Helping physicians care for patients
Aider les médecins à prendre soin des patients
Canada is a nation on the precipice of great change. This change will be driven primarily by the economic and social implications of the major demographic shift already underway. The added uncertainties of the global economy only emphasize the imperative for federal action and leadership.
In this brief, the Canadian Medical Association (CMA) is pleased to present four recommendations to the House of Commons Standing Committee on Finance for meaningful federal action in support of a national seniors strategy; these are essential measures to prepare for an aging population.
Canada's demographic and economic imperative
In 2011 the first of wave of the baby boomer generation turned 65 and Canada's seniors population stood at 5 million.1 By 2036, seniors will represent up to 25% of the population.2 The impacts of Canada's aging population on economic productivity are multi-faceted.
An obvious impact will be fewer workers and a smaller tax base. Finance Canada projects that the number of working-age Canadians for every senior will fall from about 5 today to 2.7 by 2030.3
The projected surge in demand for services for seniors that will coincide with slower economic growth and lower government revenue will add pressure to the budgets of provincial and territorial governments. Consider that while seniors account for about one-sixth of the population, they consume approximately half of public health spending.4 Based on current trends and approaches, seniors' care is forecast to consume almost 62% of provincial/territorial health budgets by 2036.5
The latest fiscal sustainability report of the Parliamentary Budget Officer explains that the demands of Canada's aging population will result in "steadily deteriorating finances" for the provinces and territories and they "cannot meet the challenges of population ageing under current policy."6
Theme 1: Productivity
A) New federal funding to provincial/territorial governments
Canada's provincial and territorial leaders are aware of the challenges ahead. This July, the premiers issued a statement calling for the federal government to increase the Canada Health Transfer to 25% of provincial and territorial health care costs to address the needs of an aging population.
To support the innovation and transformation needed to address these needs, the CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer (Table 1). For the fiscal year 2016-17, this top-up would require $1.6 billion in federal investment.
Table 1: Allocation of the federal demographic-based top-up, 2016-20 ($million)7
All of Canada
Newfoundland and Labrador
Prince Edward Island
B) Federal support for catastrophic drug coverage
A major gap in Canada's universal health care system is the lack of universal access to prescription medications, long recognized as the unfinished business of medicare. Canada stands out as the only country with universal health care without universal pharmaceutical coverage.8
According to the Angus Reid Institute, more than one in five Canadians (23%) report that they or someone in their household did not take medication as prescribed because of the cost during the past 12 months.9 Statistics Canada's Survey of Household Spending reveals that households headed by a senior spend $724 per year on prescription medications, the highest among all age groups and over 60% more than the average household.10 Another recent study found that 7% of Canadian seniors reported skipping medication or not filling a prescription because of the cost.11
In addition to the very real harms to individuals, lack of coverage contributes to the inefficient use of Canada's scarce health resources. While there are sparse economic data in Canada on this issue, earlier research indicated that this inefficiency, which includes preventable hospital visits and admissions, represents an added cost of between $1 billion and $9 billion annually.12
As an immediate measure to support the health of Canadians and the productivity of the health care sector, the CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication. The program would cover prescription medication costs above $1,500 or 3% of gross household income on an annual basis. Research commissioned by the CMA estimates this would cost $1.48 billion in 2016-17 (Table 2). This would be a positive step toward comprehensive, universal prescription drug coverage.
Table 2: Projected cost of federal contribution to cover catastrophic prescription medication costs, by age cohort, 2016-2020 ($ million)13
Share of total cost
Under 35 years
35 to 44 years
45 to 54 years
55 to 64 years
65 to 74 years
75 years +
Theme 2: Infrastructure and communities
All jurisdictions across Canada are facing shortages in the continuing care sector. Despite the increased availability of home care, research commissioned for the CMA indicates that demand for continuing care facilities will surge as the demographic shift progresses.14
In 2012, it was reported that wait times for access to a long-term care facility in Canada ranged from 27 to over 230 days. It is estimated that 85% of "alternate level of care" patients in hospitals (i.e., patients who do not require hospital-level care) are in these beds because of the lack of availability of long-term care. Due to the significant difference in the cost of hospital care (approximately $846 per day) versus long-term care ($126 per day), the CMA estimates that the shortages in the long-term care sector represent an increased cost of $2.3 billion.
Despite the recognized need for infrastructure investment in the continuing care sector, to date, this sector has been excluded from the Building Canada Plan. The CMA recommends that the federal government amend the criteria of the Building Canada Plan to include capital investment in continuing care infrastructure, including retrofit and renovation. Based on previous estimates, the CMA recommends that $540 million be allocated for 2016-17 (Table 3).
Table 3: Estimated cost to address forecasted shortage in long-term care beds, 2016-20 ($ million)15
Forecasted shortage in long-term care beds
Estimated cost to address shortage
Federal share to address shortage in long-term care beds (based on 1/3 contribution)
Theme 3: Jobs
As previously mentioned, Canada's aging population will produce significant changes in the labour force. There will be fewer Canadian workers, each with a greater likelihood of having caregiving responsibilities for family and friends.
According to the report of the federal Employer Panel for Caregivers, Canadian employers "were surprised and concerned that it already affects 35% of the Canadian workforce."16 This report highlights key findings of the 2012 General Social Survey: 1.6 million caregivers took leave from work; nearly 600,000 reduced their work hours; 160,000 turned down paid employment; and, 390,000 quit their jobs to provide care. It is estimated that informal caregiving represents $1.3 billion in lost workforce productivity. These costs will only increase as Canada's demographic shift progresses.
In parallel to the increasing informal caregiving demands on Canadian workers, Canada's aging population will also increase the demand for personal care workers and geriatric competencies across all health and social care professions.17
Theme 4: Taxation
The above section focused on the economic costs of caregiving on the workforce. The focus of this section will be on the economic value caregivers provide while they take on an increased economic burden.
Statistics Canada's latest research indicates that 8.1 million Canadians are informal caregivers, 39% of whom primarily care for a parent.18 The Conference Board of Canada reports that in 2007 informal caregivers contributed over 1.5 billion hours of home care - more than 10 times the number of paid hours in the same year.19 The economic contribution of informal caregivers was estimated to be about $25 billion in 2009.20 This same study estimated that informal caregivers incurred over $80 million in out-of-pocket expenses related to caregiving in 2009.
Despite their tremendous value and important role, only a small fraction of caregivers caring for a parent received any form of government support.21 Only 5% of caregivers providing care to parents reported receiving financial assistance while 28% reported needing more assistance than they received.22
As a first step to providing increased support for Canada's family caregivers, the CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. This would provide an increased amount of financial support for family caregivers. It is estimated that this measure will cost $90.8 million in 2016-17.23
The CMA recognizes that in the face of ongoing economic uncertainty the federal government may face pressures to avoid new spending initiatives. The CMA strongly encourages the federal government to adopt the four recommendations outlined in this submission rather than further delay making a meaningful contribution to meeting the future care needs of Canada's aging population. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation.
1 Statistics Canada. Generations in Canada. Cat. No. 98-311-X2011003. Ottawa: Statistics Canada; 2012. Available: www12.statcan.gc.ca/census-recensement/2011/as-sa/98-311-x/98-311-x2011003_2-eng.pdf
2 Statistics Canada. Canada year book 2012, seniors. Available: www.statcan.gc.ca/pub/11-402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm
3 Finance Canada. Economic and fiscal implications of Canada's aging population. Ottawa: Finance Canada; 2012. Available: www.fin.gc.ca/pub/eficap-rebvpc/eficap-rebvpc-eng.pdf
4 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2014. Ottawa: The Institute; 2014. Available: www.cihi.ca/web/resource/en/nhex_2014_report_en.pdf
5 Calculation by the Canadian Medical Association, based on Statistics Canada's M1 population projection and the Canadian Institute for Health Information age-sex profile of provincial-territorial health spending.
6 Office of the Parliamentary Budget Officer. Fiscal sustainability report 2015. Ottawa: The Office; 2015. Available: www.pbo-dpb.gc.ca/files/files/FSR_2015_EN.pdf
7 Conference Board of Canada. Research commissioned for the CMA, July 2015.
8 Morgan SG, Martin D, Gagnon MA, Mintzes B, Daw JR, Lexchin J. Pharmacare 2020: The future of drug coverage in Canada. Vancouver: Pharmaceutical Policy Research Collaboration, University of British Columbia; 2015. Available: http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_in_Canada.pdf
9 Angus Reid Institute. Prescription drug access and affordability an issue for nearly a quarter of Canadian households. Available: http://angusreid.org/wp-content/uploads/2015/07/2015.07.09-Pharma.pdf
10 Statistics Canada. Survey of household spending. Ottawa: Statistics Canada; 2013.
11 Canadian Institute for Health Information. How Canada compares: results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults. Available: www.cihi.ca/en/health-system-performance/performance-reporting/international/commonwealth-survey-2014
12 British Columbia Pharmacy Association. Clinical service proposal: medication adherence services. Vancouver: The Association; 2013. Available: www.bcpharmacy.ca/uploads/Medication_Adherence.pdf
13 Supra at note 7.
14 Conference Board of Canada. Research commissioned for the CMA, January 2013.
16 Government of Canada. Report from the Employer Panel for Caregivers: when work and caregiving collide, how employers can support their employees who are caregivers. Available: www.esdc.gc.ca/eng/seniors/reports/cec.shtml
17 Stall S, Cummings G, Sullivan T. Caring for Canada's seniors will take our entire health care workforce. Available: http://healthydebate.ca/2013/09/topic/community-long-term-care/non-md-geriatrics
18 Statistics Canada. Family caregivers: What are the consequences? Available: www.statcan.gc.ca/pub/75-006-x/2013001/article/11858-eng.htm
19 Conference Board of Canada. Home and community care in Canada: an economic footprint. Ottawa: The Board; 2012. Available: http://www.conferenceboard.ca/cashc/research/2012/homecommunitycare.aspx
20 Hollander MJ, Liu G, Chappeel NL. Who cares and how much? The imputed economic contribution to the Canadian health care system of middle aged and older unpaid caregivers providing care to the elderly. Healthc Q. 2009;12(2):42-59.
