directives are legally binding, as set out in the Act respecting end-of-life care, which recognizes "the primacy of freely and clearly expressed wishes with respect to care. . ."22 Current legislation does not allow for medical assistance in dying to be requested by an advance directive.23 The CMA acknowledges that considerable public, expert and legal debate exists around the issue. Informed consent To obtain informed consent, physicians must provide adequate information to the patient or capable decision-maker about the proposed procedure or treatment; the anticipated outcome; the potential risks, benefits and complications; and reasonable available alternatives, including not having the treatment; and they must answer questions posed by the patient. Consent is only informed if there is disclosure of matters that a reasonable person in the same circumstances would want to know.24 Consent must be given voluntarily, must not be obtained through misrepresentation or fraud, must relate to the treatment and must be informed. Substitute decision-maker (SDM or agent or proxy) A substitute decision-maker is a capable person who will make health care decisions on behalf of an incapable individual. In all jurisdictions the health care provider must take reasonable steps to become aware of whether or not there is a substitute decision-maker before providing health treatment to an incapable patient. Legally there are implementation differences across the country. For example, in BC a substitute decision-maker is appointed through a representation agreement, in Alberta through a personal directive and in Ontario through a power of attorney for personal care. Approved by the CMA Board of Directors May 2017 1 Canadian Medical Association. Policy resolution GC14-25 - strategy for advance care planning, palliative and end-of-life care. Ottawa (ON): The Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 Oct 17) 2 Houben CHM, Spruit MA, Groenen MTJ, et al. Efficacy of advance care planning: a systematic review and meta-analysis. J Am Med Dir Assoc 2014;15:477-89. 3 Martin RS, Hayes B, Gregorevic K, et al. The effects of advance care planning interventions on nursing home residents: a systematic review. J Am Med Dir Assoc 2016;7:284-93. 4 Mack JW, Weeks JC, Wright AA, et al. End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol 2010;28(7):1203-8. 5 Canadian Hospice Palliative Care Association. Advance care planning in Canada: national framework. Ottawa; The Association; 2010. 6 Teo WSK, Raj AG, Tan WS, et al. Economic impact analysis of an end-of-life programme for nursing home residents. Palliat Med 2014;28(5):430-7. 7 Zhang B, Wright AA, Huskamp HA, et al. Health care costs in the last week of life: associations with end-of-life conversations. Arch Intern Med 2009;169(5):480-8. 8 Wahl J, Dykeman MJ, Gray B. Health care consent and advance care planning in Ontario. Toronto (ON): Law Commission of Ontario; 2014. 9 Canadian Medical Association. CMA Code of Ethics (update 2004). Ottawa: The Association; 2004. 10 Physician involvement is not mandatory in the process. However, it is important for physicians to engage with their patients in ACP as this can facilitate change in patients' ACP behaviour and understanding. 11 Wahl JA, Dykeman MJ, Walton T. Health care consent, advance care planning, and goals of care practice tools: the challenge to get it right. Improving the last stages of life. Toronto (ON): Law Commission of Ontario; 2016. 12www.med.uottawa.ca/sim/data/Images/CMPA_Consent_guide_e.pdf 13 Frank C, Puxty J. Facilitating effective end-of-life communication - helping people decide. CJS Journal of CME 2016;6(2). Available: http://canadiangeriatrics.ca/wp-content/uploads/2017/02/Facilitating-Effective-End-of-Life-Communication---Helping-People-Decide.pdf (accessed 2017 April 25). 14 Fleming v Reid (1991) 82 DLR (4th) 298 (CA ON); Cuthbertson v Rasouli, 2013 SCC 53; Malette v Shulman (1990), 72 OR (2d) 417; Starson v Swayze (2003) 1 SCR 722. 15 Harmon SHE. Consent and conflict in medico-legal decision-making at the end of life: a critical issue in the Canadian context. University of New Brunswick Law Journal 2010;60(1):208-29. 16 Canadian Medical Association. Policy resolution GC13-69 - training in advance care planning. Ottawa (ON): The Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 May 26). 17 Touchie C, De Champlain A, Pugh D, et al. Supervising incoming first-year residents: faculty expectations versus residents' experiences. Med Educ 2014;48(9):921-9. 18 Canadian Medical Association. Policy resolution GC14-19 - advance care plans. Ottawa (ON): The Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 May 26). 19 Canadian Medical Association. BD14-05-163 Advance care directive functionality. Ottawa (ON): The Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 May 26). 20 Conversations matter. Edmonton (AB): Alberta Health Services. Available: http://goals.conversationsmatter.ca.s3-website-us-east-1.amazonaws.com/ (accessed 2017 May 19). 21 Health Care (Consent) and Care Facility (Admission) Act, RSBC 1996, c 181, s.3 22 Act respecting end-of-life care, S-32.0001. Government of Quebec. Available : http://legisquebec.gouv.qc.ca/en/ShowDoc/cs/S-32.0001 23 An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) S.C. 2016, c.3. Ottawa: Government of Canada; 2016. Available: http://canlii.ca/t/52rs0 (accessed 2016 Oct 17) 24 Riebl v Hughes, [1980] 2 SCR 880; Hopp v Lepp, [1980] 2 SCR 192.
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
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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).
