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

https://policybase.cma.ca/en/permalink/policy10322
Last Reviewed
2019-03-03
Date
2011-10-23
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-10-23
Replaces
Operational principles for the measurement and management of waiting lists
Topics
Health systems, system funding and performance
Text
This policy statement provides operational principles for the measurement and management of wait list systems that support timely access to necessary care for patients. This statement is based on the understanding that in order for wait list systems to be effective in improving timely access to medically necessary care for patients, physicians and other providers must be centrally involved and appropriately supported to assist in their development, measurement and management. Since the late 1990s, Canadians have become increasingly concerned over lengthening wait times to access medically necessary care. As a result, a major focus of the 2004 Health Care Accord (10-Year Agreement to Strengthen Health Care) was to improve timely access to necessary medical care. Since then, provinces and territories have taken steps to measure, monitor and manage patient wait times. However, most efforts thus far to improve wait times have been focused on the wait between the specialist consultation and the scheduled date for treatment. Patients may also experience waits in accessing a family physician (many Canadians do not have a family physician) and waiting to see a specialist following a referral by a family physician. Canadians deserve timely access to medically necessary care. Governments must ensure that patients are treated within established wait-time benchmarks for all major diagnostic, therapeutic, and surgical services. Physicians recognize that it is desirable to minimize waits and to properly prioritize and manage patients' wait for care by accurately capturing and utilizing wait-time data. However, there remain serious concerns over the quality of wait-time data and who has the primary responsibility for capturing the data. Physicians and other providers are increasingly being requested to input wait-time data (e.g., length of wait for consultation or for start of treatment). Yet, in many instances, they are expected to do so without the necessary resources and supports. Outlined below are Operational Principles for the Measurement and Management of Wait Lists developed originally through CMA's Access to Quality Health Care Project(1) with input from public opinion research as well as stakeholder groups, including CMA Core Committees, Provincial-Territorial Medical Associations and CMA Affiliates. Goals 1. To maintain or enhance patients' quality of life and health status through effective development, measurement and management of wait lists. 2. To ensure that the development, measurement and management of wait lists are based on the best available evidence of clinical appropriateness, clinical effectiveness, rational use of resources, clinical need and patient quality of life. Principles A. Stakeholder Involvement 1. Physicians in clinical practice must have a leadership role: - in identifying clinically relevant data elements through consensus; - in developing standard definitions and measures for prioritization for wait lists; and - in developing wait-time benchmarks. 2. Health care providers and other stakeholders should be involved in the development, measurement, maintenance, monitoring, management and evaluation of wait list systems, and should be appropriately compensated for their time and effort. B. Database Development and Management Systems 1. Systems for developing and managing wait lists must require and provide reliable, current, useful and valid data and information. 2. Database development and wait list management requires involvement of multidisciplinary panels. 3. Systems for managing wait lists should: - provide accurate, reliable, timely, publicly accessible and real-time information in a cost-effective manner. Deadlines for inputting data should be reasonable and implemented without the use of threats or penalties; - collect and assess data on need, quality of life and health outcomes; be flexible and dynamic so that they can adapt over time with the development of new technologies and approaches to treatment; and - require policies and procedures on confidentiality, so that patients' and providers' privacy are protected. C. Investment 1. Systems for managing wait lists require initial and sustained investment in dedicated human resources, sophisticated information systems and information technology infrastructure at all levels (e.g., medical offices, hospitals, health regions). D. Accountability 1. The parties involved in managing wait lists must accept their responsibilities and obligations to each other and to the public. 2. Privacy and confidentiality of patient and provider information must be respected. 3. The systems, processes and results for managing wait lists should be widely communicated to obtain stakeholder involvement and support. E. Evaluation 1. Systems for managing wait lists must: - be continually monitored and evaluated to identify opportunities for improvement; and - regularly undergo independent data audits and evaluations of process and outcome. F. Governance 1. An independent, stakeholder-based, non-governmental organization with an advisory committee should be responsible for overseeing and administering systems for managing wait lists. (1) Canadian Medical Association, Access to Quality Health Care Project, January 1998. Ottawa.
