Canadians are deeply concerned about their health care system. They worry about situations such as whether they will have access to diagnostic testing when they need it or whether they can get a family physician if they move to a new community. This is not what was envisioned when Canada embarked upon a universal public health care system in 1966. Over the past two years an unprecedented number of reports and commissions have been examining what can and must be done to ensure the long-term sustainability of the system. But Canadians are growing inpatient. The time for studying the issues is quickly passing. They are counting on governments, to listen to the reports and then act upon them quickly – turning the corner from debate to action.
This year’s submission from the CMA to the Standing Committee on Finance focuses on the need for action in the short and longer terms by identifying strategic investments that will ensure a strong health care system that is securely supported by a dependable and comprehensive public health infrastructure as its foundation. Hand in hand with new financing, the CMA firmly believes that additional financing must be accompanied by updated governance structures, including a Canadian Health Charter and a Canadian Health Commission that can inject real accountability into the system.
The CMA believes that the federal government has responsibility, alongside the provinces and territories, to increase its financial support of Canada’s health care system. Only by increasing funding and identifying clearly the amount allocated to health will the federal government be able to regain its position as an equal player with the provinces.
In our submission to the Commission on the Future of Health Care in Canada, the CMA recommended that the federal contribution to the public health care system be locked in for a 5-year period. We indicated that the longer-term goal would be for the federal contribution to rise to 50% of total spending for core services over time as new and improved services and technologies products became available. We also said that it should be tied to a built-in GDP-growth escalator once that target is reached. To be specific, in order to raise funding to the 50% target level the CMA recommends that funding for new services and technologies be introduced on a 50/50 cost-sharing basis. This would encourage provinces and territories to become early adopters of new technology and help to update the basket of core services available to Canadians.
For illustration purposes the CMA recommends an initial investment of $16 billion over the first five years starting in 2003/04 with the majority of that funding weighted towards the back-end of the five-year period. This investment would take us partway (45 federal/55 provincial cost sharing) towards reaching our goal of 50/50 cost sharing.
To further support funding for health care across the country, a buffer is needed to protect provincial and territorial health care budgets from the ebbs and flows of the economic cycle. This could be done, for example, by renewing the Fiscal Stabilisation Program or removing the cap on the current Equalisation program.
In conjunction with the longer-term financing needs of Canada’s health care system, there are some urgent objectives that cannot wait for governments to finalise and implement their plan.
The pressing nature of these issues warrants the use of one-time, targeted, special-purpose transfers in the areas of health human resources supply and training; capital infrastructure; and health information technology.
Finally, last year, our submission reflected Canadians’ concerns following the September 11, 2001 events in the United States. It highlighted people’s anxiety about security in our country, the safety of our airlines and the vulnerability of our public health infrastructure and health care systems to potential threats. We believe that this work has not been completed and there is ongoing need to support public health as a priority for Canada’s health care system particularly in the areas of emergency preparedness, childhood immunisation and a national drug strategy.
Reform of Canada’s health care system is a formidable task. It involves the participation and agreement of all levels of government as well as providers, other stakeholders and ultimately the acceptance of the end-users, Canadians. The CMA looks forward eagerly to the Romanow Commission’s recommendations and those of the Senate Committee. We will be watching carefully over the coming months on behalf of Canadian physicians, and our patients, to ensure that these discussions result in a timely, action-oriented response and that involvement of the community of providers is early, ongoing and meaningful. Canadian physicians are ready to do our part, all we ask is for the opportunity.
The Canadian Medical Association (CMA) values participating once again in the Standing Committee on Finance’s Pre-Budget Consultations process. We see these consultations as an essential part of Canada’s democratic process, allowing non-government organisations and individuals the opportunity to provide input into the government’s fiscal agenda.
We know Canadians value their health care system and the high-quality treatment they receive. What concerns them is whether they’ll be able to access the care they need when and where they need it. The past two years have seen the most significant public concern over Canada’s health care system in a generation. Governments have responded by examining the system through an unprecedented number of reports and commissions. In addition to the Commission on the Future of Health Care in Canada (the Romanow Commission) and the Standing Senate Committee on Social Affairs, Science and Technology’s work on the state of the health care system (the Kirby Commission), since 2000 there have been four other major provincial reviews of health care systems in Canada.i
Canadians are now looking to governments to turn the corner from studying what needs to be done to acting upon this work. This year’s submission from the CMA to the Standing Committee on Finance focuses on this need for action in the short and longer terms by identifying strategic investments that will ensure a strong health care system that is securely supported by a dependable and comprehensive public health infrastructure as its foundation. In this way, it is the belief of the CMA that health and health care go hand in hand.
The CMA believes that to achieve real reform, more than “tweaking” of our current system is required. We see change as requiring a fundamental rethinking of the system including its governance and accountability structures in order to move forward and turn the corner towards a sustainable health care system. The momentum created with the release of the Romanow Commission’s report provides a unique opportunity for the federal government, in partnership with the provinces and territories, to capitalise on that energy by responding in a substantive way to the report within 100 days of its release with an implementation plan.
We were very encouraged by the commitment made in the September 30, 2002 Speech from the Throne to hold a First Ministers’ Meeting early in 2003 to put in place a comprehensive plan for reform. We were also encouraged by the commitment to an action plan in the areas of health policy under direct federal jurisdiction such as addressing emerging health risks and the adoption of modern technology.
We will be watching carefully over the coming months on behalf of Canadian physicians, and our patients, to ensure that these discussions result in a timely, action-oriented response and that involvement of the community of providers is early, ongoing and meaningful.
On June 6, 2002, the CMA released its final submission to the Romanow Commission, A Prescription for Sustainability. In this submission, we outlined what the Commissioner called “bold and intriguing” changes to reaffirm and realign our health care system. Specifically, the CMA report laid out an approach for the renewal of Canada’s health care system comprised of three essential interrelated components: a Canadian Health Charter; a Canadian Health Commission; and renewal of the federal legislative framework (including federal-provincial fiscal transfers).
Canada’s health care system does not have the governance structures in place to provide for real accountability or transparency. Often governments meet behind closed doors and make decisions with little or no input from those who ultimately have to implement change and use the system. Rather, full accountability requires the involvement of all key players – federal and provincial/territorial governments, health care providers and patients.
Fundamentally, the current lack of accountability in Canada’s health care system comes down to an inherent conflict of interest between public accountability, which Canadians are demanding, and governments’ desire to retain maximum fiscal control and flexibility. Even with increased cash transfers identified in the September 2000 First Ministers Accord, the federal government has fallen well short of providing the necessary funding to ensure compliance with national principles today and for the future. Clearly, the financial means must be equal to the desired health outcomes. The CMA believes that with appropriate financial reinvestment and updated governance structures the federal government will be on the path towards putting national back into national heath care insurance system.
Canadian Health Charter
Currently, neither the Canada Health Act nor the Charter of Rights and Freedoms offers Canadians an explicit right of access to quality health care delivered within an acceptable time frame.ii Increasingly, this has resulted in an unacceptable degree of uncertainty not only for patients but also for health care providers and ultimately for those (both private and public) who contribute to the financing of the health care system.
A Canadian Health Charter would underline governments’ shared commitment to ensuring that Canadians have access to quality health care within an acceptable time frame. It would clearly articulate a national health policy that sets out our collective understanding of Medicare and the rights and mutual obligations of individual Canadians, health care providers, and governments.
Canadian Health Commission
Creating a permanent, independent Canadian Health Commission, would help address the lack of transparency and accountability at the national level. It would create an institution, the very purpose of which would be to report annually to Canadians on the performance of the health care system and the health status of the population. It would put health on the same level as other national priorities such as the environment, transportation and research. Its legitimacy would be strengthened by not having to report to any one government or governments. Rather it would forge a direct reporting relationship with Canadians and not leave Canadians hostage to ongoing inter-governmental disputes.
A Canadian Health Commission would also be uniquely situated to provide ongoing advice and guidance on other key national health care issues. Issues such as: defining the basket of core services that would be publicly financed; establishing national benchmarks for timeliness; accessibility and quality of health care; planning and coordinating health system resources at the national level; and developing national goals and targets to improve the health of Canadians.