Documents
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The physician appointment and reappointment process 2016

https://policybase.cma.ca/en/permalink/policy13564
Date
2016-12-03
Topics
Health human resources
Physician practice/ compensation/ forms
  1 document  
Policy Type
Policy document
Date
2016-12-03
Topics
Health human resources
Physician practice/ compensation/ forms
Text
Beginning in the 1990s most jurisdictions established regional health authorities (RHAs) with consolidated medical staff structures and there has been a trend toward requiring all physicians practising in a region to hold an appointment with the RHA in order to access health resources such as diagnostic imaging and laboratory services, irrespective of whether they hold hospital privileges or not. Subsequent to the consolidation of medical staff governance there have been several developments over the past decade that have implications for where and how physicians can practise, and for their ability to advocate freely on behalf of their patients. These include: * the establishment of formal physician resource plans that link the appointment process to the ability to participate in the provincial/territorial medical insurance plan; * a greater focus on clinical governance that includes detailed attention on scope of practice and privileges; * a growing concern about the ability of physicians to advocate on behalf of their patients and the communities they serve; and * an increase in the number of physicians entering into employment or contractual arrangements. The Canadian Medical Association (CMA) puts forward the following recommendations for governments, regulatory authorities, RHAs and medical staff structures within RHAs and hospitals. Recommendations Where physician appointments are to be approved in relation to Physician Resource Plans, the CMA recommends that such plans must: * take into consideration both population need and projected physician supply; * include transparency in the provision of information about available practice opportunities and on the criteria and processes through which applications for appointments are approved; * be based on a documented methodology with results in the public domain; and * be based on a medium-term projection range, using the most current and reliable data available, and be regularly reviewed and updated. The CMA recommends that the application of standardized credential templates must take into consideration the quality of care being provided by the physician and local circumstances such as the complement of medical and hospital resources available locally and the timeliness of proximity to secondary and tertiary care. The CMA strongly supports the implementation of policy to safeguard physicians from fear of reprisal and retaliation when speaking out as advocates for their patients and communities, and the right and duty of medical officers of health to speak publicly to the citizens they serve. The CMA supports provincial/territorial amendments to public health legislation to protect the right and duty of medical officers of health to speak publicly to the citizens they serve without political interference or risk of adverse employment consequences. The CMA believes that medical staff bylaws should expressly extend to physicians under contract entitlement to the procedural protections set out in the hospital or health authority bylaws. The CMA recommends that the processes of granting appointments, reappointments and privileges and allocating resources respect the following principles: 1. All processes should be fair, equitable, documented and transparent and should protect confidentiality. 2. Criteria for reappointment should be clearly specified in medical staff bylaws and should be no more onerous than necessary to verify the ongoing provision of quality care by the medical staff. 3. A regular evaluation of appointed physicians should be conducted by the appropriate clinical chief. 4. The quality of a physician's care is the most important criterion to be considered at the time of appointment, reappointment and the granting of privileges. 5. The information required for the granting of appointments, reappointments or privileges or for the allocation of medical resources must be accurate, valid and appropriate. 6. The processes of granting appointments, reappointments and privileges and allocating resources should recognize and accommodate the changes in practice patterns that may occur over the medical career cycle. 7. Physicians with established community practices have a significant investment in their practice and the community; this investment should be considered at the time of reappointment or change in privileges. 8. A recommendation, without just cause, to withdraw an appointment, to restrict privileges or to significantly reduce resources available to a physician must include appropriate compensation based on individual circumstances. 9. The reporting of legal actions or disciplinary actions as part of the reappointment or reappointment process should be restricted to those matters in which a final determination has been rendered and in which there has been an adverse finding to the physician. Objective This policy outlines the principles that should be considered for the granting of physician appointments, reappointments, privileges and access to resources at the health care facility, district or RHA level. Key definitions Appointment: The process by which a physician joins the medical staff of a health region or health facility in order to access resources to care for patients. Credentialing: An approach to obtaining, verifying and assessing the qualifications of a health professional against consistent criteria for the purposes of licensing and/or granting privileges.1 Privileges: Permission from an authorized body to a health care provider to conduct a specific scope and content of patient care. Privileges are granted based upon an evaluation of the provider's training, experience and competence related to the service, and are specific to a defined practice setting.1 Clinical peer review: The process by which physician peers assess each other's performance. A peer is a physician with relevant clinical experience in similar health care environments who also has the competence to contribute to the review of other physicians' performance.2 Background Historically the formal appointment process applied to physicians wishing to practise in hospitals. Beginning in the 1990s most jurisdictions established RHAs with consolidated medical staff structures and there has been a trend toward requiring all physicians practising in a region to hold an appointment with the RHA in order to access health resources such as diagnostic imaging and laboratory services, irrespective of