21 Supra at note 16.
23 Supra at note 7.
The Canadian Medical Association (CMA) is pleased to provide the House of Commons Standing Committee on Finance this pre-budget submission. It provides recommendations to address major pan-Canadian challenges to the health of Canadians: improve how we provide care to our growing elderly population; improve access to primary care across the country; increase digital health literacy to take advantage of the benefits of new health information technologies; and better prepare for and mitigate the health impacts of a changing climate on Canadians.
Health systems across the country are currently struggling to meet the needs of our aging population. People aged 85 years and over—many of whom are frail—make up the fastest growing age group in Canadai.
Provincial and territorial health care systems (as well as care systems for populations falling under federal jurisdiction) are facing many challenges to meet the needs of an aging population. Canadians support a strong role for the federal government in leading a national seniors strategy and working with the provinces to ensure that all Canadians have the same level of access and quality of services, no matter where they live.
The 2017 federal/provincial/territorial funding agreement involving $6 billion over 10 years to improve access to home care services is a welcomed building block. But without greater investment in seniors care, health systems will not keep up. To be truly relevant and effectively respond to Canadians’ present and future needs, our health care system must provide integrated, continuing care able to meet the chronic and complex care needs of our growing and aging population. This includes recognizing the increased role for patients and their caregivers in the care process.
The federal government must ensure transfers are able to keep up with the real cost of health care. Current funding levels clearly fail to do so. Health transfers are estimated to rise by 3.6% while health care costs are expected to rise by 5.1% annually over the next decade.ii
The federal government ensure provincial and territorial health care systems meet the care needs of their aging populations by means of a demographic top-up to the Canada Health Transfer.iii
Providing care often comes with a financial cost such as lost income due to the caregiver’s withdrawal from the workforce to provide care. There are also increasing out-of-pocket costs for both caregivers and care receivers for health care-related expenses—privately covered expenditures on home and long-term care for seniors are projected to grow by an average of 5.8 per cent annually—nearly 1.5 times the pace of household disposable income growth. While the federal government offers tax credits that can be claimed by care receivers/caregivers, they are significantly under-utilized. While representing a significant proportion of caregivers, those with low or no income receive little to no federal government support through these programs. Middle-income earners also receive less than those earning high incomes.
The federal government create a Seniors Care Benefit that would be an easier, fairer and more effective way to support caregivers and care receivers alike.iv
Access to Care
Since the mid-1990s, the federal and provincial/territorial governments (FPT) have provided sustained leadership in promoting and supporting the transformation of primary care in Canada. In 2000, the First Ministers concluded the first of three Health Accords in which they agreed to promote the establishment of primary health care teamsv supported by a $800 million Primary Health Care Transition Fund (PHCTF) funded by the federal government, but jointly governed. The PHCTF resulted in large-scale sustained change in primary care delivery models in Ontario, Quebec and Alberta with interest in other jurisdictions as well.
However, the job is far from finished. Across Canada, access to primary care is challenging for many Canadians with a persistent shortage of family physicians. In 2017, 4.7 million Canadians aged 12+ reported they did not have a regular health care provider.vi Even those who have a regular provider experience wait time issues.
There has been widespread interest in primary care models since the development of the College of Family Physicians of Canada’s (CFPC) vision document Family Practice: The Patient’s Medical Home (PMH), initially launched in 2011vii and recently re-launched.viii The model is founded on 10 pillars depicted in Figure 1.
Figure 1. The Patient’s Medical Home, 2019
The updated model places increased emphasis on team-based care and introduces the concept of the patient’s medical neighborhood that sets out connections between the primacy care practice and all delivery points in the surrounding community. While comprehensive baseline data are lacking, it seems
safe to conjecture that most Canadians are not enrolled in a primary care model that would measure up to the model’s 10 pillars.
The federal government, in concert with provinces and territories, establish a targeted fund in the amount of $1.2 billion to support a new time-limited Primary Health Care Transition Fund that would build on the success of the fund launched in 2000 with the goal of widely introducing a sustainable medical home model across jurisdictions. This would include the following key elements:
Age-sex-weighted per capita allocation across the provinces and territories;
Joint governance of the FPT governments with meaningful stakeholder engagement;
Respect for the Canada Health Act principles;
Common objectives (e.g., modeled on the CFPC Patient’s Medical Home framework);
Canada and most industrialized countries will experience a digital health revolution over the next decade with great potential to improve patient and population health. Digital health can be described as the integration of the electronic collection and compilation of health data, decision support tools and analytics with the use of audio, video and other technologies to deliver preventive, diagnostic and treatment services that promote patient and population health.
While most Canadian physicians’ offices and health care facilities are now using some form of electronic record keeping and most households have internet access, there remains a large deficit in using virtual care, both within jurisdictions and across provincial/territorial boundaries. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify opportunities for digital health to improve health care delivery, including what regulatory changes are required for physicians to deliver care to patients within and across provincial/territorial boundaries.
To take full advantage of digital health capabilities it will be essential for the population to have a functional level of digital health literacy: the ability to seek, find, understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.ix This also includes the capability of communicating about one’s health to health care professionals (e.g., e-consults), self-monitoring health (e.g., patient portals) and receiving treatment online (e.g., Web-based cognitive behavioral therapy).x
There are no current data available on health literacy in Canada, let alone digital health literacy. One basic barrier to achieving digital health literacy is access to, and usage of the Internet, which has been termed the “digital divide” (e.g., older Canadians and low income households are less likely to have Internet access).Error! Bookmark not defined.
In 2001 the federal government established the Financial Consumer Agency of Canada (FCAC). Its mandate includes informing consumers about their rights and responsibilities in dealing with financial institutions and providing information and tools to help consumers understand and shop for financial products and services.xi In 2014 the FCAC appointed a Financial Literacy Leader who has focused on financial literacy, including activities such as conducting financial capability surveys and the development of a National Strategy for Financial Literacy.xii
Considering the anticipated growth of digital/virtual care it would be desirable to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy could serve as a template for digital health literacy.
The federal government establish a Digital Health Literacy Secretariat to:
Develop indicators and conducting surveys to measure and track the digital health literacy of Canadians;
Develop tools that can be used both by Canadians and their health care providers to enhance their digital health literacy; and
Assess and make recommendations on the “digital divide” that may exist among some population sub-groups due to a lack of access to information technology and lower digital health literacy.
Climate Change and Health
Climate change is the public health imperative of our time. There is a high level of concern among Canadians about their changing climate. A 2017 poll commissioned by Health Canada demonstrates a high level of concern among Canadians about their changing climate: 79% were convinced that climate change is happening, and of these, 53% accepted that it is a current health risk, with 40% believing it will be a health risk in the future.
The World Health Organization (WHO) has identified air pollution and climate change as one of the biggest threats to global health. Health care professionals see first-hand the devastating health impacts of our changing climate including increased deaths from fine particulate matter air pollution and increased heat-related conditions. Impacts are most common in vulnerable populations such as adults over 65 years, the homeless, urban dwellers and people with a pre-existing disease.
Canada’s health care system is already treating the health effects of climate change. A lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of Canada’s health system, with the potential to disrupt core public health infrastructure and overwhelm health services, not to mention the economic and social costs. The federal government must provide leadership to deal with the impact already being felt in Canada and around the world.