* Implement a Canadian Health Charter and provide federal funding for a permanent Canadian Health Commission to reaffirm Medicare’s social contract and to promote accountability and transparency within the health care system.
Improved accountability is an essential, but not complete, answer with respect to reforming Canada’s health care system. The CMA believes that the federal government has a responsibility, alongside the provinces and territories, to increase its financial support of Canada’s health care system. At the same time, the CMA also believes that governments must provide financing in an accountable and transparent manner that links the funding sources with the use of those funds.
The way we see it, much of the current tension between the two levels of government on health care issues can be traced back to unilateral federal changes to the funding formula. It started with the first changes to the Established Programs Financing (EPF) in 1982, and culminated with the introduction of the Canada Health and Social Transfer (CHST – 1995) when the federal government unilaterally announced substantially reduced funding for health, social services and post-secondary education. By claiming to spend the same taxpayers dollar three times – once for health, again for post secondary education and again for social services – the federal government’s moral authority to uphold national principles for health is undermined.
Together, these initiatives weaken the federal government’s legitimacy in health care and encumber its ability to stand-up for Canadians, as was highlighted in the most recent Auditor General’s report.
In order to regain this authority the federal government must be willing to clearly identify a discrete contribution to health care that is large enough so as to be relevant in all jurisdictions. In our submission to the Commission on the Future of Health Care in Canada, we recommended that the federal contribution to the public health care system be locked in for a 5-year period. We indicated that the longer-term goal would be for the federal contribution to rise to 50% of total spending for core services over time as new and improved services and technologies became available. We also said that it should be tied to a built-in GDP-growth escalator once that target is reached.
This submission provides more detailed financial projections and recommendations on the federal contribution to the health care system. To be specific, in order to raise funding to the 50% target level the CMA recommends that financing of new services and technologies be introduced on a 50/50 cost-sharing basis. This would encourage provinces and territories to become early adopters of new technology and help to update the basket of core services available to Canadians. How quickly 50% cost-sharing of all core services were realised would depend on the rate of uptake of new technologies. However, for illustration purposes the CMA recommends an initial investment of $16 billion over the first five years starting in 2003/04 with the majority of that funding weighted towards the back-end of the five-year period. This investment would take us partway (45 federal/55 provincial cost sharing) towards reaching our goal of 50/50 cost sharing. The expectation would also be that expansion beyond the current basket of services would be funded on a 50/50 cost-sharing basis.
The key message is that the federal government must be an equal partner with the provinces and territories in providing funding for new pressures. This includes taking measures to meet the needs of Canadians living in rural and remote areas where there are unique considerations with respect to ensuring access to, and support of, physicians and other health care services.
To further support funding for health care across the country, a buffer is needed to protect provincial and territorial health care budgets from the ebbs and flows of the economic cycle. As well, varying fiscal capacities of individual provinces and territories has made it increasingly difficult to ensure the provision of reasonably comparable health services across Canada.
Currently, the federal Fiscal Stabilisation Program compensates provinces if their revenues fall substantially from one year to the next due to changes in economic circumstances. However, this program is not health-specific and only takes effect when provincial revenues drop by over 5%. The federal Equalisation program also provides some protection for have-not provinces. However, its effectiveness is limited by virtue of the “ceiling provision” that places a cap on increases in payments to the rate of national GDP growth. This provision was temporarily lifted for fiscal year 1999/2000 in conjunction with the September 2000 health accord, generating an additional $700 million in Equalisation payments to the have-not provinces.
It is the CMA’s belief that this ceiling is one of the contributing factors to the disparity that exists between provinces in their capacity to provide funding for health care services and as such, should be permanently removed.
Making improvements to either or both of these programs would help address the concern raised in the CMA’s submission to the Romanow Commission on the need to provide provinces with ways to curb the impact on the health care system from the ebbs and flows of the business cycle.
LONG-TERM FINANCING REQUIREMENTS ($16 Billion over 5 years)
* Provide funding for new core services and technologies on a 50/50 cost-shared basis with the ultimate goal of reaching 50% of provincial/territorial spending on core services over time.
* Provide greater protection against provincial/territorial revenue shortfalls for example by removing the ceiling on the federal Equalisation program or enhancing the federal Fiscal Stabilisation Program.
Short-Term Bridge Financing of Health Infrastructure
In conjunction with the longer-term financing needs of Canada’s health care system, there are some urgent objectives that cannot wait for governments to finalise and implement their plan. We think of these shorter-term objectives as requiring “bridge financing” in areas of health infrastructure that are necessary to support health care innovation.
As roads and highways are the backbone to the production and delivery of products, so too is Canada’s health infrastructure the foundation on which the health care system delivers care to Canadians. We applaud the Canadian Foundation for Innovation and other similar programs for their important contributions in this area. Increasingly, however, “infrastructure” incorporates more than bricks and mortar – it can also mean providing improving health information capacity in hospitals; providing human resource infrastructure or the latest diagnostic equipment. Experience has taught us that investments of this type lead to increased innovation, productivity and efficiency.
The pressing nature of these issues warrants the use of one-time, targeted, special-purpose transfersiii specifically in the areas of:
* Health human resources supply and training;
* Capital infrastructure; and
* Health information technology.
Health Human Resources Supply and Training
Consistently, Canadians point to the shortage of physicians as a key health care system concern. Factors underlying this shortage include physician demographics (e.g., age and gender distribution), changing lifestyle choices and productivity levels (expectations of younger physicians and women differ from those of older generations), and insufficient numbers entering certain medical fields. According to 2001 data from the Organisation for Economic Co-operation and Development (OECD), Canada ranked 21st out of 26 countries in terms of the ratio of practising physicians to population.iv
The need is particularly great in rural and remote areas where 30% of Canadians live but where only approximately 10% of Canadian physicians practice.v This is complicated by the fact that accessing services for patients in rural and remote areas can be difficult. In a survey done by the CMA in 1999, physicians living in rural communities indicated that their level of professional satisfaction – i.e., how they are able to meet the health care needs of their patients – fell significantly since the early 1990s. In a striking example, only 17% reported being very satisfied with the availability of hospital services in 1999 compared to 40% in 1991.
The necessary increases in undergraduate enrolment in medicine needed to address this situation require funding not only for the positions themselves, but also for the infrastructure (human and physical resources) needed to ensure high-quality training that meets North American accreditation standards. In addition, capacity must be sufficient to provide training to international medical graduates and allow currently practising physicians the opportunity to return to school to obtain postgraduate training in new skill areas.vi
As well, the CMA remains very concerned about high and rapidly escalating increases in medical school tuition fees across Canada. According to data from the Association of Canadian Medical Colleges (ACMC), between 1996 and 2001 average first-year medical school tuition fees increased 100%. In Ontario, they went up by 223% over the same period. Student financial support through loans and scholarships has simply not kept pace with this rapid escalation in tuition fees.
Findings from recent research show that high tuition fees and fear of high debt loads create barriers that discourage people to apply to medical school and potentially threaten the socio-economic diversity of future physicians serving the public. They may also exacerbate the “brain drain” of physicians to the United States where newly graduated physicians can pay down their large student debts much more quickly. In addition, high debt loads may influence physicians’ choice of specialty and practice location.
Medical Equipment and other Capital Infrastructure
The crisis in health human resources is exacerbated by an underdeveloped capital infrastructure - brick, mortar and tools. This is seriously jeopardising timely access to quality care within the health care system.
In September 2000, the federal government announced a series of new investments to support agreements by First Ministers on Health Renewal and Early Childhood Development. One of these investments was a two-year $1 billion fund for the provinces and territories, the Medical Equipment Fund (MEF), to purchase new health technologies and diagnostic equipment. However, analysis done by the CMA suggests that of the $1 billion allocated through the Medical Equipment Fund, only approximately 60% was used to pay for new (incremental) expenditures on medical equipment. It appears the remaining 40% replaced what provinces and territories would have already spent in this area from their own funding sources.
Additional analysis suggests that there continues to be a significant gap between access in Canada to medical equipment and availability of medical equipment in other OECD countries. Cost estimates suggest that an additional investment of some $1.15 billion in health technology is still needed to bring Canada up to the level of the 7-country OECD comparator country average. Of that amount $650 million is required for capital expenditures and $500 million is required to provide the provinces/territories with 3 years of operating funds.