whether they hold hospital privileges or not. Since the CMA first adopted principles for the physician appointment and reappointment process in 1997 there have been several developments that are reviewed below: * the establishment of formal physician resource plans that link the appointment process to the ability to participate in the provincial/territorial medical insurance plan; * a greater focus on clinical governance that includes detailed attention on scope of practice and privileges; * a growing concern about the ability of physicians to advocate on behalf of their patients and the communities they serve; and * an increase in the number of physicians entering into employment or contractual arrangements. Physician Resource Plans (PRPs): New Brunswick was the first province to require physicians to have privileges with an RHA in order to obtain a billing number.3 More recently jurisdictions such as Nova Scotia (N.S.) have introduced medium to longer range PRPs that are to be used when approving new appointments. In 2012 N.S. released a PRP for 2012-2021, which has since been updated to 2013-2022.4 Under the terms of the Nova Scotia Health Authority Medical Staff Bylaws, the RHA CEO or their designate will assess applications for new appointments in relation to need and availability of resources. The assessment is to be completed within 60 days and there is no right of review or appeal of the CEO's decision.5 Manitoba's medical staff bylaws make a similar provision.6 While Ontario has not regionalized to the same extent as other jurisdictions, legislation has been introduced that proposes to make the 14 Local Health Integration Networks (LHINs) responsible for primary care planning and performance management.7 Moreover the Bill will amend the Health Insurance Act to authorize the health minister to delegate non-fee-for-service physician compensation to the LHIN. Recommendation Where physician appointments are to be approved in relation to PRPs, the CMA recommends that such plans must: * take into consideration both population need and projected physician supply; * include transparency in the provision of information about available practice opportunities and on the criteria and processes through which applications for appointments are approved; * be based on a documented methodology with results in the public domain; and * be based on a medium-term projection range, using the most current and reliable data available, and be regularly reviewed and updated. Other physician resource planning considerations are set out in the CMA's comprehensive policy on PRPs.8 Clinical governance: Since the late 1990s there has been a great deal of attention paid to the concept of clinical governance, which may be defined as the structures, processes and culture needed to ensure that health care organizations and all individuals within them can assure the quality of the care they provide and are continuously seeking to improve it. During the past decade several provinces have carried out inquiries related to problems with pathology and radiology. In British Columbia (B.C.) the Chair of the BC Patient Safety & Quality Council conducted a review of the medical imaging credentialing and quality assurance that reported in 2011. In his final report, Dr. Douglas Cochrane set out 35 recommendations that called for much more rigorous and uniform oversight of medical practice in B.C.9 The recommendations included a call for: * the creation of a single medical staff administration to serve all health authorities and affiliated organizations; * the development of standardized processes for medical staff appointment, and credentialing and privileging, including common definitions; and * the development of performance assessment and review process for all physicians.9 The Cochrane report has resulted in the British Columbia Medical Quality Initiative (BC MQI). BC MQI is implementing an online Provincial Practitioner Credentialing and Privileging System (CACTUS Software) that will be used by all of B.C.'s RHAs to manage these processes for physicians, midwives, dentists and nurse practitioners.10 BC MQI has developed 62 privileging dictionaries for medical directors and department heads to use with their colleagues during initial and renewal privileging processes. The dictionaries recommend the required current experience to perform a certain activity in the form of numbers where applicable and also recommend the requirements for renewal of privileges and the requirements for return to practice. These recommendations are meant to take into account the individual's own experience and the context of the local site in which they work. They are meant to begin a conversation as needed with the department head, colleagues and others. The Society of Rural Physicians of Canada (SRPC) has raised concerns about the potential impact of volume-based credentialing on rural medical practice. For example, the dictionary for Family Practice with Enhanced Surgical Skills recommends that for operative delivery, a volume of at least five caesarean section deliveries be performed per year averaged over 24 months.11The SRPC has put forward recommendations that emphasize the need for appropriate peer review and consideration of geographic diversity and the range of medical practice, and that credential revalidation should be based on the actual quality of care provided by the physician, the continuing medical education completed by the physician and should also consider the impact of changes in delivery on the health outcomes in the community.12 It seems likely that other jurisdictions will be watching the CACTUS program with interest. Recommendation The CMA recommends that the application of standardized credential templates must take into consideration the quality of care being provided by the physician and local circumstances such as the complement of medical and hospital resources available locally and the timeliness of proximity to secondary and tertiary care. Advocacy: Advocacy has been identified as one of seven core roles of every physician by the Royal College of Physicians and Surgeons of Canada13 and the College of Family Physicians of Canada.14 This role entails physicians using their expertise and influence in the interests of their individual patients and the communities and populations they serve. Over the past decade there have been several instances where physicians have either expressed concern about their ability to advocate or have had disciplinary action taken against them, likely as a result of their advocacy activities. As a result of an inquiry carried out by the Health Quality Council of Alberta, the Alberta Medical Association, Alberta Health Services and the College of Physicians and Surgeons of Alberta have adopted a joint policy statement