The federal government make strong commitments to minimize the impact of climate change on the health of Canadians by:
Ensuring pan-Canadian and inter-jurisdictional coordination to standardize surveillance and reporting of climate-related health impacts such as heat-related deaths, develop knowledge translation strategies to inform the public, and generate clinical and public health response plans that minimize the health impacts;
Increasing funding for research on the mental health impacts of climate change and psychosocial adaptation opportunities; and
Ensuring funding is provided to the health sector to prepare for climate change impacts through efforts to increase resiliency (i.e., risk assessments, readiness to manage disease outbreaks, sustainable practice).
i Statistics Canada. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2014: Public Health in the Future. Ottawa: Statistics Canada; 2015. Available: http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2014/chang-eng.php; (accessed 2016 Sep 19).
ii The Conference Board of Canada. Meeting the care needs of Canada’s aging population. Ottawa: The Conference Board; 2018.
iii Canadian Medical Association. Meeting the demographic challenge: Investments in seniors care. Pre-budget submission to the House of Commons Standing Committee on Finance. August 3, 2018. https://policybase.cma.ca/documents/Briefpdf/BR2018-16.pdf
iv The Conference Board of Canada. Measures to Better Support Seniors and Their Caregivers. March 2019. https://www.cma.ca/sites/default/files/pdf/health-advocacy/Measures-to-better-support-seniors-and-their-caregivers-e.pdf
v Canadian Intergovernmental Conference Secretariat. News release – First Ministers’ meeting communiqué on health. September 11, 2000. http://www.scics.ca/en/product-produit/news-release-first-ministers-meeting-communique-on-health/. Accessed 04/22/19.
vi Statistics Canada. Primary health care providers, 2017. https://www150.statcan.gc.ca/n1/en/pub/82-625-x/2019001/article/00001-eng.pdf?st=NGPiUkM5. Accessed 04/21/19.
vii College of Family Physicians of Canada. A vision for Canada. Family Practice: the patient’s medical home. http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf. Accessed 04/22/19.
viii College of Family Physicians of Canada. The patient’s medical home 2019. https://patientsmedicalhome.ca/files/uploads/PMH_VISION2019_ENG_WEB_2.pdf. Accessed 04/21/19.
ix Norman C, Skinner H. eHealth literacy: essential skills for consumer health in a networked world. J Med Internet Res 2006;8(2):e9. Doi:10.2196/jmir.8.2.e9.
x Van der Vaart R, Drossaert C. Development of the digital health literacy instrument: measuring a broad spectrum of health 1.0 and health 2.0 skills. J Med Internet Res. 2017;19(1):e27. Doi:10.2196/jmir.6709.
xi Financial Consumer Agency of Canada. About FCAC.
xii Financial Consumer Agency of Canada. National Strategy for Financial Literacy. Phase 1: strengthening seniors’ financial literacy. https://www.canada.ca/content/dam/canada/financial-consumer-agency/migration/eng/financialliteracy/financialliteracycanada/documents/seniorsstrategyen.pdf. Accessed 06/24/19. https://www.canada.ca/en/financial-consumer-agency/corporate/about.html. Accessed 07/01/19.
Canadians are living longer, healthier lives than ever before. The number of seniors expected to need help or care in the next 30 years will double, placing an unprecedented challenge on Canada’s health care system. That we face this challenge speaks to the immense success story that is modern medicine, but it doesn’t in any way minimize the task ahead.
Publicly funded health care was created about 50 years ago when Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. People 85 and older make up the fastest growing age group in our country, and the growth in the number of centenarians is also expected to continue.
The Canadian Medical Association is pleased that the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities is studying ways Canada can respond to these challenges. Here, for your consideration, we present 15 comprehensive recommendations that would help our seniors remain active, contributing citizens of their communities while improving the quality of their lives. These range from increasing capital investment in residential care infrastructure, to enhancing assistance for caregivers, to improving the senior-friendliness of our neighbourhoods.
The task faced by this committee, indeed the task faced by all of Canada, is daunting. That said, it is manageable and great advances can be made on behalf of seniors. By doing so, we will ultimately deliver both health and financial benefits to all Canadians.
Dr. Laurent Marcoux, CMA President
The Canadian Medical Association (CMA) is pleased to submit this brief to the Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities as part of its study regarding how the Government can support vulnerable seniors today while preparing for the diverse and growing seniors population of tomorrow. This brief directly addresses the three themes considered by this Committee:
How the Government can improve access to housing for seniors including aging in place and affordable and accessible housing;
How the Government can improve income security for vulnerable seniors; and
How the Government can improve the overall quality of life and well-being for seniors including community programming, social inclusivity, and social determinants of health.
Improving access to housing for seniors
As part of a new National Housing Strategy, the federal government announced in the 2017 Budget that it will invest more than $11.2 billion in a range of initiatives designed to build, renew, and repair Canada’s stock of affordable housing and help to ensure that Canadians have adequate and affordable housing that meets their needs. While a welcome step, physicians continue to see the problems facing seniors in relation to a lack of housing options and supports — problems that cascade across the entire health care system.
A major hindrance to social equity in health care delivery and a serious cause of wait times is the inappropriate placement of patients, particularly seniors, in hospitals. Alternate level of care (ALC) beds are often used in acute care hospitals to accommodate patients — most of whom are medically stable seniors — waiting for appropriate levels of home care or access to a residential care home/facility. High rates of ALC patients in hospitals affect all patients by contributing to hospital overcrowding, lengthy waits in emergency departments, delayed hospital admissions, cancelled elective surgeries, and sidelined ambulance services waiting to offload new arrivals (often referred to as code gridlock).1 Moreover, unnecessarily long hospital stays can leave patients vulnerable to hospital-acquired illnesses and disabilities such as delirium, deconditioning, and falls.
Daily costs - Ontario
$842: acute care hospital, per patient
$126: long-term care residence, per patient
$42: home care, per patient
# of acute care hospital beds = 18,571 14% waiting for placement = 2,600 beds
Providing more cost-effective and appropriate solutions will optimize the use of health care resources. It has been estimated that it costs $842 per day for a hospital bed versus $126 per day for a long-term care bed and $42 per day for care at home.2 An investment in appropriate home or residential care, which can take many forms, will alleviate inappropriate hospital admissions and facilitate timely discharges.
The residential care sector is facing significant challenges because of the rising numbers of older seniors with increasingly complex care needs. The demand for residential care will increase significantly over the next several years because of the growing number of frail elderly seniors requiring this service. New facilities will need to be constructed and existing facilities will need to be upgraded to comply with enhanced regulatory requirements and respond to residents’ higher care needs.
The Conference Board of Canada has produced a residential care bed forecast tied to population growth of age cohorts. It is estimated that Canada will require an average of 10,500 new beds per year over the next 19 years, for a total of 199,000 new beds by 2035. This forecast does not include the investments needed to renovate and retrofit existing long-term care homes.3 A recent report by the Canadian Institute for Health Information indicated that residential care capacity must double over the next 20 years (assuming no change in how care is currently provided), necessitating a transformation in how seniors care is provided across the continuum of care.4 These findings provide a sense of the immense challenges Canada faces in addressing the residential care needs of older seniors.
Investments in residential care infrastructure and continuing care will improve care for seniors while significantly reducing wait times in hospitals and across the system, benefiting all patients. Efforts to de-hospitalize the system and address the housing and residential care options for Canada’s aging population are key. The federal government can provide significant pan-Canadian assistance by investing in residential care infrastructure.
The CMA recommends that the federal government include capital investment in residential care infrastructure, including retrofit and renovation, as part of its commitment to invest in social infrastructure.
Improving income security for vulnerable seniors
Income is a key factor impacting the health of individuals and communities. Higher income and social status are linked to better health.5
Adequate Income: Poverty among seniors in Canada dropped sharply in the 1970s and 1980s but it has been rising in recent years. In 2012, the incidence of low income among people aged 65 years and over was 12.1%. This rate was considerably higher for single seniors at 28.5%.6
Incidence of low income (2012)
Seniors overall: 12.1%
Single seniors: 28.5%
Most older Canadians rely on Old Age Security (OAS), the Canada Pension Plan (CPP), and their personal pensions or investments to maintain their basic standard of living in retirement. Some seniors are also eligible for a Guaranteed Income Supplement (GIS) to improve their financial security. The CMA recognizes the federal government’s actions to strengthen these programs and initiatives to ensure their viability and to provide sustainable tax relief. These measures must continue and evolve to support aging Canadians so they can afford to live at home or in age-friendly communities as they get older. The government’s actions to ensure adequate income support will also assist aging Canadians to take care of their health, maintain independence, and continue living safely without the need for institutional care.
On the topic of seniors’ income security, the financial abuse of seniors cannot be overlooked. Elder abuse can take many forms: financial, physical, psychological, sexual, and neglect. Often the abuser is a family member, friend, or other person in a position of trust. Researchers estimate that 4 to 10% of Canadian seniors experience abuse or neglect, but that only a small portion of this is reported. The CMA supports public awareness initiatives that bring attention to elder abuse, as well as programs to intervene with seniors who are abused and with their abusers.
The CMA recommends that the federal government take steps to provide adequate income support for older Canadians, as well as education and protection from financial abuse.
Improving the overall quality of life and well-being for seniors
Improving how we support and care for Canada’s growing seniors population has been a priority for CMA over the past several years. For the first time in Canada’s history, persons aged 65 years and older outnumber those under the age of 15 years.7 Seniors are projected to represent over 20% of the population by 2024 and up to 25% of the population by 2036.8 People aged 85 years and over make up the fastest growing age group in Canada — this portion of the population grew by 127% between 1993 and 2013.9 Statistics Canada projects, on the basis of a medium-growth scenario, that there will be over 11,100 Canadians aged 100 years and older by 2021, 14,800 by 2026 and 20,300 by 2036.7
Though age does not automatically mean ill health or disability, the risk of both increases with age. Approximately 75 to 80% of Canadian seniors report having one or more chronic conditions.10 Because of increasing rates of disability and chronic disease, the demand for health services is expected to increase as Canada’s population ages. The Conference Board of Canada has estimated 2.4 million Canadians 65 years and older will need continuing care, both paid and unpaid, by 2026 — a 71% increase since 2011.11
When publicly funded health care was created about 50 years ago, Canada’s population was just over 20 million and the average life expectancy was 71. Today, our population is over 36 million and the average life expectancy is 10 years longer. The aging of our population is both a success story and a pressing health policy issue.