All governments have the responsibility to be transparent and accountable to taxpayers for health care spending. The conditions of the Medical Equipment Fund did not live up to this responsibility. Provinces and territories provided widely variable and often incomplete information that is largely inaccessible to the public, and at the very least difficult to trace. To this end, one of the responsibilities envisioned for a Canadian Health Commission would be to report on the health of health care in Canada and keep Canadians informed as to how their taxpayer dollars are being spent.
Health Information Technology
While the health sector is as information intensive as other industries, it has lagged behind other sectors in investing in information and communication technologies (ICTs). The benefits that ICT promises to deliver the health care system include better quality care, enhanced access to health services (particularly for those 30% of Canadians living in rural and remote locations), and better utilisation of scarce human health resources.
As part of the September 2000 Health Accord, the federal government invested $500 million to create Canada Health Infoway Inc. with a mandate to accelerate the development and adoption of modern systems of information technology, such as electronic patient records. The CMA applauds this investment, but notes that the $500-million needs to be seen as a “down-payment”. It provides only a fraction of the $4.1 billion the CMA estimates it would cost to fully connect the Canadian health care system with all the health benefits that would flow from this in terms of improved national safety and a reduced number of duplicate tests.
Studies point to two key ingredients for successful uptake of information and communication technology: creating mechanisms to help people adapt to the new environment and testing out solutions in real work situations before moving to full-scale implementation. To date, very little investment has been directed towards helping providers prepare for new investments in infrastructure being made by the provinces, territories and the federal government.
The CMA is prepared to play a pivotal partnership role in achieving the buy-in and cooperation of physicians and other health care providers through a multi-stakeholder process.
As well, currently the majority of ICT investments have targeted acute care and primary care settings. Changing demographics in the Canadian population suggest that new pressures are likely to emerge in home care settings – an area that has hitherto been largely neglected with respect to ICT and is currently ill equipped to cope with growing demand. A potential safety valve that could be made available, however, is the application of remote healthcare solutions amenable to care provided in the home.
SHORT-TERM BRIDGE FINANCING ($2.5B over five years)
* Establish a $1-billion, five-year Health Resources Education and Training Fund.
* Increase targeted funding to post-secondary institutions to alleviate some of the pressures driving the rise in tuition fees. Provide enhanced direct financial support to students, in particular, through bursaries and scholarships.
* Establish a one-time catch-up fund of $1.15 billion to restore medical equipment to an acceptable level.
* Assist providers to improve and/or gain skill sets to work to become more ICT enabled and provide for aggressive piloting of remote ICT solutions.
The proposals as outlined above for the overall financing of the health care system recommend an incremental approach to increased federal support for health care with the more significant investments not beginning until after 2005/06. We feel that this approach would allow for the majority of funds to come from within existing (or anticipated) fiscal frameworks.
Within the context of broader discussion, the CMA brought together key experts on September 25, 2002 to discuss issues related to the interface between tax and health. One of the issues discussed was the potential for using earmarked taxes as a mechanism for raising revenue, particularly for short-term capital-type investments. With respect to any new funding mechanism, there was agreement on the need to take into account the principles of fairness, progressivity and horizontal and vertical equity in determining any new source of funding for health care services.
While some suggest that efficiencies remain in the system, that if eliminated could provide funding for future health care needs, this is not the view of CMA members working on the front-line of the health care system. CMA’s challenge to governments is to not allow the lack of a revenue source to provide an excuse for not proceeding with health care reform in Canada. The CMA is looking forward to the recommendations in the Kirby and Romanow reports to further inform work in this area.
INVESTMENTS IN PUBLIC HEALTH
In essence, public health is the organised response by society to protect and promote health and to prevent illness, injury and disability. These efforts require co-ordination and co-operation between individuals, federal, provincial, territorial, and municipal governments, community organisations and the private sector. A major component of public health is focused on the promotion of healthy living to improve the health status of the population and reduce the burden and impact of chronic and infectious diseases. A recent commitment of $4.3 billion in the U.S. for the Centers for Disease Control and Prevention challenges us to equally support activities that further strengthen Canada’s public health system.vii
The September 30, 2002 Speech from the Throne noted the importance of a strong public health system and promised to “move ahead with an action plan in health policy areas under its direct responsibility” including addressing emerging risks, adapting to modern technology and emphasizing health prevention activities. We see this as an important commitment and will be watching closely as the plan is developed. In the meantime, we have identified three areas of public health that require more immediate federal assistance.
Last year our submission to the Standing Committee addressed the urgent health security and health care issues arising out of the tragic events of September 11, 2001 in the United States. The CMA raised serious concerns with the ability of Canada’s public health care system to respond to disasters and made a number of recommendations to address national preparedness in terms of security, health and capacity of the system. While there has been some movement towards meeting these needs, the CMA firmly believes that there remain significant shortcomings in our capacity to respond to health care emergencies.
At the time of an emergency, among the first points of contact with the health system for Canadians are doctors’ offices and hospital emergency rooms. As noted in past CMA submissions to the Standing Committee, we have witnessed in recent years the enormous strain these facilities can face when even something quite routine like influenza strikes a community.
Regardless of how well prepared any municipality is, under certain circumstances public health officials will need to turn to the province, territory and/or the federal government for help. The success of such a multi-jurisdictional approach is contingent upon good planning beforehand between the federal, provincial/territorial and local-level governments. There is an important role for the federal government to urgently improve the co-ordination amongst authorities and reduce the variability between various response plans in co-operation with provincial authorities (including assisting in the preparation of plans where none exist).
At the beginning of the last century, infectious diseases were the leading cause of death worldwide. In Canada, they are now responsible for less than 5% of all deaths thanks to immunisation programs. Immunisation protects an entire population by preventing the spread of disease from one individual to another: the more people immunised, the less chance of disease. To minimise the spread of vaccine-preventable diseases the maintenance of very high levels of immunisation is required. The National Advisory Committee on Immunisation (NACI) has provided general Canadian recommendations on the use of vaccines, drawing upon the expertise of specialists in public health, infectious diseases and paediatrics from across the country.
Canadian children in all provinces are routinely immunised against nine diseases. For approximately $150 worth of vaccines, a Canadian child can be vaccinated against these diseases from infancy to adolescence, the impact of which can last a lifetime. Unfortunately, the level of immunisation varies across Canada. This is unacceptable. All children in Canada should and must have the protection that current science has made available against vaccine-preventable diseases according to the recommendations of public health experts.
The CMA recommends a two-step strategy. First we encourage the federal government to work with the provinces and territories to jointly develop goals in the area of vaccination, such as linking record-keeping systems, implementing vaccine safety guidelines and seeking purchasing partnerships. Second, we urge the federal government to work within this framework to ensure that three new vaccines be introduced across the country to prevent children from contracting varicella (chicken pox); meningitis and pneumococcus (the leading cause of invasive bacterial infections, bacterial pneumonia and middle ear infection in children).
National Drug Strategy
The development of a national strategy for addressing issues related to illicit drug use should be a priority for federal leadership and investment. Illicit drug use has adverse effects on the personal health of Canadians and the well-being of society. The CMA believes that the government must take a broad public-health policy approach to address illicit drug use.
A single-handed criminal justice approach to dealing with illicit drug use is inappropriate particularly when there is increasing consensus that it is ineffective and exacerbates harm. Addiction should be regarded as a disease and therefore, individuals suffering with drug dependency should be diverted, whenever possible, from the criminal justice system to treatment and rehabilitation.
We applaud the recent commitment in the September 30, 2002 Speech from the Throne to implement a national drug strategy to address addiction while promoting public safety. In keeping with this, the CMA urges the government to fully implement and evaluate a national drug strategy prior to proceeding with any movement toward changes in the legal status of marijuana.
INVESTMENTS IN PUBLIC HEALTH ($700 million over three years)
* Create an assistance fund for municipal and provincial authorities to support public health infrastructure renewal at a local level, improve the co-ordination among public health officials, police, fire and ambulance services, hospitals and other services and to support the infrastructure for public health emergency response.
* Continue to invest in the resources and infrastructure (i.e., medical supplies, equipment, laboratory facilities, and training for health care professionals) needed to anticipate and respond to disasters.