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Physician compensation (Update 2013)

https://policybase.cma.ca/en/permalink/policy11060
Last Reviewed
2018-03-03
Date
2013-12-07
Topics
Physician practice/ compensation/ forms
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2013-12-07
Replaces
Physician Compensation (Update 2001)
Topics
Physician practice/ compensation/ forms
Text
CMA's position on physician compensation is based on several overarching principles. Physicians must receive fair and reasonable remuneration for the full spectrum of their professional activities. Payment models must not compromise the ability of physicians to provide high quality medical services to their patients, and should also be consistent with overall health system objectives including timely access to quality care. There should be an appropriate relationship between the provincial /territorial medical association and its respective government-one built on mutual respect, trust, consultation and co-operation as well as an expectation of bargaining in good faith. Key tenets of CMA's policy are as follows: * Physicians should have the liberty to choose among payment methods. Physicians should not be compelled to adopt any particular method of payment where options are available. * Physician compensation arrangements must allow for a balance between professional demands and physician wellness. * Physicians must receive reasonable consideration and compensation when facilities and programs are discontinued, reduced or transferred. * Provincial/territorial governments should enact legislation that expressly recognizes the representational role of the provincial and territorial medical associations or federations in negotiations and dispute resolutions. Provincial and territorial medical associations must be expressly recognized as the sole bargaining agent for physicians. * In the event a negotiated settlement is not achieved, such disagreement must be resolved by binding arbitration or other mutually agreed upon, timely process of dispute resolution. Trends in physician compensation Many different physician compensation models have been introduced over the past two decades in Canada and elsewhere. Some include alternatives to fee-for-service models while others involve a blended approach that incorporate a variety of compensation models (e.g., capitation, salary, sessional fees and fee-for-service). In recent years, pay-for-performance models have been introduced in some provinces and other countries that involve the use of an incentive payment to reward a provider for achieving a target for the quality of patient care. This may be linked to processes or outcomes of care and could be related to the attainment of a specified threshold and/or percentage improvement.i Fee for service remains the predominant option for the provision of insured medical services for Canadian physicians although an increasing number of physicians are compensated through blended funding modelsii. Overarching values for physician compensation Regardless of which funding models are considered, they should all be consistent with several important overarching values. Recognizing that the range of professional responsibilities placed on physicians extends well beyond the strict provision of medically required services, the CMA maintains that all medical practitioners are entitled to receive fair and reasonable remuneration for the full spectrum of their professional activities including administration, teaching, research and committee work, as well as throughout the full spectrum of payment modalities. In addition, service complexity, length of training and the demands of work should be considered. Payment systems must not compromise the ability of physicians to provide high quality cost effective medical services to their patients, and should also be consistent with overall health system objectives including timely access to quality care and ensuring a productive and effective use of resources. Finally, an appropriate relationship between the provincial/territorial medical association and its respective government is necessary-one built on mutual respect, trust, consultation and co-operation as well as an expectation of bargaining in good faith. Choice of payment model Physicians may have the option of remuneration through an increasing array of payment methods. In keeping with the democratic rights accorded to all associations the CMA maintains that all individual medical practitioners should have freedom to choose their method of remuneration. Physicians should not be compelled to adopt any particular method of payment where options are available. Moreover, the implementation of these models should not result in intersectional fee/income inequities. Funding for physicians negotiated with provincial and territorial governments should be flowed exclusively to physicians regardless of whether the funds are channeled through other agencies. Balance between professional demands and physician wellness Physician compensation arrangements must allow for a balance between professional demands and physician wellness. This is important when considering issues such as on-call services and availability of locum tenens. In this regard, the scheduling of physicians' services and training need to be limited to reasonable hours, both to safeguard their ability to provide quality care and in consideration of their need to balance professional and personal life. Reasonable compensation when programs are discontinued, reduced or transferred Health care professionals in hospitals and institutional settings are normally