National seniors strategy
Canada needs a new approach to ensure that both our aging population and the rest of Canadians can get the care they need, when and where they need it. The CMA believes that the federal government should invest in seniors care now, guided by a pan-Canadian seniors strategy. In doing so, it can help aging Canadians be as productive as possible — at work, in their communities, and in their homes.
The CMA is pleased with the June 2017 Report of the Standing Senate Committee on National Finance that called for the federal government to develop, in collaboration with the provinces and territories and Indigenous partners, a national seniors strategy in order to control spending growth while ensuring appropriate and accessible care.12 The CMA is also pleased that MP Marc Serré (Nickel Belt) secured support for his private members’ motion calling for the development of a national seniors strategy. Over 50,000 Canadians have already lent their support to this cause (see www.DemandaPlan.ca).
The CMA recommends that the federal government provide targeted funding to support the development of a pan-Canadian seniors strategy to address the needs of the aging population.
Improving assistance for home care and Canada’s caregivers
Many of the services required by seniors, in particular home care and long-term care, are not covered by the Canada Health Act. Funding for these services varies widely from province to province. The disparity among the provinces in terms of their fiscal capacity in the current economic climate will mean improvements in seniors care will advance at an uneven pace. The funding and delivery of accessible home care services will help more aging Canadians to recover from illness, live at home longer, and contribute to their families and communities. Multi-year funding arrangements to reinforce commitment to and financial investment in home care should be carefully considered.13 The development of innovative partnerships and models to help ensure services and resources for seniors’ seamless transition across the continuum of care are also important.
The CMA recommends governments work with the health and social services sectors, and with private insurers, to develop a framework for the funding and delivery of accessible and sustainable home care and long-term care services.
Family and friend caregivers are an extremely important part of the health care system. A 2012 Statistics Canada study found that 5.4 million Canadians provided care to a senior family member or friend, and 62% of caregivers helping seniors said that the care receiver lived in a private residence separate from their own.14 According to a report by Carers Canada, the Canadian Home Care Association, and the Canadian Cancer Action Network, caregivers provide an array of services including personal and medical care, housekeeping, advocacy, financial management, and social/emotional support. The report also indicated that caregivers contribute $25 billion in unpaid labour to our health system.15 Given their enormous contributions, Canada’s caregivers need support in the form of financial assistance, education, peer support, and respite care. A pan-Canadian caregiver strategy is needed to ensure caregivers are provided with the support they require.15
Personal and Medical Care
worth $25 billion in
Social-emo ional Suppor
The CMA recommends that the federal government and other stakeholders work together to develop and implement a pan-Canadian caregiver strategy, and expand the support programs currently offered to informal caregivers.
Canadians want governments to do more to help seniors and their family caregivers.16 The federal government’s new combined Canada Caregiver Credit
(CCC) is a non-refundable credit to individuals caring for dependent relatives with infirmities (including persons with disabilities). The CCC will be more accessible and will extend tax relief to more caregivers by including dependent relatives who do not live with their caregivers and by increasing the income threshold. Making the new CCC a refundable tax credit for caregivers whose tax owing is less than the total credit would result in a refund payment to provide further financial support for low-income families.
The CMA recommends that the federal government improve awareness of the new Canada Caregiver Credit and amend it to make it a refundable tax credit for caregivers.
The federal government’s recent commitment to provide $6 billion over 10 years to the provinces and territories for home care, including support for caregivers, is a welcome step toward improving opportunities for seniors to remain in their homes. As with previous bilateral funding agreements, it is important to establish clear operating principles between the parties to oversee the funding implementation and for the development of clear metrics to measure performance.
The CMA recommends that the federal government develop explicit operating principles for the home care funding that has been negotiated with the provinces and territories to recognize funding for caregivers and respite care as eligible areas of investment.
The federal government’s recent funding investments in home care and mental health recognize the importance of these aspects of the health care system. They also signal that Canada has under-invested in home and community-based care to date. Other countries have more supportive systems and programs in place — systems and programs that Canada should consider.
The CMA recommends the federal government convene an all-party parliamentary international study that includes stakeholders to examine the approaches taken to mitigate the inappropriate use of acute care for elderly persons and provide support for caregivers.
Programs and supports to promote healthy aging
The CMA believes that governments at all levels should invest in programs and supports to promote healthy aging, a comprehensive continuum of health services to provide optimal care and support to older Canadians, and an environment and society that is “age friendly”.17
The Public Health Agency of Canada (PHAC) defines healthy aging as “the process of optimizing opportunities for physical, social and mental health to enable seniors to take an active part in society without discrimination and to enjoy independence and quality of life.”18 It is believed that initiatives to promote healthy aging and enable older Canadians to maintain their health will help lower health care costs by reducing the overall burden of disability and chronic disease. Such initiatives should focus on physical activity, good nutrition, injury (e.g. falls) prevention, and seniors’ mental health (including depression).
The CMA recommends that governments at all levels support programs to promote physical activity, nutrition, injury prevention, and mental health among older Canadians.
For seniors who have multiple chronic diseases or disabilities, care needs can be complex, and they may vary greatly from one person to another and involve many health care providers. Complex care needs demand a flexible and responsive health system. The CMA believes that quality health care for older Canadians should be delivered on a continuum from community-based health care (e.g. primary health care, chronic disease management programs), to home care
(e.g. visiting health care workers to give baths and foot care), to long-term care and palliative care. Ideally, this continuum should be managed so that the senior can remain at home and out of emergency departments, hospitals, and long-term care unless appropriate; easily access necessary care; and make a smooth transition from one level of care to another when necessary.
The CMA recommends governments and other stakeholders work together to develop and implement models of integrated, interdisciplinary health service delivery for older Canadians.
Every senior should have the opportunity to have a family physician or to be part of a family practice that serves as a medical home. This provides a central hub for the timely provision and coordination of the comprehensive menu of health and medical services. A medical home should provide patients with access to medical advice and the provision of, or direction to, needed care 24 hours a day, seven days a week, 365 days a year. Research in 2014 by the Commonwealth Fund found that the percentage of Canadian seniors who have a regular family physician or place of care is very high (98%); however, their ability to get timely access based on same-day or next-day appointments was among the lowest of 11 nations.19 Compared to seniors in most other countries surveyed, Canadian seniors were also more likely to use the emergency department and experience problems with care coordination.
The CMA recommends governments continue efforts to ensure that older Canadians have access to a family physician, supported by specialized geriatric services as appropriate.
Prescription drugs represent the fastest-growing item in the health budget and the second-largest category of health expenditure. As the population of seniors grows, there will be an ongoing need for detailed information regarding seniors’ drug use and expenditure to support the overall management of public drug programs.20 Despite some level of drug coverage for seniors in all provinces and territories, some seniors still skip doses or avoid filling prescriptions due to cost, and more research into the extent of this problem is required.21 The CMA supports the development of an equitable and comprehensive pan-Canadian pharmacare program. As a step toward comprehensive, universal coverage, the CMA has repeatedly called on the federal government to implement a system of catastrophic coverage for prescription medication to reduce cost barriers of treatment and ensure Canadians do not experience undue financial hardship. Moreover, with more drugs available to treat a large number of complex and chronic health conditions, the CMA supports the development of a coordinated national approach to reduce polypharmacy among the elderly.
The CMA recommends governments and other stakeholders work together to develop and implement a pan-Canadian pharmaceutical strategy that addresses both comprehensive coverage of essential medicines for all Canadians, and programs to encourage optimal prescribing and drug therapy.
Optimal care and support for older Canadians also depends on identifying, adapting, and implementing best practices in the care of seniors. PHAC’s Best Practices Portal22 is one noteworthy initiative, and the system needs to spread and scale best practices by leveraging and enhancing pan-Canadian resources that build capacity and improve performance in home care and other sectors.13
The CMA recommends that governments and other stakeholders support ongoing research to identify best practices in the care of seniors, and monitor the impact of various interventions on health outcomes and costs.
An environment and society that is “age friendly”
One of the primary goals of seniors policy in Canada is to promote the independence of older Canadians, avoiding costly institutionalization for as long as feasible. To help older Canadians successfully maintain their independence, governments and society must keep the social determinants of health in mind when developing and implementing policy that affects seniors. It is also important to eliminate discrimination against seniors and promote positive messaging around aging. An age-friendly society respects the experience, knowledge, and capabilities of its older members and accords them the same worth and dignity as it does other citizens.
Employment is also important for seniors who need or desire it. Many seniors are choosing to remain active in the workplace for a variety of reasons, such as adding to their financial resources or staying connected to a social network.23 The CMA recognizes the federal government’s support for seniors who opt to continue working. And, while many employers encourage older workers and accommodate their needs, employment may be difficult to find in workplaces that are unwilling to hire older workers.