* Implement a National Immunisation Strategy to achieve the optimal level of immunisation for all Canadians and ensure coverage of all children with routinely recommended childhood vaccines.
* Develop a comprehensive national drug strategy on the non-medical use of drugs that re-balances the distribution of resources so that a greater proportion is allocated to drug treatment, prevention, cessation and harm reduction.
Reform of Canada’s health care system is a formidable task. It involves the participation and agreement of all levels of government. It also requires that providers, other stakeholders and ultimately the acceptance of the end-user, Canadians are at the planning table. The Commission on the Future of Health Care in Canada, over the past year and a half, has undertaken a vast review of the issues impacting Canada’s health care system including Canadians’ values. As providers of care at the front-line of the health care system, Canadian physicians see themselves as key partners in this reform.
The CMA will be looking eagerly at the Romanow Commission’s recommendations and those of the Senate Committee. We will be holding the federal, provincial and territorial governments accountable for implementing, in a timely fashion, a response with clear deliverables. Clearly, we see the report’s release as offering a short window of opportunity to turn the corner on health care system reform. We need to act now and not just wait for the system to fix itself. Canadian physicians are ready to do our part, all we ask is for the opportunity.
i Since 2000 there have been four major provincial reviews of their health care systems (Caring for Medicare: Sustaining a Quality System (the Fyke Commission), April 2001; la commission d’étude sur les services de santé et les services sociaux (the Clair Commission); Patients First: Renewal and Reform of British Columbia’s Health Care System, December 2001; A Framework for Reform: Report of the Premier’s Advisory Council on Health (the Mazankowski Report), January, 2002.
ii A recent article by Patrick Monahan and Stanley Hartt published by the C.D. Howe Institute argues that Canadians have a constitutional right to access privately-funded health care if the publicly funded system does not provide access to care in a timely way.
iii Precedents for these types of transfers include the National Health Grants Program created in 1948 to develop hospital infrastructure across the country. More recently, several funds were created to support early child development, medical equipment, the health infoway and primary care renewal at the time of the First Ministers’ Agreement on Health in September 2000.
iv Organisation for Economic Cooperation and Development. Health at a Glance. Paris, France: OECD; 2001.
v The CMA has developed a policy on Rural and Remove Practice Issues which was released on October 17, 2000 (CMAJ, October 17, 2000, Vol. 163 (8)).
vi Canadian Medical Forum membership includes: CMA, Association of Canadian Medical Colleges, College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada, Canadian Federation of Medical Students, Canadian Association of Interns and Residents, Federation of Medical Licensing Authorities of Canada, Medical Council of Canada, and Association of Canadian Academic Healthcare Organizations.
vii As announced on December 20, 2001 by the United States Department of Health and Human Services. Copy available at: http://www.hhs.gov/news
It has been over three years since the Social Union Framework Agreement (SUFA) was signed by the federal and provincial/territorial governments, with the exception of Quebec. At the time, it was heralded as an important breakthrough in federal-provincial relations that would clear the way for greater intergovernmental cooperation on pressing social policy issues such as health care renewal.
Functional federalism is essential to achieving social policy objectives that will be of benefit to Canadians from coast to coast. While SUFA may not be perfect, it is better than the alternative of federal-provincial paralysis and dysfunction. And as SUFA acknowledges, Canada’s social union is about more that how governments relate to each other: it is about how governments can and should work with external stakeholders and individual Canadians to improve the social policies and programs.
The health sector is an important test case for SUFA. It is the most cherished of Canada’s social programs. Canadians want and expect their governments to work together to improve the health care system and ensure its future sustainability. Ironically, it is also the area where government intergovernmental discord has been the greatest. On the eve of the final report of the Commission on the Future of Health Care in Canada, it is timely to reflect on SUFA and its role in the renewal of Canada’s health system.
SUFA and the Health Sector – Strengths and Weaknesses
The attached table provides a summary of the key elements of SUFA and the CMA’s assessment of how well SUFA provisions have been applied in the health sector.
On the positive side, the health sector has fared relatively well in the area of mobility within Canada. Physicians and other regulated health care providers generally enjoy a high degree of mobility. Portability of hospital and medical benefits is largely ensured through interprovincial eligibility and portability agreements. There are, however, two areas of concern. First, there is the longstanding failure to resolve the non-portability of medical benefits for Quebec residents. Second, there is growing disparity in coverage for services that are currently not subject to national standards under the Canada Health Act, particularly prescription drugs and home care.
In the area of dispute avoidance and resolution, governments have agreed to a formal process to address concerns with the Canada Health Act. This is a positive step, though few details have been made public. The real test will be whether this new process accelerates the resolution of non-compliance issues (most of which, as the Auditor-General recently pointed out, have remained unresolved for five years or longer), and whether the federal government will have the political will to levy discretionary penalties for non-compliance.
There has also been progress on public accountability and transparency as governments have begun reporting results in 14 health indicator areas pursuant to the September 2000 health accord. The CMA is disappointed, however, that governments did not fulfil their pledge to involve stakeholders at all levels in the development of these indicators. Moreover, governments have short-changed Canadians by not providing them with a national roll-up of indicators that would facilitate comparisons across jurisdictions. Looking to the future, it will be critical to put in place a process that moves from benchmarks (indicators) to the bedside (best practices, better outcomes). This must be done in collaboration with health care researchers, providers and health managers—those individuals who understand the importance of taking research and importing it into practice. Clinical researchers across the country are doing this work and must to be supported.
Overshadowing these relative successes in the first three years of the Social Union Framework Agreement are three key challenges that must be addressed:
* inadequate institutional mechanisms to improve accountability across the system
* failure to reduce uncertainty about what the health system will deliver, now and into the future
* resistance on the part of governments to engage stakeholders in a true partnership for health system renewal
The CMA is concerned that if these fundamental weaknesses are not addressed, they will undermine future attempts to renew Canada’s health system.
With the adoption of SUFA, governments have significantly increased emphasis on performance measurement and public reporting. While this is a positive development, it also has the potential to lead towards information overload and paralysis, unless two critical elements are addressed. First, there is a need for a clear accountability framework that sets out the roles, rights and responsibilities of all key players in Canada’s health system: patients, health care providers and governments. This, in turn, requires the creation of a credible arm’s length institution to monitor compliance with this framework and rise above the fray to give Canadians the straight goods on health care. One has to look no further that the recent rekindling of the so-called “shares debate” between the federal and provincial governments as an example of why these changes are necessary.
Over the past decade, Canada’s health system has been plagued by an escalating crisis of uncertainty. Patients have faced increasing uncertainty about the accessibility and timeliness of essential health care services. Health care providers have seen working conditions deteriorate. Employers and private insurers have seen their contribution to funding health services increase unpredictably as governments have scaled back their funding commitments. Furthermore, provincial and territorial governments have had to contend with an unstable federal funding partner.
Canadians deserve better. They need more certainty that their public health system will care for them when they need it most. They need more transparency from governments about “what’s in” and “what’s out” in terms of public or private coverage. They need their governments to act on their SUFA undertaking to make service commitments for social programs publicly available such as establishing standards for acceptable waiting times for health care. And they need governments to follow through with their SUFA commitment to ensure stable and adequate funding for the health system and other social programs.
Fostering real partnerships
In the health care field, deliberations and agreements have taken place behind closed doors and governments have discounted the role that non-governmental organizations and citizens should play in decision-making. It is these very providers and patients who are expected to implement and live with the results of such cloistered decision-making. The consequences of this systematic exclusion are all too evident in the current critical and growing shortages of physicians, nurses and other health professionals. If we are to achieve the vision of a sustainable Medicare program, it is critical that governments come clean on their SUFA commitment to work in partnership with stakeholders and ensure opportunities for meaningful input into social policies and programs.
CMA’s Prescription for Sustainability – Building on SUFA
The Social Union Framework Agreement has created the necessary, but not sufficient, conditions for health system renewal. It has codified the emerging consensus on federal-provincial relations and has clarified the "rules of the game". However, it is an enabling framework that is of limited value in the health sector unless it is given life through institutional mechanisms that establish enduring partnerships not just between governments, but between governments health care providers, and patients.