that sets out guidelines for physician advocacy.15 Eastern Health in Newfoundland and Labrador has a privacy/confidentiality oath or affirmation for physicians that acknowledges that they may have professional standards for disclosure and advocacy regarding patient safety, but stipulates the expectation that such concerns be first addressed through Eastern Health as an initial step.16 The CMA's policy on the evolving professional relationship between physicians and the health care system sets out nine factors for physicians to consider before undertaking advocacy.17 As predominantly employees of some level of government, and with a responsibility to sound an alert on population health risks, public health physicians are at greater risk of being disciplined for advocacy. There have been two high profile cases of public health physicians who have been dismissed for advocacy-related activities since 2000. Thus far only B.C. has enacted public health legislation to protect medical officers of health from political interference and adverse employment consequences. B.C.'s Public Health Act stipulates that the provincial health officer (PHO) has a duty to advise on provincial public health issues, which includes public reporting where the PHO believes it will best serve the public interest. Similarly sub-provincial medical health officers must advise on local public health issues and publicly report on them after consultation with the PHO. B.C.'s legislation also provides health officers with immunity from legal proceedings for actions done in good faith in the performance of their duties and for reports they are required to make. In addition the legislation protects health officers from "adverse actions", defined as an action that would either affect or threaten "the personal, financial or other interests of a person, or a relative, dependent, friend or business or other close association of that person" as a result of performing their duties in good faith.18 Recommendations The CMA strongly supports the implementation of policy to safeguard physicians from fear of reprisal and retaliation when speaking out as advocates for their patients and communities, and the right and duty of medical officers of health to speak publicly to the citizens they serve. The CMA supports provincial/territorial amendments to public health legislation to protect the right and duty of medical officers of health to speak publicly to the citizens they serve without political interference or risk of adverse employment consequences. Growing employment/contractual relationships: The move to RHAs, consolidation in the hospital sector and changing delivery models have had significant implications for the relationships between physicians and hospitals. The Canadian Medical Protective Association (CMPA) has identified several areas of concern, including patient advocacy, reporting of physicians, responding to adverse events, collection and use of physician information, practice arrangements and liability provision.19 One issue that the CMPA has highlighted in particular is the increasing trend in some jurisdictions for physicians to be engaged on a contracted employee basis rather than as independent contractors appointed with privileges.20 This is seen among facility-based physicians such as hospitalists, clinical and surgical assistants and laboratory physicians. The CMPA has cautioned that physicians engaged on a contractual basis may not have the same procedural rights on termination of contracts as those engaged under the privileging model and it has issued guidance on issues to consider with individual contracts, including CMPA assistance, indemnification clauses, liability provisions, confidentiality, termination of contract, dispute resolution and governing law.21 Recommendation The CMA believes that medical staff bylaws should expressly extend to physicians under contract entitlement to the procedural protections set out in the hospital or health authority bylaws. Principles Physicians must take a leadership role and be active participants in the development of appointment, reappointment and related processes; medical communities must therefore be aware of the basic principles that should be reflected in these processes. Once a physician has obtained a licence to practice, the process of appointment approval is the next step in obtaining permission to practise medicine in a health care facility, district or region. The next step is the granting of privileges. This bestows the right to perform specific medical acts within the health care facility, district or region. The final step is the provision of the necessary resources so that the physician is able to provide appropriate medical services for patient care. A medical committee with a clear structure and mandate to deal with appointments, reappointments and privileges must be maintained in all health care facilities, districts and regions so that physician input may be given during the appointment, reappointment and related processes. Clinical peer review must be foundational to these processes. Time, training and resources must be sufficient to support consistent peer review processes. The principles proposed below apply to all of the following processes: the appointment and reappointment processes, the granting of privileges and the allocation of health care facility, district or regional resources. Principles for the processes of granting appointments, reappointments and privileges and allocating resources 1. All processes should be fair, equitable, documented and transparent and should protect confidentiality. They should be completed in a timely manner and follow the rules of natural justice. At a minimum, the rules of natural justice give the physician the right to notice and the right to be heard before, and provided with reasons by, an impartial adjudicator. Given the nature of the physician's interests in the appointment, reappointment and other related processes, the following principles should also be included: * the right to be heard, either in person and (or) by representation; * the right to full disclosure of the information being considered by the committee that makes recommendations on appointments, reappointments and privileges; * the right to present evidence; * the right to a hearing free from bias, either real or perceived; * the right to a record of the proceedings; * a decision within a reasonable period; * the right to receive written reasons for the decision; and * the right to an appeal process by an independent and impartial body other than the board of the health care facility, district or region. It is important that all processes, including any review processes, follow the principles of natural justice. These processes should be part of the medical staff bylaws that guide the operation of the health care facility, district or region and should be known to all appointed physicians. 