given reasonable compensation packages when facilities are closed, downsized, transferred, etc. In these settings, physicians' employment status may not necessarily be the same as other staff members. They may therefore lack certain benefits and risk having their interests inadequately captured by existing mechanisms. Physicians therefore need to receive reasonable consideration and compensation when facilities and programs are discontinued, reduced or transferred. Affected physicians should be involved in any discussions and decision making relating to the discontinuing, reduction or transfer of programs/facilities. Right to representation All physicians, including those indirectly affected, exercise their freedom of association through their respective provincial or territorial medical association, and have the right to be represented by their respective association in negotiations on issues of payment, funding and the terms and conditions of their work. The CMA strongly supports the provincial and territorial medical associations in their right to representation as the sole bargaining agents for physicians, regardless of payment method, and in their efforts to fulfill the profession's commitments to negotiated agreements. The CMA exhorts all provincial/territorial governments to immediately enact legislation that expressly recognizes the representation status of provincial and territorial medical associations in negotiations and dispute resolutions. Consistent with the process of negotiation and the guiding principles of contract law, the CMA fully expects paying agencies to fulfill the terms of agreements with the medical profession and be obliged to honour a mutually agreed upon and established process of negotiation. Appropriate dispute resolution process The CMA's Code of Ethics places a high priority on patient care. Withdrawal of services by physicians has been infrequent. The medical profession must be afforded the protection of good-faith negotiations and binding arbitration.iii The CMA calls on the federal minister of health to strengthen the provisions of the Canada Health Act (section 12.2) to mandate provincial and territorial governments to enter into an agreement with provincial and territorial medical associations with regard to negotiations on compensation and requiring binding arbitration or other mutually agreed upon timely process of dispute resolution for the settlement of disputes related to physician compensation to satisfy the "reasonable compensation" criteria of section 12.1 (c) of the Act for full federal funding. In instances where the compensation agreement has expired before a new agreement between the jurisdiction and its medical association can be reached, all pre-existing funding arrangements and programs should be continued until such time that a new agreement comes into effect. i Canadian Medical Association, Health Care Transformation in Canada: Change that works. Care that lasts. Ottawa. 2010. ii 2010 National Physician Survey. The College of Family Physicians of Canada, Canadian Medical Association, The Royal College of Physicians and Surgeons of Canada. http://www.nationalphysiciansurvey.ca/nps/2010_Survey/2010nps-e.asp. See also, Canadian Collaborative Centre for Physician Resources, How Physician in Canada are paid? Results of the 2010 National Physician Survey. http://www.nationalphysiciansurvey.ca/nps/news/PDF-e/PhysicianRemuneration-Nov-2011.pdf iii This was acknowledged by Justice Emmett Hall in his 1980 report to the minister of national health and welfare, Canada's National-Provincial Health Program for the 1980's. Hall concluded that "when negotiations fail and an impasse occurs, the issues in dispute must be sent to binding arbitration."
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Position statement on prescription drug shortages in Canada

https://policybase.cma.ca/en/permalink/policy10756
Last Reviewed
2017-03-04
Date
2013-05-25
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2017-03-04
Date
2013-05-25
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Position Statement on Prescription Drug Shortages in Canada The escalation in shortages of prescription drugs in the past few years and the ongoing disruptions to supply experienced in Canada and globally are matters of grave concern to the Canadian Medical Association (CMA) and its members. Drug shortages are having a detrimental impact on the delivery of patient care and treatment and the availability of health care services across the country. CMA has advocated for a thorough examination of the drug supply system to identify points where we in Canada can influence supply problems. Solutions will have to involve the various players in the drug supply chain, from manufacturers through to healthcare providers and levels of government. Background Drug shortages are not a problem confined to Canada. In the United States the number of drug shortages from 2006 to 2010 grew by more than 200 per cent.1 In 2011, 251 shortages were reported to the FDA. 2 Canada has not had an accurate record of the number of drugs in short supply over past years but in April 2013 253 drugs were listed on the industry sponsored Canadian Drug Shortage Website.3 Factors that influence the occurrence of a drug shortage can occur at any stage of the drug supply chain and any disruptions can ripple through the system. Figure 1 Drug supply chain in Canada4 [See PDF] There are many causes that can lead to a drug shortage. Disruptions in the supply of an active or key ingredient contribute to drug shortages and this is exacerbated when the active ingredient is produced by a