The CMA recommends that governments at all levels and other partners give older Canadians access to opportunities for meaningful employment if they desire.
The physical environment, including the built environment, can help to promote seniors’ independence and successful, healthy aging. The World Health Organization defines an “age-friendly environment” as one that fosters health and well-being and the participation of people as they age.24 Age-friendly environments are accessible, equitable, inclusive, safe and secure, and supportive. They promote health and prevent or delay the onset of disease and functional decline. They provide people-centered services and support to enable recovery or to compensate for the loss of function so that people can continue to do the things that are important to them.24 These factors should be taken into consideration by those who design and build communities. For example, buildings should be designed with entrance ramps and elevators; sidewalks could have sloping curbs for walkers and wheelchairs; and frequent, accessible public transportation should be provided in neighbourhoods with large concentrations of seniors.
The CMA recommends that governments and communities take the needs of older Canadians into account when designing buildings, walkways, transportation systems, and other aspects of the built environment.
The CMA recognizes the federal government’s commitment to support vulnerable seniors today while preparing for the diverse and growing seniors’ population of tomorrow. The CMA’s recommendations in this submission can assist the government as it seeks to improve access to housing for seniors, enhance income security for vulnerable seniors, and improve the overall quality of life for seniors in ways that will help to advance inclusion, well-being, and the health of Canada’s aging population.
To maximize the health and well-being of older Canadians, and ensure their active engagement and independence for as long as possible, the CMA believes that the health care system, governments, and society should work with older Canadians to promote healthy aging, provide quality patient-centred health care and support services, and build communities that value Canadians of all ages.
1 Simpson C. Code Gridlock: Why Canada needs a national seniors strategy. Address to the Canadian Club of Ottawa by Dr. Christopher Simpson, President, Canadian Medical Association; 2014 Nov. 18; Ottawa, Ontario. Available: https://www.cma.ca/En/Lists/Medias/Code_Gridlock_final. pdf#search=code%20gridlock (accessed 2016 Sep 22).
2 North East Local Health Integration Network. HOME First shifts care of seniors to HOME. LHINfo Minute, Northeastern Ontario Health Care Update. Sudbury: The Network; 2011. Cited by Home Care Ontario. Facts & figures - publicly funded home care. Hamilton: Home Care Ontario; 2017 Jun. Available: http://www.homecareontario.ca/home-care-services/facts-figures/publiclyfundedhomecare (accessed 2016 Sep 22).
3 Conference Board of Canada. A cost-benefit analysis of meeting the demand for long-term care beds. Ottawa: Conference Board of Canada; Manuscript submitted for publication.
4 Canadian Institute for Health Information (CIHI). Seniors in transition: exploring pathways across the care continuum. Ottawa: The Institute; 2017. Available: https://www.cihi.ca/sites/default/files/document/seniors-in-transition-report-2017-en.pdf (accessed 2017 Jun 30).
5 World Health Organization. Health Impact Assessment (HIA). The determinants of health. Available: http://www.who.int/hia/evidence/doh/en/ (accessed 2017 Oct 23).
6 Statistics Canada. Persons in low income (after-tax low income measure), 2012. The Daily. Ottawa: Statistics Canada; 2014 Dec 10. Available: http://www.statcan.gc.ca/daily-quotidien/141210/t141210a003-eng.htm (accessed 2017 Oct 17).
7 Statistics Canada. Population projections: Canada, the provinces and territories, 2013 to 2063. The Daily. Ottawa: Statistics Canada; 2014 Sep 17. Available: http://www.statcan.gc.ca/daily-quotidien/140917/dq140917a-eng.pdf (accessed 2016 Sep 19).
8 Statistics Canada. Canada Year Book 2012, seniors. Ottawa: Statistics Canada; 2012. Available: https://www.statcan.gc.ca/pub/11
402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm (accessed 2017 Oct 18).
9 Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada, 2014: public health in the future. Ottawa: Public Health Agency of Canada; 2014. Available: https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/ cphorsphc-respcacsp/2014/assets/pdf/2014-eng.pdf (accessed 2016 Sep 19).
10 Canadian Institute for Health Information (CIHI). Health Care in Canada, 2011: A Focus on Seniors and Aging. Ottawa: The Institute; 2014 Nov. Available: https://secure.cihi.ca/free_products/HCIC_2011_seniors_report_en.pdf (accessed 2016 Sept 19).
11 Stonebridge C, Hermus G, Edenhoffer K. Future care for Canadian seniors: a status quo forecast. Ottawa: Conference Board of Canada; 2015. Available: http://www.conferenceboard.ca/e-library/abstract.aspx?did=7374 (accessed 2016 Sep 20).
12 Report of the Standing Senate Committee on National Finance. Getting ready: For a new generation of active seniors. Ottawa: The Committee; 2017 Jun. Available: https://sencanada.ca/content/sen/committee/421/NFFN/Reports/NFFN_Final19th_Aging_e.pdf (accessed 2017 Oct 18).
13 Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association. Better Home Care in Canada: A National Action Plan. 2016. Ottawa: Canadian Home Care Association, The College of Family Physicians of Canada, Canadian Nurses Association; 2016. Available: http://www.thehomecareplan.ca/wp-content/uploads/2016/10/Better-Home-Care-Report-Oct-web.pdf (accessed 2017 Oct 23).
14 Turcotte M, Sawaya C. Senior care: differences by type of housing. Insights on Canadian society. Cat. No. 75-006-X. Ottawa: Statistics Canada; 2015 Feb 25. Available: http://www.statcan.gc.ca/pub/75-006-x/2015001/article/14142-eng.pdf (accessed 2016 Sep 22).
15 Carers Canada, Canadian Home Care Association, Canadian Cancer Action Network. Advancing Collective Priorities: A Canadian Carer Strategy. 2017. Mississauga: Canadian Home Care Association, Canadian Cancer Action Network; 2017. Available: http://www.cdnhomecare.ca/media. php?mid=4918 (accessed 2017 Oct 23).
16 Ipsos Public Affairs, HealthCareCAN, Canadian College of Health Leaders. National Health Leadership Conference report. Toronto: Ipsos Public Affairs; 2016 Jun 6. Available: http://www.nhlc-cnls.ca/assets/2016%20Ottawa/NHLCIpsosReportJune1.pdf (accessed 2016 Jun 06).
17 Canadian Medical Association. Health and Health Care for an Aging Population. Ottawa: The Association; December 2013. Available: https:// www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Health_and_Health_Care_for_an_Aging-Population_ PD14-03-e.pdf (accessed 2017 Oct 20).
18 Government of Canada. The Chief Public Health Officer’s Report on the State of Public Health in Canada 2010 – Canada’s experience in setting the stage for healthy aging. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/public-health/corporate/publications/ chief-public-health-officer-reports-state-public-health-canada/annual-report-on-state-public-health-canada-2010/chapter-2.html (accessed 2017 Oct 23).
19 Commonwealth Fund. 2014 International Health Policy Survey of Older Adults in Eleven Countries. 2014. New York: Commonweath Fund; 2014. Available: http://www.commonwealthfund.org/~/media/files/publications/in-the-literature/2014/nov/pdf_1787_commonwealth_fund_2014_intl_ survey_chartpack.pdf (accessed 2017 Oct 23).
20 Canadian Institute for Health Information. Drug Use among Seniors on Public Drug Programs in Canada, 2002 to 2008. (2010). Ottawa: The Institute; 2010. Available: https://secure.cihi.ca/free_products/drug_use_in_seniors_2002-2008_e.pdf (accessed 2017 Oct 23).
21 Law MR, Cheng L, Dhalla IA, Heard D, Morgan SG. The effect of cost on adherence to prescription medications in Canada. CMAJ. 2012 Feb21;184(3):297-302. Available: http://www.cmaj.ca/content/184/3/297.short. (accessed 2017 Oct 23).
22 Public Health Agency of Canada. Canadian Best Practices Portal. Ottawa: Public Health Agency of Canada; 2016. Available: http://cbpp-pcpe. phac-aspc.gc.ca/public-health-topics/seniors/ (accessed 2017 Oct 23).
23 Government of Canada. Action for Seniors report. 2014. Ottawa: Government of Canada; 2014. Available: https://www.canada.ca/en/ employment-social-development/programs/seniors-action-report.html (accessed 2017 Oct 23).
24 World Health Organization (WHO). Age-friendly environments. Geneva: WHO; 2017. Available: http://www.who.int/ageing/projects/age
friendly-environments/en/ (accessed 2017 Oct 23).
The public health system in Canada lies at the heart of our community values. It is the quintessential “public good” and is central to the continued good health of our population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong — like the Walkerton tragedy or when we are faced with a new threat like SARS — is the integral, ongoing role of public health really recognized.
The Canadian Medical Association (CMA) has been warning that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to the latest crises. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada.
Our public health system is the first — and often the only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health armaments must be in a constant state of “battle readiness.” In today’s climate of SARS, West Nile Virus, mad cow disease and monkey pox, even the thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians.
Physicians have always been an integral part of the public health system serving as medical officers of health, community health specialists and other related roles. Indeed public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians.