In its final submission to the Commission on the Future of Health Care in Canada entitled “Prescription for Sustainability”, the CMA proposes the implementation of three integrated “pillars of sustainability” that together would improve accountability and transparency in the system: a Canadian Health Charter, a Canadian Health Commission, and federal legislative renewal.
Canadian Health Charter
A Canadian Health Charter would clearly articulate a national health policy that sets out our collective understanding of Medicare and the rights and mutual obligations of individual Canadians, health care providers, and governments. It would also underline governments’ shared commitment to ensuring that Canadians will have access to quality health care within an acceptable time frame. The existence of such a Charter would ensure that a rational, evidence-based, and collaborative approach to managing and modernizing Canada’s health system is being followed.
Canadian Health Commission
In conjunction with the Canadian Health Charter, a permanent, independent Canadian Health Commission would be created to promote accountability and transparency within the system. It would have a mandate to monitor compliance with and measure progress towards Charter provisions, report to Canadians on the performance of the health care system, and provide ongoing advice and guidance to the Conference on Federal-Provincial-Territorial ministers on key national health care issues. Recognizing the shared federal and provincial/territorial obligations to the health care system, one of the main purposes of the Canadian Health Charter is to reinforce the national character of the health system.
Federal legislative renewal
Finally, the CMA’s prescription calls for the federal government to make significant commitments in three areas: 1) a review of the Canada Health Act, 2) changes to the federal transfers to provinces and territories to provide increased and more targeted support for health care, and 3) a review of federal tax legislation to realign tax instruments with health policy goals.
While these three “pillars” will address the broader structural and procedural problems facing Canada’s health care system, there is many other changes required to meet specific needs within the system in the short to medium term. The CMA’s Prescription for Sustainability provides specific recommendations in the following key areas:
* Defining the publicly-funded health system (e.g. a more rational and transparent approach to defining core services, a “safety valve” if the public system fails to deliver, and increased attention to public health and Aboriginal health)
* Investing in the health care system (e.g. human resources, capital infrastructure, surge capacity to deal with emergencies, information technology, and research and innovation)
* Organization and delivery of services (e.g. consideration of the full continuum of care, physician compensation, rural health, and the role of the private sector, the voluntary sector and informal caregivers)
On balance, the Social Union Framework Agreement has been a positive step forward for social policy in Canada, though its potential is far from being fully realized.
The CMA’s proposal for a Canadian Health Charter, a Canadian Health Commission and federal legislative review entail significant changes to the governance of Canada’s health system. These changes would be consistent with the Social Union Framework Agreement and would help “turn the corner” from debate to action on health system renewal.
The early, ongoing and meaningful engagement of health care providers is the sine qua non of securing the long-term sustainability of Canada’s health system. Canada’s health professionals, who have the most to contribute, and next to patients – who have the most at stake – must be at the table when the future of health and health care is being discussed.
The CMA’s Assessment of the Social Union Framework Agreement ANNEX
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1. All Canadians to be treated with fairness and equity
2. Promote equality of opportunity for all Canadians
3. Respect for the equality, rights and dignity of all Canadian women and men and their diverse needs
4. Ensure access for all Canadians to essential social programs and services of reasonably comparable quality
5. Provide appropriate assistance to those in need
6. Respect the principles of Medicare: comprehensiveness, universality, portability, public administration and accessibility
7. Promote the full and active participation of all Canadians in Canada’s economic and social life
8. Work in partnership with stakeholders and ensure opportunities for meaningful input into social policies and programs
9. Ensure adequate, affordable, stable and sustainable funding for social programs
10. Respect Aboriginal treaties and rights
[#4] Progress towards the objective of ensuring access to essential health services of reasonably comparable quality is difficult to assess. First, there is no agreed-upon definition of essential health services. Second there the development of indicators and benchmarks of health care quality is still in its infancy. However, the CMA is very concerned that the system is not headed in the right direction, with growing shortages of physicians, nurses and other health care providers. According to Statistics Canada’s recently released survey on access to health care services, an estimated 4.3 million Canadians reported difficulties accessing first contact services and approximately 1.4 million Canadians reported difficulties accessing specialized services.
[#6]Although there is broad support for the five principles of Medicare, there continue to be a number of longstanding violations of Canada Health Act that are not being addressed, including the portability of medical benefits for Quebec residents. The emergence of privately-owned clinics that charge patients for medically-necessary MRI scans is also cause for concern.
[#8] There is no formal, ongoing mechanism for input from stakeholders and the individual Canadians in debates about national health policy issues. (See also #17 below).
[#9] Ensuring adequate, affordable, and stable funding for Canada’s health system is essential to its long-term sustainability. During the 1990s, billions of dollars were siphoned out of the system to eliminate government deficits. To put Medicare back on a sustainable path, governments must make long-term funding commitments to meet the health care needs of Canadians. The CMA has recommended that the federal government should significantly increase its financial contribution to restore the federal-provincial partnership in health care, and increase accountability and transparency through a new earmarked health transfer.
Mobility within Canada
11. Removal of residency-based policies governing access to social services
12. Compliance with the mobility provisions of the Agreement on Internal Trade
[#11] Residency-based policies are generally not an issue for physician and hospital services, where inter-provincial portability is guaranteed through reciprocal billing arrangements. As noted above, however, the portability of medical benefits for many Quebec residents is limited because the province only reimburses out-of-province services at home-province (as opposed to host-province) rates.
[#12] Regulatory authorities initiated work towards meeting the obligations of the Labour Mobility Chapter of the Agreement on Internal Trade in fall 1999. A Mutual Recognition Agreement has been developed and endorsed by all physician licensing authorities.
Public accountability & transparency
13. Performance measurement and public reporting
14. Development of comparable indicators to measure progress
15. Public recognition of roles and contributions of governments
16. Use funds transferred from another order of government for purposes agreed and pass on increases to residents
17. Ensure effective mechanisms for Canadians to participate in developing social priorities and reviewing outcomes
18. Make eligibility criteria and service commitments for social programs publicly available
19. Have mechanisms in place to appeal unfair administrative practices
20. Report publicly on appeals and complaints
[#13-14] Pursuant to the September 2000 Health Accord, the federal government and provinces have developed common health indicators in 14 areas and have released a first slate of reports. However, the usefulness of these reports is hampered by missing data elements on quality of care (access and waiting times in particular) and the absence of a national roll-up to facilitate inter-provincial comparisons.
[#15] Continuing federal-provincial bickering about shares of health funding makes it clear that this provision is not being met.
[#16] The CMA’s analysis of the Medical Equipment Fund found that incremental spending by provinces on medical technology accounted for only 60% of the $500 million transferred by the federal government for this purpose.
[#17] There is no mechanism in place to ensure ongoing input from Canadians and health care providers in national health policy development. The CMA has recommended the creation of a Canadian Health Commission, with representation from the public and stakeholders to provide advice and input to governments on key national health policy issues.
[#18] Although there have been proposals to this effect in a couple of provinces, governments currently do not make explicit commitments about the quality and accessibility of health services. In order to reduce the uncertainty Canadians are feeling with respect to Medicare, the CMA has recommended the creation of a Canadian Health Charter that would set out the rights and responsibilities of patients, health care providers and governments. In particular, the health charter would require all governments to set out care guarantees for timely access to health services based on the best available evidence.
[#19-20] The Auditor-General recently reported that Health Canada provides inadequate reporting on the extent of compliance with the Canada Health Act.
Governments working in partnership
21. Governments to undertake joint planning and information sharing, and work together to identify priorities for collaborative action
22. Governments to collaborate on implementation of joint priorities when this would result in more effective and efficient service to Canadians.
23. Advance notice prior to implementation of a major policy or program change that will substantially affect another government
24. Offer to consult prior to implementing new social policies and programs that are likely to substantially affect other governments.
25. For any new Canada-wide social initiative, arrangements made with one province/territory will be made available to all provinces/territories.
26. Governments will work with the Aboriginal peoples of Canada to find practical solutions to address their pressing needs
The requirement for governments to work together collaboratively is perhaps the most important part of SUFA, yet there it is impossible for organizations and individuals outside of government to assess the degree to which these provisions have been met. This so-called “black box of executive federalism” is not serving Canadians well. In the health sector, there are too many examples of governments developing policy and making decisions with little or no input from those who will ultimately have to implement change.