single raw material supplier. If the supplier is unable to meet demand than all manufacturers relying on that supply become vulnerable to disruptions. The sourcing of raw materials from outside of North America, primarily China and India, whose safety and regulatory standards may not be stringently enforced can result in regulatory authorities closing down facilities thereby impacting supply of active ingredients or necessitating a lengthy search for a new supplier. Additional manufacturing issues contributing to shortages can include complex manufacturing processes like those used to make sterile injectables, changes in product formulations, problems in the production process or regulatory enforcement of good manufacturing processes, limited capacity, an unexpected surge in demand, regulatory delays in product approvals and business decisions. 5 Shortages may also be due to factors outside the manufacturers control such as various interruptions in the normal delivery of medicines through the pharmacy supply chain and distribution network6. Just in time inventory management practices can lead to a reduction of available drug inventories. In addition procurement strategies that lead to sole source contracts for bulk purchases has been identified as the single most avoidable cause of drug shortages. 7 Health Consequences Disruptions in the supply of medications have the potential to impact patient care, patient health and the efficiency of the overall health care system. Among the impacts of drug shortages are: - delays in access to needed medication; - delays or disruptions to clinical treatment; - delayed or cancelled surgeries, - loss of therapeutic effectiveness when an appropriate alternate therapy is not available; - increased risk of side effects; - increased non-compliance when changes in medication make it confusing and harder to comply with a new medication regime particularly for those on long term therapy.8 Any and all of these situations can result in a disruption to clinical stability and deterioration, particularly in patients with complex problems. Drug substitution can also result in unintended consequences. In 2010 an Institute of Safe Medication Practices survey of 1800 US health professionals revealed that in one year drug shortages caused over 1000 incidents involving negative side effects or medical errors. 9 In many instances shortages can lead to an increase in the use of the health care system, be it in physician or emergency room visits or treatments. A CMA survey of physicians in September 2012 found that 66% of respondents indicated that drug shortages have gotten worse since 2010 and 64% stated that the shortages have had consequences for their patients or practice. Similarly, the results of the 2012 Canadian Pharmacists Association (CPhA) survey of pharmacists found that over 91% of pharmacists indicated that patients had been inconvenienced by shortages and 51% indicated that patients' care had been compromised.10 Drug shortages also have an impact on the practices of physicians and pharmacists. Sixty seven percent of the respondents to the CMA survey stated that drug shortages do have an impact on their practice most notably by increasing time spent on research or consultation with health professional colleagues to source alternative medicine, increase in length of patient visits due to medication substitution concerns, and increase in time spent on forms such as insurance claims. Seventy six percent of hospital pharmacists and 76 percent of community pharmacists also report an impact on their workload and practice.11 Recommendations Since as early as 2005, the CMA has supported a comprehensive strategy and adequately resourced system for monitoring domestic drug supply. In response to a Health Canada consultation in October 2005 on a report entitled "Developing a Drug Supply Network" CMA recommended that Canada needs such a system to identify shortages and respond quickly to remedy them, and to ensure that policy and regulatory decisions are founded on accurate and reliable knowledge. In March 2011 this position was reinforced in communication with the Government of Canada stating that Canada needs a sustainable, adequately resourced process to identify shortages, rapidly communicate them to health professionals and respond quickly to resolve them. 1. The Canadian Medical Association supports an investigation into the underlying causes of prescription drug shortages in Canada. 2. The Canadian Medical Association recommends the creation of a monitoring unit to track drug production disruptions in Canada and abroad. The communication of information to health professionals once a shortage occurs, or is expected, is critical to their ability to make patient centered decisions and provide continuity of optimum care. CMA has participated on a Multi Stakeholder Working Group on Drug Shortages that has had the pharmaceutical industry and health professional organizations working together to establish a national drug shortage reporting website. CMA provided key input on the needs of needs of physicians to ensure that information required to provide optimum care when managing a drug shortage such as product information including name, manufacturer, formulation, strength, package size, expected duration of shortage, notification that shortage is resolved as well as automatic alerts and search and sort functionality was included on the website. The establishment of the Canadian drug shortage website marks an improvement in the management of drug shortages but significant issues remain. Of great concern are drugs that are 'single sourced'. When