In this submission, we reflect on the lessons to be learned from our recent experience with SARS and reflect on the longer-term needs of the public health system as a whole. The objectives of the pan-Canadian Public Health Action Plan proposed by the CMA are, first to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies; and, second, to enhance the system’s capacity to respond to public health threats across the country (see recommendations, below, and Appendix 1).
To achieve these twin objectives, three broad strategies are presented for immediate attention. They are legislative reform; capacity enhancement; and research, surveillance and communications.
Legislative reform (see recommendations 1–3)
The country’s response to SARS has brought into stark relief the urgent need for national leadership and coordination of public health activity across the country, especially during a health crisis. The apparent reluctance to act quickly to institute screening at airports, the delay in unifying the practice community for a concerted response and the appalling communications confusion worked against optimum handling of the outbreak — despite the best efforts of health care professionals.
This is a wake-up call that highlights the need for comprehensive legislative reform to clarify the roles of governments with respect to the management of public health threats. A renewed and enhanced national commitment to public health should be anchored in new federal legislation to be negotiated with the provinces and territories.
Specifically, the CMA recommends an Emergency Health Measures Act, to deal with emergent situations in tandem with the creation of a Canadian public health agency headed by a Chief Public Health Officer of Canada.
Capacity enhancement (see recommendations 4–7)
The SARS crisis has demonstrated the diminished capacity within the public health system. The Greater Toronto Area (GTA), with one of Canada’s most sophisticated public and acute health systems, has not been able to manage the SARS crisis adequately and carry on other health programs. The acute care system virtually ground to a halt in dealing with SARS. There was little or no surge capacity in Canada’s largest city. We should be grateful that SARS did not first strike a smaller centre in a far less-advantaged region of Canada.
A critical element of the public health system is its workforce and the health professionals within the acute care system, such as hospital-based infectious disease specialists and emergency physicians who are the front-line interface. Let there be no doubt that the ongoing efforts of the GTA front-line providers are nothing short of heroic. However, the lack of coordinated contingency planning of hospital and community-based disease control efforts was striking. The overall shortage of critical care professionals and the inability of governments to quickly deploy the required professionals to areas of need contributed to the enormous strain on the public and health care system.
Considering the importance of the public health system and its clearly limited capacity to protect and promote the health of Canadians, it is incomprehensible that we do not know how much is actually spent on the system. It is imperative that public health expenditures and capacity, in terms of both physical and human resources, be tracked and reported publicly.
The CMA recommends a $1-billion, 5-year capacity-enhancement program to be coordinated with and through the new Canadian public health agency.
Research, surveillance and communications (see recommendations 8–10)
Canada’s ability to respond to public health threats and acute events, such as SARS, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications.
A concerted pan-Canadian effort is required to take full advantage of our capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. New-millennium challenges require moving beyond old-millennium responses. Enhanced surveillance is an overdue and integral part of public health, performing an essential function in early detection and response to threats of infectious diseases. Mandatory national reporting of identified diseases by all provinces and territories is critical for national and international surveillance.
During times of crisis, rapid communication to the public, public health staff and front-line clinicians is of critical importance, but in many jurisdictions impossible. We tested our systems during the SARS outbreak and they came up short.
The CMA recommends a one-time federal investment to enhance technical capacity to allow for real-time communication.
The CMA believes that its proposed three-pronged strategy, as set out in the attached recommendations, will go a long way toward addressing shortfalls of the Canadian public health system. Action now will help to ensure that Canadians can once again be confident that they are protected from any future threat of new infectious diseases. Action now will help Canada regain its position as a leader in public health.
We wish the advisory committee well in its deliberations and offer the CMA’s assistance at any time in clarifying the strategies set out in our submission.
Recommendations to the National Advisory Committee on SARS and Public Health
Legislative reform ($20 million / 5 years*)
1. The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada.
2. The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government.
3. The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan.
Capacity enhancement ( $1.2 billion / 5 years*)
4. The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals.
5. The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies.
6. Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the proposed Canadian Office for Disease Surveillance and Control.
7. Federal government funding in the amount of $1 Billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions.
Research, surveillance and communications ($310 million / 5 years*)
8. An immediate, sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures.
9. The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and intervention.
10. The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies.
*See Appendix 2: Estimated cost of implementing recommendations.
The CMA prepared this submission in response to an invitation from Dr. Naylor to provide input to the National Advisory Committee on SARS and Public Health.
We applaud this initiative and welcome the opportunity to present the views of Canada’s medical community to the committee. The CMA’s basic message is that our health protection laws are woefully outdated and the public health system is stretched beyond capacity. This submission draws on our long history of engagement in public health in Canada and our experience both post-September 11, 2001 and with SARS. It builds on the knowledge and experience of our members, national specialist affiliated societies and provincial and territorial divisions. (We acknowledge, in particular, the outstanding efforts of the Ontario Medical Association and the Canadian Association of Emergency Physicians in battling SARS.)
In this submission, we examine the lessons to be learned from our experience with the SARS outbreak and reflect on both the immediate and longer-term needs of the public health system as a whole. The objectives of the public health action plan proposed by the CMA are, first, to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies and, second, to enhance the system’s capacity to respond to public health threats across the country, including those posed by preventable chronic disease.
The public health system in Canada lies at the heart of our community values. It is the quintessential “public good” and is central to the continued good health of the population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong — like the contamination of the blood supply in the 1980s, the Walkerton tragedy or SARS — is the integral, ongoing role of public health recognized.
Our public health system is the first — and often the only — line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health system must be in a constant state of “battle readiness.” We can ill afford any weakness in our public health preparedness. In today’s climate of SARS, West Nile Virus, mad cow disease and monkey pox, the mere thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians.
Physicians have always been an integral part of the public health system serving as medical officers of health, specialists in infectious disease and community medicine (who will not remember the stalwart efforts of Dr. Donald Low on SARS?) and in other related roles. Indeed, public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians.
The CMA has been warning for some time that our system is stretched to capacity in dealing with everyday demands, let alone responding to crises. Canada’s physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. For example, the CMA’s submission to the House of Commons Standing Committee on Finance’s prebudget consultations on October 22, 2001 called for substantial investments in public health and emergency response as a first step to improve the public health system infrastructure and its surge capacity.
This submission not only reiterates our previous recommendations, but also outlines specific actions that the CMA believes must be taken to ensure a strong public health system in Canada.
The Enduring Impact of Severe Acute Respiratory Syndrome
SARS (Severe Acute Respiratory Syndrome): in February 2003, these four letters sent massive shock waves around the world, causing widespread fear and confusion among health care officials and citizens of many countries. The “fear factor” extended across Canada as people realized the full threat of SARS.
Since SARS was first identified in a patient in Toronto in March 2003, 438 probable or suspected cases have been reported to Health Canada and 38 people have died (as of June 23, 2003). However, these numbers do not reflect the full impact of the outbreak. The number of indirect deaths due to system shutdown will never be known.
Local public health authorities across the country went on high alert. Those in the Greater Toronto Area (GTA) as well as their provincial counterparts diverted almost all of their resources to respond to the crisis.
Acute care services were adversely affected as stringent infection-control and screening measures were put into place to control the spread of SARS. In the GTA, the health system — acute and public — was brought to its knees. Over half of the reported SARS cases involved front-line providers as the outbreak largely affected health care settings. Approximately 20 physicians in Ontario contracted SARS and close to 1000 were quarantined. Thousands of nurses and other health care workers also faced quarantine, some more than once.
Institutions closed their doors, limiting access to emergency departments, clinics and physicians’ offices. Intensive care units were full and surgeries were cancelled. Front-line health care professionals involved in critical care were stretched to their physical and mental limits. Others found themselves underutilized due to the impact of the infection-control measures on their practice settings. Feast and famine co-existed.
Although the outbreak was mainly confined to health care settings, the entire GTA felt the effects. Upwards of 20,000 people entered voluntary quarantine. Businesses were affected. The tourism industry is still reeling. The disruption that SARS caused continues to reverberate through health care systems and economies.
In response to urgent requests from both the Ontario Medical Association and Health Canada, the CMA mobilized its membership and assisted in the country’s response to SARS. Everything that could be done was done to facilitate bringing in qualified personnel to relieve those on the front line and make appropriate information available in real time. The CMA has learned its own lessons, both positive and negative. A full chronology of CMA activity is attached as Appendix 3.
It has become abundantly clear that Canada’s public health system was ill prepared to deal with the SARS outbreak. If not for the heroic efforts of public health officials, health care providers and research scientists, Canada’s experience would have been much worse.
Public health in Canada
Public health is the science and art of protecting and promoting health, preventing disease and injury, and prolonging life. It complements the health care system, which focuses primarily on treatment and rehabilitation, sharing the same goal of maximizing the health of Canadians. However, the public health system is distinct from other parts of the health system in two key respects: its primary emphasis is on preventing disease and disability and its focus is on the health needs of populations rather than those of specific individuals.