2. Criteria for reappointment should be clearly specified in medical staff bylaws and should be no more onerous than necessary to verify the ongoing provision of quality care by the medical staff. Medical staff appointments are typically for a one-year term. Criteria for reappointment vary across Canada, ranging from the provision of evidence of renewed licensure and liability coverage with a discretionary in-depth performance evaluation to the foregoing plus a mandated in-depth performance evaluation and reporting on continuing professional development activity. 3. A regular evaluation of appointed physicians should be conducted by the appropriate clinical chief. It should consist of a fair, documented process with explicit, agreed-upon criteria for the review of the physician's qualifications and credentials and the quality of care provided. If there is demonstrated inappropriate behaviour or a quality-of-care issue, a program for remediation should be established with regular follow-up over a period deemed appropriate by the physician's peers. As in other jobs, the objective of regular performance evaluations for a physician is to improve the physician's performance and the focus should be on opportunities for learning and improvement. The appraisal should entail a standardized peer evaluation process, in addition to self-assessment. The self-assessment process should include the recognition of satisfactory existing skills and the identification of new skills to be learned. In some situations remediation may be justified, for example when there is a need to upgrade skills, when interpersonal and communication skills are unacceptable, and when there is alcohol or drug abuse. Physician evaluations conducted by RHAs should take into account requirements already asked of the physician by their certifying and/or licensing body or other speciality organization in order to avoid duplication of effort. Looking ahead, with the increasing focus on team-based collaborative care, performance of team function and its impact on overall performance to meet health service requirements and quality of care is expected to become increasingly relevant. Conflict resolution mechanisms, scopes of practice and shared roles and responsibilities will need to be considered in order to assess individual and team performance. 4. The quality of a physician's care is the most important criterion to be considered at the time of appointment, reappointment and the granting of privileges. Quality care may be defined as the provision of service that satisfies the needs of the patient and meets the standards set out by recognized bodies of the profession, such as licensing bodies, national clinical societies and others. The essential components of quality include competence, accessibility, acceptability, effectiveness, appropriateness, efficiency, affordability and safety. The cost of a physician's care should not be the primary criterion considered during appointment, reappointment and related processes. Practice patterns, resulting in differences in cost of care, will differ for numerous reasons, including severity of illness, patient mix and patient choices. If there is a local, regional or district physician resource plan, then the need for a particular physician skill base as identified in the plan is an important criterion for appointment or reappointment to institutions within the plan. Physicians must be involved in the development of such a plan, and the plan must be supported by physicians at the local, district or regional level. If a practice and remuneration plan is introduced for a facility, hospital or academic health sciences centre, then participation in such a plan should not be a criterion for reappointment. 5. The information required for the granting of appointments, reappointments or privileges or for the allocation of medical resources must be accurate, valid and appropriate. The information required for these purposes should generally be limited to that which is reasonably necessary to determine the physician's ability to provide safe care. Physician's privacy should only be violated if it is determined that a medical condition or other disability poses an unacceptable risk to patients. The physician's credentials, skills, expertise and quality of care, as judged by peer assessment, should be considered during the appointment or reappointment process. Utilization data and associated indicators are being used more frequently as criteria for appointment and reappointment. Therefore, physicians must be involved in the development of such indicators, and there must be agreement by all parties on the type and quality of data or indicators to be used. In addition, before appointment or reappointment, physicians must be made aware of the data or indicators that will be used to evaluate them and the criteria by which these indicators will be applied. 6. The processes of granting appointments, reappointments and privileges and allocating resources should recognize and accommodate the changes in practice patterns that may occur over the medical career cycle. These processes should be flexible and reasonable concerning other issues such as on-call responsibilities or time needed to fulfil research and teaching commitments. It is important to recognize that a physician's practice pattern may change during his or her medical career. These changes may reflect the desire to no longer take call, the narrowing of the physician's practice to achieve a higher level of expertise in a specific area or the desire to pursue academic interests or responsibilities. Pregnancy, parental leave and the wish to practice part-time must also be considered. The quality of a physician's personal life and other special needs should be viewed as important and should be considered by those making decisions in these areas. 7. Physicians with established community practices have a significant investment in their practice and the community; this investment should be considered at the time of reappointment or change in privileges. An established physician may face financial loss if he or she is not reappointed or if there is a recommendation to substantially change his or her privileges. This possibility should be considered at the time of reappointment or change in privileges. 