there are shortages of single sourced medications there are no clear substitutes. Related to this are the unintended consequences of sole sourcing products from one manufacturer to secure a lower price. This introduces a vulnerability to the marketplace if the sole supplier experiences production disruptions. The 2011 production stoppage at a Sandoz facility in Quebec due to regulatory compliance issues and a subsequent fire in the plant resulted in a scramble to find alternate sources of many essential medications. The CMA supports the development of strategies at the provincial/territorial and federal level to discourage single source purchasing decisions. The inclusion of incentives or penalties for guaranteed supplies, or a contingency plan for supply disruptions should be inserted into purchase contracts. We must be extremely careful not to exacerbate supply problems while trying to address cost issues. 3. The Canadian Medical Association calls for a review of the supply processes in place for drugs and equipment considered essential for medical practice. 4. The Canadian Medical Association supports strategies to discourage single-source purchasing decisions for prescription medications. Advance notice, by manufacturers to Health Canada, of expected drug shortages can provide a window of opportunity for the manufacturer and regulators to work together to resolve production problems or identify alternate supply. We are encouraged by recent initiatives by Health Canada to collect information on planned discontinuances from manufacturers. 5. The Canadian Medical Association calls for the establishment of a legislative framework requiring pharmaceutical companies to provide advance notice of production stoppages and any forecast disruptions in the drug supply. Because of the complexity of the drug supply system, to effectively identify the situations that lead to drug shortages and find Canadian based solutions that can decrease the incidence of shortages or mitigate their impact requires the involvement and cooperation of all players in the process. CMA has consistently asked the government of Canada to work with the provinces and territories, the private sector and health professionals to address this potentially dangerous threat to the lives of Canadian patients. 6. The CMA supports the provinces and territories in their efforts to prevent drug shortages. We are heartened by actions of Health Canada in 2012 to bring together representatives of industry, federal, provincial and territorial governments and health professional associations in a Multi Stakeholder Steering Committee on Drug Shortages to respond to the need for the mitigation of drug shortages. We trust that processes can be put in place and supported by key players to allow Canada to respond in a coordinated, transparent and accountable fashion to future or actual drug shortages. Conclusions Drug Shortages represent an ongoing worry for physicians. The impact on patients, health professionals and the health care system can be significant. Substantial progress has been made since 2011 in terms of gathering and sharing drug shortage information and improving our understanding of the drug supply processes but much still remains to be done. Although complex and challenging, ongoing attention to the issue is required to ensure that Canadians can count on a secure supply of medication into the future. The CMA will continue to represent the best interests of patients and physicians to ensure that Canada's health care system delivers on patient-centered care. References 1 DRUG SHORTAGES FDA's Ability to Respond Should be Strengthened, Statement of Marcie Cross, Director, Health Care, United States Government Accountability Office, Testimony before the Committee on Health, Education, Labor, and Pensions, U.S. Senate, December 15, 2011. 2 FDA is asking the public to send in ideas for combatting drug shortages, FDA Voice, Feb. 13, 2013, U.S. Food and Drug Administration, available at http://blogs.fda.gov/fdavoice/index.php/tag/drug-shortages/ (accessed 2013 April 2). 3 Canadian Drug Shortages Database available at http://www.drugshortages.ca/drugshortages.asp (accessed 2013 April 5). 4 Drug Supply In Canada: A Multi-stakeholder Responsibility, Report of the Standing Committee on Health, 41st Parliament, First session, June 2012. 5 Drug Supply Disruptions, Environmental Scan, Canadian Agency for Drugs and Technologies in Health, Issue 17, March 2011. 6 Canadian Drug Shortages Database available at http://www.drugshortages.ca/drugshortages.asp (accessed 2013April 5). 7 Drug Supply In Canada: A Multi-stakeholder Responsibility, Report of the Standing Committee on Health, 41st Parliament, First session, June 2012. 8 Prescription Drug Shortages, E Panel Survey, Canadian Medical Association, December 2010. 9 Drug Shortages, Recommendations of the Working Group on Drug Shortages, Ordre des Pharmaciens du Québec, March 2012. 10 Impact of Drug Shortages, Member survey, Canadian Pharmacists Association, October 2012. 11 BACKGROUNDER - DRUG SHORTAGES SURVEY, Canadian Pharmacists Association, Canadian Society of Hospital Pharmacists, Canadian Medical Association, January 2013, available at http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2013/Backgrounder-Drug-shortages_en.pdf ( assessed 2013 April 2).
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Principles for health system governance

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

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

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

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