Public health is the systematic response to infectious diseases. It also ensures access to clean drinking water, good sanitation and the control of pests and other disease vectors. Further, it is immunization clinics and programs promoting healthy lifestyles. But it is also there to protect Canadians when they face a public health crisis like SARS. If the public health system is fully prepared to carry out essential services, then communities across the country will be better protected from acute health events.
The reality in Canada today is that a strong, consistently and equitably resourced and integrated public health system does not exist. Public health systems across Canada are fragmented — a patchwork of programs, services and resources across the county. In reality, it is a group of multiple systems with varying roles, strengths and linkages.
Each province has its own public health legislation. Most legislation focuses on the control of communicable diseases. Public health services are funded through a variable mix of provincial and municipal funding formulae, with inconsistent overall strategies and results, and with virtually no meaningful role for input from health professionals via organizations such as the CMA, or the federal level, in terms of strategic direction or resources.
Federal legislation is limited to the blunt instrument of the Quarantine Act and a variety of health protection-related acts. (e.g., Food and Drugs Act, Hazardous Products Act, Controlled Drugs and Substances Act, Radiation Emitting Devices Act) Some of the laws, such as the Quarantine Act, date back to the late 19th century. Taken as a whole, the legislation does not clearly identify the public health mandate, roles and responsibilities of the different levels of government. In many cases, the assignment of authorities and accountabilities is anachronistic.
Moreover, there is little information available on the functioning and financing of Canada’s public health system. There is no “one-stop shopping” for authoritative information on public health issues.
In 2001, a working group of the Federal, Provincial and Territorial Advisory Committee on Population Health assessed the capacity of the public health system through a series of key informant interviews and literature reviews. The consistent finding was that public health had experienced a loss of resources and there was concern for the resiliency of the system infrastructure to respond consistently and proactively to the demands placed on it. Significant disparities were observed between “have” and “have-not” provinces and regions in their capacity to address public health issues.
The report’s findings are consistent with previous assessments by the Krever Commission and the Auditor General of Canada. In 1999, the Auditor General said that Health Canada was unprepared to fulfill its responsibilities in public health; communication between multiple agencies was poor; and weaknesses in the key surveillance system impeded the effective monitoring of injuries and communicable and non-communicable diseases. In 1997, Justice Horace Krever reported that the “public health departments in many parts of Canada do not have sufficient resources to carry out their duties.”
The Challenges Ahead
The 21st century brings with it an awesome array of new public health risks and ancient foes. Not all of them can be identified at the present time. New diseases (e.g., SARS, West Nile Virus) will likely continue to emerge. Dr. Alan Bernstein, President of the Canadian Institutes of Health Research, recently noted that SARS is here to stay. Old threats, such as contamination of a community water supply (e.g., Walkerton), can strike quickly if vigilance is relaxed or delegated to third parties. This century will likely bring greater focus on threats from the physical environment. Our social environment is also a source of illness as shown by the recent epidemic trends in obesity and type 2 diabetes mellitus. A substantial minority of Canadians continue to smoke. In short, there is no lack of public health threats to Canadians.
Although for each of these issues, there is a clear role for clinical care, it is the public health system that will identify and monitor health threats and provide interventions to prevent disease and injury and improve health. The system will also be at the front lines in any response to a biological, chemical or nuclear event. The public health system must have the infrastructure to respond to a range of threats to health, including emergencies. The experience with SARS has reaffirmed that we do not have the system flexibility to respond to these events after they have occurred. It is vital that we take steps now “to embrace not just the essential elements of disease protection and surveillance but also new strategies and tactics capable of addressing global challenges.”<1>
CMA’S PROPOSED PUBLIC HEALTH ACTION PLAN
No one policy instrument can possibly address the multiple factors involved in meeting the public health challenge head on. Similarly, no one level of government or constituency (e.g., community medicine) can or should shoulder all of the responsibilities.
Although we need to restore public confidence quickly, we must also do what it takes to get it right. Accordingly, the CMA is proffering a three-pronged approach to meet the challenge:
* A legislative reform strategy
* A capacity enhancement strategy
* A research, surveillance and communication strategy.
These three broad strategies make up the CMA’s proposed 10-point Public Health Action Plan. Taken together, the CMA believes the Plan, if adopted, will serve us very well in the future.
Our experience with SARS — and the seeming lack of coordination between international, federal, provincial and local system levels — should be a massive wake-up call. It highlights the need for legislative reform to clarify the roles of governments with respect to the management of public health issues and threats.
Four years ago, national consultations on renewing federal health protection legislation<2> resulted in a recommendation that
* “The federal government must be given, either through legislation or through memoranda of understanding among provincial and territorial governments, the authority it needs to effectively address any outbreak of a communicable disease, where the health risk extends beyond provincial borders.
* “Federal health protection legislation should be amended to give Health Canada authority to act quickly and decisively in the event of a national health emergency... if it poses a serious threat to public health; affects particularly vulnerable segments of the population; exceeds the capacity of local authorities to deal with the risk; and involves pathogens that could be rapidly transmitted across national and international borders.”
Such legislative reform is consistent with the federal government’s well-recognized responsibility to act to protect public health and safety. It fits well with Health Minister McLellan’s recently announced plans to act now to review and update health protection legislation. The SARS outbreak has provided further experience to support these, and in our view, even stronger recommendations.
There is ample historical evidence to support the federal government’s role in the management of communicable disease, a role that dates back to the time of confederation. The quarantine power was the initial manifestation of this authority in 1867 under Section 91 of the British North America Act and it gave the federal government the responsibility for ensuring the containment of infectious diseases. The outbreak of the Spanish Flu epidemic in 1918 further highlighted the need for coordinated national efforts and (at the urging of the CMA and others) resulted in the creation of the federal Department of Health in 1919. It would be reasonable to assume that legislators at the time had an expansive view of the need for centralized authority to deal with pan-Canadian health threats.
One hundred and thirty-five years after confederation, we have a highly mobile global community. This mobility and the attendant devastating speed with which diseases can spread demand a national response. Currently, there is tremendous variation in public health system capacity among the various provinces and territories and, more particularly, among municipalities and local authorities. Inconsistencies in provincial approaches to public health matters have resulted in significant disparities between and within the provinces.<3>
Health Canada’s mandate as set out in its enabling legislation states that “[t]he powers, duties and functions of the Minister extend to and include all matters over which Parliament has jurisdiction relating to the promotion and preservation of the health of the people of Canada.” The CMA believes that it is time for the federal government to take responsibility for public health matters that touch the lives of all Canadians.
The legal staffs at CMA, in consultation with external experts, have conducted a detailed review of existing legislation. We have concluded, as Health Minister McLellan recently announced, that there is a long overdue need to consolidate and rationalize current related laws. We also believe there is now public support and a demonstrable need to enhance the powers afforded the federal government. We recognize that the government has put forward Bill C-17, the Public Safety Act and a review of health protection legislation is underway.
We believe that amending and updating existing legislation is necessary but not sufficient to address today’s public health challenges. The CMA is calling for the enhancement of the federal government’s “command and control” powers in times of national health emergencies. Specifically we are recommending a three-pronged legislative approach.
1. The CMA recommends
The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada.
The existing Emergencies Act gives the federal government the authority to become involved in public welfare emergencies when regions of the country are faced with “an emergency that is caused by a real or imminent... disease in human beings... that results or may result in a danger to life or property... so serious as to be a national emergency.” However, to use this power, the federal government must declare a “national emergency,” which itself has political and economic ramifications, particularly from an international perspective, and mitigates against its use. The CMA believes that this all-or-nothing approach is not in the public’s best interest. The concept of emergency in the context of public health requires a different response from governments in the future.
Although we recognize that provincial and municipal governments currently have preplanned sets of responses to health threats, the CMA is proposing new legislation to allow for a rapid federal response to public health emergencies. The proposed Emergency Health Measures Act clarifies the roles and authority of governments and ensures a consistent and appropriate response with sufficient human and financial resources to protect Canadians faced with a public health emergency. Of utmost importance, all Canadians, regardless of their location, can be assured that the response to a health emergency will be delivered systematically by experts who can sustain the effort as needed.
The proposed legislation would be founded on a graduated approach that would give the federal government the powers necessary to deal with a crisis, in an appropriately measured way, as it escalates. As the emergency grows, the government could implement stronger measures as required to meet the challenge — in principle, akin to the Unites States’ homeland security levels, which increase as the level of threat increases (see Appendix 4 for a description of the Canadian Emergency Health Alert System).
The CMA strongly believes that the federal government must have jurisdiction to act when the ability of the provinces to respond to public health emergencies is so disparate. The inability of one province to stop the spread of virulent disease would have serious implications for the health of residents in the rest of the country. The federal government and the provinces must work together to ensure the safety of all our citizens.
2. The CMA recommends
The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm’s length from government.
Although some provinces have established centres of public health expertise, considering the breadth of public health issues, the relative population sizes and differences in wealth, it will never be feasible to have comprehensive centres of public health expertise for each province and territory.
Even if one achieved this, there would increasingly be issues of economies of scale and unnecessary duplication among centres. This issue is not unique to Canada.1 The CMA is proposing the development of a Canadian Office for Disease Surveillance and Control (CODSC) operating at arm’s length from any level of government. CODSC would have overall responsibility for protecting the health of Canadians.