To achieve a true social union, the tenets of good collaborative working relationships – joint planning, advance notice and consultation prior to implementation – must be extended beyond the ambit of federal-provincial decision-making. The CMA’s proposal for a Canadian Health Commission would go some distance in addressing these concerns. A key part of its mandate would be to bring the perspective of health providers and patients into national health policy deliberations and decision-making.
Federal spending power
27. Federal government to consult with P/T governments at least one year prior to renewal or significant funding changes in social transfers
28. New Canada-wide initiatives supported by transfers to provinces subject to:
a) collaborative approach to identify Canada wide objectives and priorities
b) Agreement of a majority of provincial governments
c) Provincial discretion to determine detailed design to meet agreed objectives
d) Provincial freedom to reinvest funding in related area if objectives are already met
e) Jointly developed accountability framework
29. For new Canada-wide initiatives funded through direct transfers to individuals or organizations, federal government to provide 3-months notice and offer to consult
There have been three new Canada-wide health initiatives supported by the federal spending power: the $500M Medical Equipment Fund, the $800 Primary Health Care Transition Fund and the $500M fund for health information technology.
The Medical Equipment Fund was created to respond to a genuine need for more modern diagnostic and treatment equipment. However, objectives were vague, money was transferred with no strings attached, and there was no accountability framework. The result, as the CMA’s analysis has shown, is that a significant portion of the funding did not reach its destination.
The jury is still out in the case of the Primary Care Transition Fund. Delivery of this program through normal government machinery will entail a higher degree of accountability than in the case of the Medical Equipment Fund. However, objectives of this initiative may be too broad to have a significant steering effect on the system as a whole.
Canada Infoway Inc. is an arm’s length body created by the federal government to disburse the $500M in health information technology funding. While this model has the advantage of being less politicized than government-run programs; accountability to Parliament and to Canadians is weaker.
Dispute avoidance & resolution
30. Governments committed to working together and avoiding disputes
31. Sector negotiations to resolve disputes based on joint fact-finding, including the use of a third party
32. Any government can require a decision to be reviewed one year after it enters into effect
33. Governments will report publicly on an annual basis on the nature of intergovernmental disputes and their resolution
Federal and provincial governments have agreed to a formal dispute avoidance and resolution process under the Canada Health Act. The Canadian Health Commission recommended by the CMA could play a useful role as an independent fact-finder.
Review of SUFA
34. By the end of the 3rd year, governments will jointly undertake a full review of the Agreement and its implementation. This review will ensure significant opportunities for input and feedback from Canadians and all interested parties, including social policy experts, the private sector and voluntary organizations.
[#34] Governments have taken a minimalist approach to the SUFA review by opting for an internet-based consultation and closed meetings with invited external representatives.
This approach is not sufficient. Future reviews should be more inclusive of all stakeholders.
This year’s submission from the Canadian Medical Association (CMA) to the Standing Committee on Finance focused on the need for action in the short and longer terms by identifying strategic investments that will ensure a strong health care system supported by a dependable and comprehensive public health infrastructure as its foundation. Specifically, the CMA recommended an initial investment of $16 billion over five years starting in 2003/04 and an additional $3.2 billion for shorter-term and public health initiatives.
Following our October 22, 2002 presentation to the Standing Committee on Finance, the CMA has developed four supplementary specific proposals for one-time funding in areas of urgent national need. They represent highly visible initiatives that, taken together, would substantially enhance Canada’s capacity in the health care sector in areas of federal jurisdiction. They are:
ACCESS HOME (Accelerating Community Care through Electronic Services)
Funding of specific sites across Canada to undertake aggressive, large scale project implementation of remote information and communication technology (ICT) solutions to facilitate care in home and community based settings.
PRO-MISe (Pro Medical Immigrant Selection)
Establishment of an international off-shore assessment program to pre-screen potential medical graduates who wish to immigrate to and practice medicine in Canada.
RREAL HEALTH Communication and Coordination Initiative (Rapid, Reliable, Effective, Accessible and Linked)
Increased capacity in areas of public health system to ensure communication in real time, both between multiple agencies and with health care providers, especially in times of national emergency or to meet national health needs.
PAN-CANADIAN NETWORKS OF CLINICAL EXCELLENCE
Improved national planning for specialty care across Canada by implementing needs-based planning tools; building synergies around areas of expertise; maximizing the efficiency in the delivery of care; and creating mechanisms for ensuring timely access to highly specialized quaternary care throughout Canada.
This initial facet of a comprehensive federal reinvestment strategy corresponds with priorities identified in the Speech from the Throne and with the strategic priorities identified in our submission to the Standing Committee on Finance. Together, they constitute an important next step toward implementing the government’s Speech from the Throne commitments. However, given the particular urgency of these initiatives, and their ability to stand as independent projects, we feel they would be excellent candidates for modest but meaningful allocations from the federal surplus that may become available towards the end of this fiscal year.
Each of these proposals incorporates a highly visible, targeted approach that not only builds the necessary evidence for transition to a renewed health care system but is also amenable to one-time funding. They reflect priorities that, due to their inter-jurisdictional nature, are highly unlikely to be undertaken by the provinces and territories without federal assistance. They would substantially reduce the uncertainties that Canadians feel and experience in dealing with the health system. Indeed, these initiatives provide an opportunity for the federal government to show immediate leadership in areas that fall clearly under its jurisdiction in ways that are certain to be complementary to the recommendations from the Commission on the Future of Canada (the Romanow Commission).
The Canadian Medical Association believes that the time for targeted action is now as part of a comprehensive strategy for a sustainable health care system. Canadians are counting on governments to turn the corner from debating what needs to be done to implementing necessary changes. We see time-limited, targeted reinvestments as an essential part of this renewal.
Accelerating Community Care through Electronic Services
In the September 2000 Health Accord, health information and communications technology (ICT) was highlighted as an area where First Ministers agreed to work together to strengthen a Canada-wide health infostructure to improve quality, access and timeliness of health care for Canadians. As part of the funding initiatives announced at that time, Canada Health Infoway Inc. (CHII), received $500 million in funding to accelerate the adoption of modern ICTs to provide better health care.
Given that implementation of a full health ICT strategy will require significantly more funding, CHII has given priority to the development of the electronic health record. Further, with the sunsetting of the two-year $80 million Canada Health Infostructure Partnerships Program (CHIPP) there are no other federal programs that provide funding for ITC pilot projects.
Changing demographics in the Canadian population point to emerging pressures to meet increased non-institutional care needs of our aging population. To date, the home care sector has been largely neglected with respect to ICT – the majority of current ICT investments target acute and, to a lessor extent, primary care settings – and is currently ill equipped to cope with growing demand.
Remote healthcare solutions show considerable potential to improve the care provided in home and community settings. Current projects in this area have demonstrated the benefits of using ICTs to facilitate care in non-traditional settings. Larger scale testing of remote ICT solutions should be undertaken to determine how best they can be applied to facilitate the provision of care in home and community based settings, and the implications for provider practice.
Through funding of specific sites across Canada (mini centres of excellence), engage in aggressive, large scale project implementations of remote ICT solutions to facilitate care in home and community based settings. This would involve working through how best to apply ICTs in these settings, determining what works best and developing practice procedures for the provider community.
The ACCESS-HOME proposal is based on the underlying principle of a collaborative model and the following potential key partners have been identified: provinces and territories, regional health authorities, and the private sector (e.g., March Networks).
Undertake, over a three year period, a variety of home and community care projects to learn how best to apply remote ICT solutions to facilitate provision of care in these settings. These could include projects to link primary care physicians to elderly frail patients in their home; to link patients with severe chronic conditions to specialists for remote monitoring of their conditions; to link home care nurses to patients to carry out preventive and promotion related activities on line; and to link physicians with recently discharged patients to monitor their rate of recovery.
Part of the project funding proposal would include an evaluation component to build a knowledge base of what works and why. The assessments then would be placed on the Health Canada web site to promote knowledge transfer.
FUNDING & ACCOUNTABILITY MECHANISMS
A one-time, lump sum endowment of $50 million in this fiscal year to Canada Health Infoway Inc. (CHII) to manage the program and funds.