8. A recommendation, without just cause, to withdraw an appointment, to restrict privileges or to significantly reduce resources available to a physician must include appropriate compensation based on individual circumstances. Appropriate compensation includes financial restitution, retraining, relocation assistance and counselling assistance as required. Sufficient notice and other elements of due process should also be components of this recommendation. Generally, physicians are not employees of a health care facility, district or regional authority. Nonetheless, there are often extensive restrictions on physician mobility and limited opportunities to practice both inside and outside a province or territory. Age may also be a factor in the ability to find placement elsewhere, particularly if the physician is nearing retirement age. For these reasons, an interruption or cessation of a physician's career caused by withdrawal of an appointment, restriction of privileges or reduction in the resources available to the physician justifies appropriate compensation and due notice; this is in keeping with good human resource practices. Appropriate notice should be provided to physicians so that there is minimal impact on patient care. What constitutes timely and appropriate notice may in some cases be several months and will differ depending on the impact of the decision. Examples of decisions that could have a significant impact on physicians include: * temporary or permanent closure of operating rooms or other facilities; * strategic redirection of the hospital that may adversely affect a particular medical service or department, such as regionalization of laboratory testing or provincial centralization of a specialized service; and * implementation of a retirement policy. 9. The reporting of legal actions or disciplinary actions as part of the reappointment or reappointment process should be restricted to those matters in which a final determination has been rendered and in which there has been an adverse finding to the physician. References 1 Accreditation Canada. Qmentum Standards. Governance. Ottawa: Accreditation Canada; 2016. 2 Australian Commission on Safety and Quality in Healthcare. Review by peers: a guide for professional, clinical and administrative processes. Sydney: Australian Commission on Safety and Quality in Health Care; July 2010. Available: http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/37358-Review-by-Peers.pdf (accessed 2016 May 02). 3 New Brunswick Department of Health. Registration requirements. Fredericton: New Brunswick Department of Health; 2016. Available: http://www.gnb.ca/0394/prw/RegistrationRequirements-e.asp (accessed 2016 May 02). 4 Nova Scotia Department of Health and Wellness. Shaping our Physician Workforce. Updates. Halifax: Nova Scotia Department of Health and Wellness; 2016. Available: http://novascotia.ca/dhw/shapingPhysicianWorkforce/updates.asp (accessed 2016 May 02). 5 Province of Nova Scotia. Nova Scotia Health Authority Medical Staff Bylaws. Halifax: Province of Nova Scotia; April 2015. Available: https://www.novascotia.ca/just/regulations/regs/hamedstaff.htm (accessed 2016 May 02). 6 Winnipeg Regional Health Authority. WRHA Board By-Law No.3 Medical Staff. Winnipeg: Winnipeg Regional Health Authority; March 2014. Available: http://www.wrha.mb.ca/extranet/medicalstaff/files/MedByLaw.pdf (accessed 2016 May 02). 7 Bill 41. An Act to amend various Acts in the interests of patient-centred care. 2nd Sess, 41st Leg, Ontario; 2016. Available: http://www.ontla.on.ca/bills/bills-files/41_Parliament/Session2/b041.pdf (accessed 2016 Nov 07). 8 Canadian Medical Association. Physician resource planning. Updated 2015. Ottawa: The Association; 2015. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-07.pdf (accessed 2016 May 02). 9 Cochrane DD. Investigation into medical imaging, credentialing and quality assurance. Phase 2 report. Vancouver: BC Patient Safety & Quality Council; Aug 2011. Available: http://www.health.gov.bc.ca/library/publications/year/2011/cochrane-phase2-report.pdf (accessed 2016 May 02). 10 British Columbia Medical Quality Initiative. Briefing note: BC MQI - Provincial Practitioner Credentialing and Privileging System (CACTUS Software) Implementation. Vancouver: British Columbia Medical Quality Initiative; January 2016. Available: http://bcmqi.ca/wp-content/uploads/Briefing-Note_ProvincialPractitionerCPSystemImplementation.pdf (accessed 2016 May 02). 11 British Columbia Medical Quality Initiative. Family Practice with Enhanced Surgical Skills Clinical Privileges. Vancouver: British Columbia Medical Quality Initiative; March 2015. Available: http://www.srpc.ca/ess2016/summit/FamilyPracticeEnhancedSurgicalSkills.pdf (accessed 2016 Nov 06). 12 Soles H, Larsen Soles T. SRPC position statement on minimum-volume credentialing. Can J Rural Med. 2016;21(4):107-11. 13 Royal College of Physicians and Surgeons of Canada. CanMEDS 2015. Physician competency framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. Available: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf (accessed 2016 May 02). 14 College of Family Physicians of Canada. CanMEDS-Family Medicine. Working Group on Curriculum Review. Mississauga: College of Family Physicians of Canada; October 2009. Available: http://www.cfpc.ca/uploadedFiles/Education/CanMeds%20FM%20Eng.pdf (accessed 2016 May 02). 15 Alberta Medical Association, Alberta Health Services, College of Physicians and Surgeons of Alberta. Advocacy Policy Statement. Edmonton: Alberta Medical Association; 2015. Available: https://www.albertadoctors.org/Advocacy/Policy_Statement.pdf (accessed 2016 May 02). 16 Eastern Health. Privacy and confidentiality. ADM-030. St. John's, NL: Eastern Health; 2015. Available: http://www.easternhealth.ca/OurServices.aspx?d=2&id=743&p=740 (accessed 2016 Jun 23). 17 Canadian Medical Association. The evolving professional relationship between Canadian physicians and our evolving health care system: where do we stand? Ottawa: The Association; 2012. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_The_evolving_professional_relationship_between_Canadian_physicians_and_our_health_care_system_PD12-04-e.pdf (accessed 2016 May 02). 18 Public Health Act. SBC 2008, Chapter 28. Available: http://www.bclaws.ca/civix/document/id/complete/statreg/08028_01 (accessed 2016 Nov 07). 19 Canadian Medical Protective Association. Changing physician-hospital relationships: Managing the medico-legal implications of change. Ottawa: The Association; 2011. Available: https://www.cmpa-acpm.ca/-/changing-physician-hospital-relationships (accessed 2016 Nov 07). 20 Canadian Medical Protective Association. The changing practice of medicine: employment contracts and medical liability. Ottawa: The Association; 2012. Available: https://www.cmpa-acpm.ca/-/the-changing-practice-of-medicine-employment-contracts-and-medical-liability (accessed 2016 Nov 07). 21 Canadian Medical Protective Association. Medical-legal issues to consider with individual contracts. Ottawa: The Association; 2016. Available: https://www.cmpa-acpm.ca/-/medico-legal-issues-to-consider-with-individual-contracts (accessed 2016 Nov 07).