Over a three-year period, CHII would operate under a very clear mandate set out by Health Canada to fund projects ($1-2 million each) across the country, in urban, rural and isolated settings, to more aggressively apply ICTs to facilitate provision of care in home and community based settings and to explore the implications for practice management. Accountability for the funds and the program implementation would be set out in a Memorandum of Understanding between Health Canada and CHII.
Funds would be allocated on a cost-shared basis with a threshold of 70% federal funding. The remaining 30% would come from partnership contributions (in-kind costs, human resources, etc.). It is anticipated that it would take one year to get the projects operational and a second year to implement their mandates. The third year would be dedicated to completing the projects and undertaking evaluations in a format that would contribute to the overall knowledge base in this area.
Pro Medical Immigrant Selection
The establishment of an assessment program to pre-screen international medical graduates wanting to immigrate to Canada and practice medicine in this country.
International medical graduates have always been, and continue to be, a valuable addition to the Canadian medical workforce. Recently, the federal government passed new immigration legislation, changing the focus of immigration requirements away from an occupation basis toward a concentration on skills, training, and potential for successful integration into the Canadian workforce and society.
In light of the implementation of these provisions, the Canadian Medical Association (CMA) and the Medical Council of Canada (MCC) propose the establishment of a Pro Medical Immigrant Selection (PRO-MISe) program for foreign-trained physicians seeking to immigrate to Canada. The purpose of this program would be to ensure that the anticipated increased numbers of foreign-trained medical graduates applying to immigrate to Canada receive fair treatment.
The CMA and MCC have already had a preliminary meeting with a senior advisor to the Honourable Minister Denis Coderre, Minister of Citizenship and Immigration in follow-up to a meeting with his predecessor, the Honourable Elinor Caplan in May 2001.
The goal of the project is to expedite the remote processing of applications by highly qualified international medical graduates who wish to immigrate to, and practice medicine in, Canada. This could be facilitated by creating an off-shore electronic assessment system for pre-screening in their country of origin.
In these times of physician workforce shortages, Canadian jurisdictions must be cautioned against “poaching” physicians from under-serviced parts of the world to meet their own health care needs (particularly in under-serviced areas or disciplines). Ethical recruitment practices must be established and maintained.
In the longer term, the Canadian medical community strongly believes that Canada must strive for reasonable self-sufficiency in the production of physicians, while continuing to offer opportunities to qualified international medical graduates.
Even in times of physician shortages, it remains imperative that foreign applicants who wish to practise medicine in Canada undergo a comprehensive assessment of knowledge and skills, on par with the assessment of graduates of Canadian medical schools.
The process for assessing international medical graduates must be, and be seen to be, fair, transparent, and accountable to all stakeholders, expedient and cost-effective (for both the applicant and the government).
The project would be comprised of a three-phased approach. Phase I would set up five pilots sites over 4-6 months in varied geo-political areas (e.g., London, Paris, Tokyo, Hong Kong and Port-of-Spain) that would test an Internet-based assessment system providing:
1. Updated and comprehensive information on the Canadian health care system and the Canadian medical education system, with a view to managing expectations regarding opportunities to practise medicine in Canada;
2. Electronic self-assessment tools for international medical graduates, containing questions comparable to those in the official Medical Council of Canada Evaluating Exam (MCCEE);
3. An electronic assessment system for the official MCCEE; and
4. Electronic forms, including the waiver currently used by CIC (Citizenship and Immigration Canada) indicating that the applicant understands there is no guarantee of an opportunity to practise medicine in Canada.
Phase II would evaluate the project’s success. Phase III, full implementation on a global scale, would follow.
FUNDING & ACCOUNTABILITY MECHANISMS
$5 million for Physician Assessment
A one-time, lump sum endowment of a $5 million sequestered fund in this fiscal year to be made to the Medical Council of Canada, to be managed and administered in keeping with the goals and objectives of the project (disbursement criteria would be set in collaboration with Health Canada and Human Resources Development Canada, as required).
$15 million for Assessment of Other Health Care Providers
There is a shortage of many health care providers. The CMA has had preliminary discussions with the Canadian Nurses Association (CNA) and the Canadian Pharmacists Association (CPhA). The Federal Government should consider funding the development of similar programs for other professions, in partnership with CNA, CPhA and others.
RREAL HEALTH COMMUNICATION & COORDINATION INITIATIVE
Rapid, Reliable, Effective, Accessible and Linked
Through its public health initiatives society protects and promotes health and works to prevent illness, injury and disability. In today’s world these public health functions require an increasingly specialized and well-trained workforce; sophisticated surveillance, monitoring and information systems; and adequate and continuously available laboratory support. Its ultimate effectiveness, however, is dependent on the ability of the system to communicate crucial information and health advice to the right professional in real time when they need it.
The devastating impact of the failure to effectively communicate essential information is evident in examples as diverse, as the water tragedy in Walkerton, and the untimely death of Vanessa Young who died as the result of a fatal adverse drug reaction 1. In both cases, the information health professionals needed to make optimum treatment decisions was not accessible in a reliable and timely manner.
The public health infrastructure is put to the test whenever there is a disaster, large or small, in Canada and, not withstanding the best efforts of dedicated public health professionals, it does not always receive a passing grade. The public health system is further challenged by the potential for a disconnect in communications between differing jurisdictions that may be found when, for example, First Nations communities under federal jurisdiction overlap areas of provincial jurisdiction. In the aftermath of 9/11 and the anthrax scare in the United States, Canadians must be assured of a rapid, knowledgeable, expert response to emergency public health challenges.
It is essential that the federal government take a leadership role to ensure that the communication tools and information technology necessary to allow for a more rapid and informed response to situations such as natural disasters, disease out-breaks, newly-discovered adverse drug reactions, man-made disasters, or bio-terrorism is accessible in real time in all regions of the country.
A one time infusion of $30 million for the creation of a RREAL Health Communication and Co-ordination Initiative would strengthen Canada’s public health infrastructure and enhance co-ordination and communication among all levels of government, public health officials, health care providers and multiple agencies such as police, fire, ambulance and hospitals.
The RREAL Health Communication and Co-ordination Initiative would address current deficiencies, and increase the capacity of the public health system to communicate in real time, both between multiple agencies and with health care providers in order to:
* Provide a focal point for inter-jurisdictional communication and co-ordination in order to be better prepared in times of emergency; and
* Disseminate emergency information, health alerts and current best practices in public health to health professionals and targeted public health officials in real time and in an effective and accessible fashion.
The RREAL Health Communication and Co-ordination Initiative would involve such key players in public health service and delivery as the Canadian Public Health Association, the Canadian Paediatrics Society, the Chief Medical Officers of Health, the Canadian Federation of Municipalities, the Canadian Red Cross and Health Canada in a collaborative model to ensure integrated co-ordination and communication.
The initiative would undertake a planned program of demonstration projects over a five-year period.
1. To enable the widespread accessibility of information such as newly discovered adverse drug reactions to physicians and other health providers by rapid, reliable, and effective dissemination.
2. To ensure that rural and remote areas of the country and First Nations, Metis and Inuit communities under federal health jurisdiction are linked to public health information systems.
3. To enhance clinical practice guidelines to make them more user friendly and accessible to health care providers.
4. To improve the interoperability of communication technology between multiple agencies such as public health, police and fire services, disaster relief agencies and hospitals in times of emergency.
FUNDING & ACCOUNTABILITY MECHANISMS
A one-time, lump sum endowment of $30 million in this fiscal year to a designated organization positioned to manage the administration of these funds over a five-year project duration. One option would be to establish a new Canadian Foundation for Public Health as an arms-length agency associated with the Office for Public Health at the Canadian Medical Association.
PAN-CANADIAN NETWORKS OF CLINICAL EXCELLENCE
Canada’s health care system commits to providing Canadians with reasonably comparable access to medically necessary care. This commitment must be met across the spectrum, from primary care to highly specialized care. However, low volumes associated with highly specialized care often does not warrant the ongoing maintenance of the physical and human resources necessary in all regions of the country to be able to respond to patients’ needs.