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Third-party forms (Update 2017)

https://policybase.cma.ca/en/permalink/policy13643
Date
2017-05-27
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Policy document
Date
2017-05-27
Replaces
Third-party Forms: The Physician's Role (Update 2010)
Short-Term Illness Certificate
Topics
Physician practice/ compensation/ forms
Text
A physician's assessment and signature on a third-party form have a value that reflects the physician's formal education and training as well as his/her professional experience. Similar to the signatures of other professionals, a physician's signature carries certain responsibilities and a commitment that the information provided is accurate and based on objective data and the patient's medical history. This value needs to be formally recognized and appropriately used. Most third parties have historically relied on the goodwill of physicians to complete their forms free of charge. However, the steady rise of third-party form requests (see Appendix A) and the cumulative time that form completion takes away from direct patient care necessitates a more reasonable approach to form requests and fair remuneration for the physicians' time and expertise. SCOPE OF POLICY This document provides guidance for physicians, patients and organizations that request third-party forms1 subject to federal/provincial/territorial legislation and regulations. Several strategies aimed at reducing the administrative burden of third-party forms are recommended to allow more time for direct patient care.2 GENERAL PRINCIPLES The physician's role * The physician has a well-defined and limited role in form completion - to only provide objective information on physical and/or psychological impairments and abilities, limitations and restrictions, time frames and prognosis from the medical record directly required by the third party for the purpose of administering particular programs or benefits. Questions on forms directed to physicians should be restricted to seeking such information. * A physician has a duty to ensure that he/she has properly completed the form (i.e., he/she has filled out the form completely, accurately and objectively in accordance with the requirements of the physician's provincial or territorial regulatory college). * When asked to provide an opinion on functional abilities to employers or insurers, the focus should be on abilities; information on restrictions should be objective and specific, and restrictions should be listed only when absolutely medically indicated.3 * A physician must not state that a patient has been under his/her care unless that is the case. The duration of the care should be indicated. If a physician does not have sufficient knowledge of an illness to provide information or an opinion upon it, the physician should state this on the certificate. The certification of absence should be based only on patient history if the patient was seen after the illness and should be clearly documented as "patient reports." In instances where a physician is being requested to complete a form by a transient patient (i.e., not the physician's patient), the physician should only comment on observations based on their own medical assessment. * A physician must have a patient's consent to disclose information to any third party, such as the patient's employer or insurer. Unless prevented by law, the physician should ensure the patient is aware that the report he/she provides to the third party is outside the physician-patient relationship and that in completing the form, the physician has a professional obligation to accurately and objectively report upon the patient's condition. A physician must not disclose more information than is covered by the patient's consent - this includes only providing information relevant to the nature of the request and that is reasonably necessary. If a patient limits his/her consent, the physician must consider whether such limitation is relevant to his/her report and if it is, report the limitation to the third party. * An accurate and relevant narrative summary of a patient's clinical files by the physician should be sufficient information for third parties. The requesting of complete copies of clinical files is unwarranted in the significant majority of cases unless mandated by legislation. * Physicians should consult with the Canadian Medical Protective Association and their provincial regulatory college for guidance and clarification on third-party form requests (see Appendix B). The patient's role * To the greatest extent possible, patients should review the third-party form and be aware of the information being requested. * Most forms request information on patients' subjective complaints and self-reported function. In such instances, it would be more appropriate to have this information reported directly by the patient to the requesting party. * Patients must be aware of the following: o Receipt of their consent authorizes the attending physician to accurately, completely and objectively explain the patient's medical condition as part of the physician's professional responsibility. o Physicians have a professional and ethical obligation to only document that which is true and medically defensible. The physician does not act as the decision-maker for absences or claims adjudication. o In some instances (e.g., fitness to drive), physicians also have legislated requirements to complete third-party forms regarding their patient. The role of the third party * Third parties should only request medical forms when there is a need for medical information about a patient (i.e., information that could not be provided by a non-physician) to be used for employment/education purposes or the evaluation of a medically related benefit for the patient. o It is the role of the third party to adjudicate on a patient's eligibility for a benefit, not the physician. o A request for a patient's non-medical information (i.e., unrelated to the patient's medical condition/history) or a request to certify identity (e.g., asking a physician to certify the principal parent for the purpose of determining eligibility to receive child benefits) is an inappropriate use of medical resources and it is at the discretion of the physician whether to comply with such requests. o Requests for updates should be reasonable and respect the physician's prognosis. o Wherever possible, third-party forms should be standardized (e.g., program eligibility, tombstone data, wording of questions) to save time and reduce administrative errors. o Program eligibility should be made clear to patients and providers to reduce inappropriate form requests (e.g., educating tax advisors on government program eligibility to prevent inappropriate requests for the disability tax credit). * To make the process of completing a medical form effective and efficient, third parties must involve and inform physicians early and on an ongoing basis, beginning by asking physicians to help to determine whether there is a need for a medical form to be completed in the first place. Medical input is also necessary in the design of the form and to determine how often the form needs to be completed. Physicians should be involved in periodic reviews of existing medical forms with third parties (e.g., governments, insurance companies, associations) for several reasons: to determine whether the forms remain relevant and as a simple as possible; to determine appropriate remuneration for completing the forms; and to ensure that physicians are notified of any changes to requests for medical certification in writing rather than having changes communicated to the physician informally through the patient.4 * In some cases, other health professionals (e.g., occupational therapists) are in a better position to objectively assess patients' abilities and could be designated as qualified practitioners for the purpose of completing the forms, with physicians providing information pertaining to medical assessments and prognoses. Short-term illnesses * Confirmation of a short-term absence from work because of minor illness is a matter to be addressed between an employer and an employee directly. Such an absence does not require physician confirmation of illness and represents an inefficient use of scarce health care resources. It is the employer's responsibility -not the physician's - to oversee employee absenteeism. It may be that for many cases, the need for a medical certificate can be replaced by a more effective alternative that does not involve physicians and is agreed to by all parties concerned (e.g., employer and employees). * If an employer, educational institution or other third party requests an illness confirmation certificate for a short-term, minor illness that would otherwise not have required medical attention, said party should recognize that completion of the certificate is an uninsured service for which physicians are entitled to compensation, preferably from the third party requesting the information, rather than burdening the patient. Fair compensation * The third party requesting the information should be responsible for compensating the physician for their medical information and expertise. At a provincial/territorial government level, this could mean making the completion of provincial/territorial forms an insured service under the provincial/territorial health insurance plan. * Physician reimbursement should cover the time and resources devoted to the provision of medical information to third parties (submitted in writing, electronically and/or by phone). This includes compensation for any uninsured medical assessment necessary to complete the form, for the provision of copies of medical information, and for the time and resources needed to respond to any follow-up requests. Wherever possible, the compensation rates should be consistent and should reflect the time and effort necessary to complete the form(s). * Physicians should be compensated for completing forms related to return to work by provincial/territorial worker's compensation plans; they should be compensated for completing return-to-work forms for non-occupational conditions by provincial/territorial insurance plans, given the important health implications of return-to-work management. * In the absence of third-party compensation, physicians may charge the patient for the service they provide. As stated in the CMA's Code of Ethics, physicians should consider the nature of the service provided and the ability of the patient to pay, and they should be prepared to discuss the fee with the patient.5 Patient decisions about payment for uninsured services must not negatively affect the physician-patient relationship or pose a barrier to accessing health care services. The physician may decide to reduce or waive his/her fees if the patient lacks the financial ability to pay. Physicians should consult their provincial/territorial medical association for guidance regarding direct billing of patients. Appendix A The increasing administrative burden Physicians face a multitude of requests on a daily basis to complete medical forms and certificates. Requests come from many sources, including governments, government agencies (e.g., workers' compensation boards) and the private/non-governmental sectors (e.g., employers, insurance companies, schools, sporting organizations). In a 2016 survey of CMA physician members on third-party forms, physicians identified sick notes as the form that they were most frequently asked to complete (67.0% of respondents reported having to fill this form out more than five times per week). Short-term disability claim forms were the second most frequently requested form, with 42.3% of respondents reporting completing this form more than five times per week. Medical certificates for sickness benefit claims under the federal government's employment insurance program - just one example of a third-party form requiring medical input - had to be completed for 336,800 approved applications in 2013-20146 (the vast majority of these certificates would have been completed by physicians). Physicians continue to devote considerable time to completing forms. Government disability forms, just one type of third-party form, require considerable amount of time to complete. Over 62% of the physicians in the 2016 survey indicated they spend 21-30 minutes (31% of respondents) or more than 30 minutes (31% of respondents) to complete the Canada Pension Plan disability form. Similarly, 60% indicated they spend 21-30 minutes (33% of respondents) or more than 30 minutes (27% of respondents) to complete the Veterans' Affairs disability benefit form. The most frequently identified concern that physicians have with completing third-party forms (75% of those who participated in the 2016 survey) was the time it took from direct patient care. The second most frequently identified concern (63.4%) was the number of inappropriate requests from third parties.7 Increasing administrative workload/paperwork has been identified by physicians as one of the biggest contributors increasing the demand for their time at work. 8 In many cases, these requests can be an inappropriate use of a physician's time, such as requests for patient information for administrative purposes. Responding to such requests reduces both timely access to care and the time available for direct patient care. Appendix B Policies in the office to better manage third-party form requests Office policies and strategies can be instituted by physicians to better manage third-party requests. These strategies include: * having an office policy or standardized method to manage third-party form requests; * having clear communication and posted signage on patient and physician responsibilities regarding forms and fees; * using a standard form template (e.g., for sick notes)9; and * organizing time to complete forms. Physicians are also encouraged to consult with their provincial/territorial medical association and their regulatory college for guidance related to form requests. These strategies can be part of an overall effort by organizations to raise the awareness of employers, governments and other third parties of the need for a more appropriate approach to form requests to eliminate time wasted for all parties and reduce the inappropriate use of health care resources. 1 The term third-party form refers to any form, letter, medical certificate, mandatory reporting form, photocopy or other document containing medical information about the patient that a physician has been requested to complete or provide by a third party on behalf of their patient. [0]The term third party refers to an employer, government department or agency, private insurer or other organization that is requesting medical information about the patient with the intention of using it. 2 This policy should be considered in conjunction with CMA's policy statement entitled The Treating Physician's Role in Helping Patients Return to Work after an Illness or Injury. 3 Choosing Wisely Canada. Occupational Medicine Specialists of Canada. Five things physicians and patients should question; 2014 Oct 29. Available: www.choosingwiselycanada.org/wp-content/uploads/2014/09/Occupational-Medicine.pdf 4 Saskatchewan Medical Association. SMA relative value guide. Saskatoon: The Association; 2004. 5 Canadian Medical Association. Code of Ethics. Ottawa: The Association; 2004. 6 This figure does not include the number of forms completed for individuals who applied but did not qualify for the program. Canada Employment Insurance Commission. Employment insurance monitoring and assessment report 2013/14. Ottawa: Employment and Social Development Canada. Available: www.esdc.gc.ca/en/reports/ei/monitoring2014/chapter2_4.page 7 Canadian Medical Association. e-Panel survey summary: third-party forms. Ottawa: The Association; 2017. 8 Royal College of Physicians and Surgeons of Canada. National physician survey 2013. Results by FP/GP or other specialist, sex, age and all physicians [table]. Ottawa: The College; 2013. Available: http://nationalphysiciansurvey.ca/wp-content/uploads/2013/08/2013-National-EN-Q13r.pdf 9 Steven Harrison. OMA sickness certificate template: a practical office resource. Ontario Medical Review 2004 Dec.
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