Recent evidence has found that a critical volume of patients is required to ensure a high quality standard of care. In the Canadian Institute for Health Information’s 2002 Health Care in Canada report, they state that “for many types of care and for many different surgeries, research shows that patients treated in hospitals with higher numbers of cases are often less likely to have complications or to die after surgery”. 2
Although clinical centres of excellence (hospitals/clinics that house the human and physical resources necessary to deliver care that meets or exceeds accepted professional standards) currently exist, in Canada they are generally focussed on serving the patient needs of a single province and, in some cases, the city in which they reside. There are no formal mechanisms at the national level to facilitate needs-based planning and sharing of best practices and pooling of resources for highly specialized care. The resulting capacity “deficit” manifests itself in difficulties in accessing care – an issue that has become central to the debate on the renewal of Canada’s health care system.
This proposal is about networking existing centres to achieve improved economies of scale and to accelerate quality improvement. It would build the infrastructure necessary to support and link these centres across the country. It would not aim to further consolidate or centralize the delivery of highly specialized services.
Implement a Pan-Canadian Networks of Clinical Excellence program as a means to improve the quality and accessibility of highly specialized care in Canada.
This proposal is premised on:
* A collaborative/partnership model between health organizations such as the Canadian Stroke Network, the Association of Canadian Academic Health Organizations (ACAHO); and the Canadian Medical Association (CMA);
* Support the Provincial/Territorial Premiers’ commitment to develop Sites of Excellence in various fields such as paediatric cardiac surgery and gamma knife neurosurgery 3 ;
* Consensus building and consultation;
* Build on, and learn from, existing provincial models (e.g., Cardiac Care Network of Ontario, Ontario Stroke System);
* Reliance on evidence-based practices;
* Improved quality of care;
* Rapid diffusion and adoption of new and emerging technologies;
* Pilots and on-going evaluation leading to additional networks; and
* Adoption of an evidence-based approach to network development.
Building on the experience of earlier network models, activities envisioned for a Pan-Canadian Networks of Clinical Excellence program would be to:
* Develop electronic registries to track and connect patients and physicians across the country;
* Support collaborative research extending from the bench to bedside 4 ;
* Establish and implement clinical best practices;
* Develop and implement knowledge translation plans; and
* Promote the sharing of human capital and expertise across jurisdictions.
Beyond striving to reach optimum efficiency in the delivery of sub-acute care specialties, a Pan-Canadian Networks of Clinical Excellence program would support the development of internationally competitive centres of excellence that would offer attractive employment opportunities for the best and brightest in health human resources thereby helping to attract and retain health human resources in Canada.
FUNDING & ACCOUNTABILITY MECHANISMS
A five year phased approach to the development of the networks is envisaged.
The first phase (two years) would involve piloting and evaluating a small number of networks. Based on detailed evaluation of the pilots, the second phase (year 2) could involve additional networks to be determined through consultation with partners. It is anticipated that by year 5, there would be five networks fully operational. The funding would be ideally delivered through a single year endowment of $25 million to existing foundations such as the Canadian Stroke Network. The new consortium would allocate funding over a 5-year period based on established criteria with regular reporting to the funding consortium partnership and ultimate accountability to report back to Parliament. A steering committee would be struck with representatives from each of the participating partners to provide direction and guidance on the project’s implementation.
1 Canadian Medical Association Journal, May 1, 2001, 164(9), page 1269.
2 Dudley RA, Johansen KL, Brand R, Rennie DJ, Milstein A. (2000). Selective referral to high-volume hospitals: Estimating potentially avoidable deaths. Journal of the American Medical Association, 283(9), 1159-1166 as cited in Health Care in Canada, 2002, Canadian Institute for Health Information, Ottawa: May 2002, p. 52.
3 As agreed to at the January 24-25, 2002 Provincial-Territorial Premiers’ Meeting in Vancouver. Information available at: www.scics.gc.ca/cinfo02/850085004_e.html
4As discussed in a presentation to the House of Commons Standing Committee on Health regarding Bill C-13: An Act to Establish the Canadian Institutes of Health Research. Dr. Peter Vaughan, Secretary General and CEO, Canadian Medical Association, December 6, 1999, Ottawa, Ontario.
The Canadian Medical Association is pleased to present this submission to the House of Commons Standing Committee on Health regarding Bill C-422, National Lyme disease strategy.
The Canadian Medical Association (CMA) is the national organization representing over 80,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care.
Lyme disease is a growing problem in Canada. According to the Public Health Agency of Canada (PHAC) there were 315 cases of Lyme disease reported in Canada in 2012 -two and one-half times more cases than the 128 reported in 2009, the year that it became a reportable disease. In the Ottawa area, cases have increased almost 8 fold from 6 in 2009 to 47 in 2013. The PHAC surveillance indicates that established populations of blacklegged ticks are spreading their geographic scope, and are increasing in number, in much of southern Canada. In 2013 the US Center for Disease Control and Prevention released new estimates of Lyme disease that was 10 times higher than the previous yearly reported number of 30,000 reported cases.1 This highlights the difficulty in establishing the true burden of illness from Lyme disease.
Why this matters to Canada's physicians
The Canadian Medical Association supports the implementation of a national strategy that can address the breath of public health and medical issues surrounding the spread of Lyme disease in Canada. As with any new infectious disease threat, Canada needs to ensure that we are prepared to address the impact of Lyme disease on Canadians.
CMA's policy on climate change and human health notes that changes in the range of some infectious disease vectors such as blacklegged ticks, are a possible consequence of climate change in Canada. Research has suggested that the tick vector of Lyme disease has been expanding into southeastern Canada which can lead to increased disease risk for those living in areas with tick populations.2
In this policy, CMA recommends that the federal government report diseases that emerge in relation to global climate change, and participate in field investigations, as with outbreaks of infectious diseases like Lyme disease, and develop and expand surveillance systems to include diseases caused by global climate change.
The World Medical Association Declaration of Delhi on Health and Climate Change urges colleges and universities to develop locally appropriate continuing medical and public health education on the clinical signs, diagnosis and treatment of new diseases that are introduced into communities as a result of climate change. Diagnosis of Lyme disease can be difficult, as signs and symptoms can be non-specific and found in other conditions. 3 If Lyme disease is not recognized during the early stages, patients may suffer seriously debilitating disease, which may be more difficult to treat.4 Given the increasing incidence of Lyme disease in Canada, continuing education for health care and public health professionals and a national standard of care would improve identification, treatment and management of Lyme disease. Greater awareness of where blacklegged ticks are endemic in Canada, as well as information on the disease and prevention measures, can help Canadians protect themselves from infection.
The CMA supports a national Lyme disease strategy which includes the federal, provincial and territorial governments and the medical and patient communities. This strategy must address concerns around research, surveillance, diagnosis, treatment and management of the disease and public health prevention measures will advance our current knowledge base, and improve the care and treatment of those suffering from Lyme disease.
Once again, CMA is pleased to provide this brief to the Standing Committee on Health as part of its study on this important issue. Canada's physicians recognize the importance of monitoring all emerging infectious diseases in Canada. In addition, Canada's physicians recognize the importance of developing strategies to treat, manage, and prevent Lyme disease in Canada.
1 CDC provides estimate of Americans diagnosed with Lyme disease each year, media release August 19, 2013 Accessed at http://www.cdc.gov/media/releases/2013/p0819-lyme-disease.html on Feb 21, 2014.
2 Ogden, N., L. Lindsay, and P. Leighton. 2013. Predicting the rate of invasion of the agent of Lyme disease Borrelia burgdorferi. Journal of Applied Ecology. April, 2013. 50(2):510-518.
3 Mayo Clinic, accessed at http://www.mayoclinic.org/diseases-conditions/lyme-disease/basics/tests-diagnosis/con-20019701 on Feb 21, 2014.
4 Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006;43: 1089-134.
The Canadian Medical Association will seek a current-state assessment of the federal government’s preparedness for national health emergencies with respect to mechanisms for providing timely knowledge translation of public health directives for clinicians and increased surveillance by physicians and health officials.
The Canadian Medical Association will seek a current-state assessment of the federal government’s preparedness for national health emergencies with respect to mechanisms for providing timely knowledge translation of public health directives for clinicians and increased surveillance by physicians and health officials.
The Canadian Medical Association will seek a current-state assessment of the federal government’s preparedness for national health emergencies with respect to mechanisms for providing timely knowledge translation of public health directives for clinicians and increased surveillance by physicians and health officials.