The Office would provide credible information to enhance health decisions and promote health by developing and applying disease prevention and control, environmental health and health promotion and education activities.
CODSC would enable a consistent and coordinated approach to public health emergencies as well as play a key role in the prevention and control of chronic diseases and injuries. It would provide national health surveillance, apolitical scientific expertise, system development including standards and guideline development, development and dissemination of an evidence base for public health interventions, skills training and transfer of expertise (i.e., through secondment of staff) and resources, including funding for core programs, to other levels of the system (e.g., provincial and local).
3. The CMA recommends
The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan.
Many national or federal–provincial–territorial committees play an important role in recommending public health strategies or actions. The National Advisory Committee on Immunization and the Federal, Provincial and Territorial Advisory Committee on Population Health are two excellent examples. But there is currently no single credible public health authority in whom is vested, through legislation or federal–provincial–territorial agreement, the overall responsibility for pan-Canadian public health issues.
Therefore, the CMA is recommending the appointment of a Chief Public Health Officer of Canada. Potential roles for this officer may include:
* Serve as the head of the Canadian Office for Disease Surveillance and Control
* Serve as the national spokesperson for public health with the independence to comment on critical public health issues
* Report annually on the health of the population
* Develop, implement and report independently to parliament on public health system performance measures
* Lead processes to identify and address gaps in the nation’s public health system.
The public health system infrastructure is the foundation that supports the planning, delivery and evaluation of public health activities. In March 2001, the Federal, Provincial and Territorial Advisory Committee on Public Health<3> reported,
In the view of respondents the system ‘is lacking in depth.’ This means that a sustained crisis would seriously compromise other programming. While the research does not indicate that the public health system in Canada is strained beyond capacity, there does appear to be agreement that there is a capacity to manage just one crisis at a time.
However, just 2 years later, the GTA, an area with one of Canada’s most sophisticated public and acute care health systems, was not able to manage the SARS crisis and carry on any other programs. The Ontario government recognized this state of affairs when, on 12 June, Ontario’s Health Minister Tony Clement said, “I was concerned that if we had one additional large-scale crisis, that the system would crash.”
Important public health issues ranging from immunization to suicide prevention went virtually unaddressed, as the public health capacity in Toronto was overwhelmed. In the absence of a mechanism to share resources within the system and a general lack of overall system surge capacity, the city of Toronto and the province competed with each other to recruit trained staff from other health departments. The SARS outbreak has shown there is no surge capacity in Canada’s largest city. The acute care system in Toronto virtually ground to a halt in dealing with SARS. We must ask ourselves what would have happened if SARS had struck first in a smaller centre in a far less-advantaged region of Canada.
Clearly Canada is not fully prepared. We should not have needed a crisis to tell us this. The CMA sees several components to rebuilding the capacity of the public health system.
Public health human resources
For the essential functions of the public health system to be realized, public health agencies need a workforce with appropriate and constantly updated skills. Canada’s public health workforce is extremely thin. There appear to be too few graduate-level public health professionals (i.e., those holding a master’s degree and physicians who are certified specialists in community medicine); those who do exist are not distributed equitably across jurisdictions. The scarcity of hospital-based infection control practitioners and emergency physicians within the acute care system and the lack of integration of hospital and community-based disease control efforts have been particularly striking during the SARS outbreak.
The knowledge and skills required for effective public health practice are not static. They continually evolve as new evidence is identified. However, continuing education programming for public health practitioners is woefully underdeveloped in Canada. Health Canada has made some limited progress in this area, but the issue needs to be addressed much more substantively.
4. The CMA recommends
The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals.
Canada has world-class expertise in public health. However, it does not have the depth of other countries, partly because we do not have a national multidisciplinary school of public health of the calibre of Harvard in Boston, Johns Hopkins in Baltimore and the School of Hygiene and Tropical Medicine in London.
A national school of public health, which might be based on a virtual network of centres nationwide, could
* Develop a plan to assess and address the substantial educational needs of new and existing public health staff
* Address the coordination of the various academic training programs to meet the needs of the field
* Ensure self-sufficiency of our public health workforce.
5. The CMA recommends
The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies.
The SARS outbreak clearly demonstrated the need for a pre-planned approach to supporting and augmenting the public health and acute care workforce during a crisis. When health professionals in the GTA were overwhelmed, we were ill prepared to move health professionals in from other jurisdictions to help. Health professional associations like the CMA took the first steps in investigating and overcoming obstacles regarding licensure and insurance. We were taken aback when we found that the Ontario government had unilaterally awarded an exclusive contract to a for-profit company to arrange for emergency relief. The further delay caused by concerns about privacy, confidentiality and harmonizing fees hampered relief efforts. The deployment of health professionals during health emergencies is too important to be left in the hands of for-profit organizations as it was during the SARS experience.
An established Canadian Public Health Emergency Response Service, operating on a non-profit basis, would
* Maintain a “reserve” of public health professionals who are fully trained and could be deployed to areas of need during times of crisis
* Co-ordinate the logistics of issues such as portable licensing, malpractice and disability insurance
* Identify funding for staff training and a more equitable distribution of numbers and skills among jurisdictions.
Investment in public health
Considering the importance of the public health system and its capacity to protect and promote the health of Canadians, it is amazing that we have no reliable or comprehensive information about how much money is actually spent on the system or what public health human resources are available across Canada. This is partially due to the lack of uniform definitions, service delivery mechanisms and accounting practices. Even in the absence of reliable data on public health expenditures, there is ample evidence that the public health system continues to operate under serious resource constraints across Canada.
6. The CMA recommends
Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the Canadian Office for Disease Surveillance and Control.
In its latest report on health system expenditures, the CIHI states that 6% of total expenditures in 2000 were spent on “public health and administration.”<4> The inclusion of administrative costs in this figure means that public health funding is substantially less than 6% of health system expenditures.2
Federal Government Estimates report that Health Canada allocated $433 million in 2003–2004 for health promotion and prevention activities with spending scheduled to decrease to $308 million by 2005–2006 or by almost 30%. This decrease in spending exemplifies a decade that has seen tremendous fluctuations in spending on public health activities.
The situation is alarming when looked at from a current-dollar basis; there was an 8.8% decrease in funding of public health activities between 1994–1995 and 1997–1998. In fact, federal spending on public health on a constant dollar basis did not regain its 1994–1995 level until 2000–2001.
Although the late 1990s saw some reinvestment in public health initiatives, the most recent 2003–2004 estimates suggest that, once again, federal investment in public health will decrease dramatically over the next few years. Indeed, public health continues to represent only a small fraction of total federal direct spending on health (9.7% in 2002–2003).
At the provincial level, although we cannot distance public health from administration, we know that it fell victim to the brutal climate of fiscal retrenchment of the 1990s, when in real terms provincial–territorial per capita health spending declined for 5 consecutive years after 1991–1992.
During this period, public health was further destabilized by regionalization. According to the Survey of Public Health Capacity in Canada most provincial and territorial officials reported reductions in programming as a result of the transfer of funding and responsibility to regional structures. Although Ontario did not regionalize, in 1997 public health funding was downloaded to municipalities, which left public health departments scrambling to find funds to meet existing programs as well as new services that were mandated by the provincial Health Protection and Promotion Act.
Whether talking about federal or provincial–territorial jurisdictions, we can no longer afford to have funding for health and safety subject to the vagaries of financial cycles.
However, what perhaps is most alarming is the potentially large economic impact of underinvestment in this area. Although the net cost of the SARS outbreak in Ontario is not yet known, recent estimates suggest that it could be as high as $2.1 billion.3 Given this, the proverbial ounce of prevention that is worth a pound of cure comes to mind suggesting that a relatively modest increase in funding for public health could potentially result in substantial savings in the longer term.
7. The CMA recommends
Federal government funding in the amount of $1 billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions.
The best way to ensure that the public health system is capable of addressing the range of public health threats, including emergencies, is to significantly increase investment in its capacity. This investment must assist all levels of the system to fulfill essential public health functions, with particular attention to local and regional agencies. The strategic national leadership that we are calling for includes the development of new mechanisms for federal cost sharing of basic public health services and the guarantee of a basic core set of local programs serving everyone in Canada, regardless of where they live.
The system also needs to receive targeted funds so that it can do its work smarter and more effectively. Priority areas for this targeted funding should include development of an integrated information system and staff training.
Research, surveillance and communications
Canada’s ability to respond to emerging public health threats and acute events, such as the SARS outbreak, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications.
8. The CMA recommends
An immediate sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures.
Similar to the efforts in clinical care to support the use of evidence-based practices, interventions in public health must be based on research, evidence and best practices. A national effort should be undertaken to develop and make widely available, on an ongoing basis, a comprehensive and up-to-date review of the evidence base for public health programs. This information would support effective practice, enhance public health research capacity and support other infrastructure elements (e.g., minimum programs and services, performance measurement, system funding). It could also reduce unnecessary duplication of efforts by different public health agencies.
We applaud the tremendous work of the unique trans-Canada partnership of 4 CIHR-funded research teams who, in just 11 weeks, discovered the complete DNA sequence of the coronavirus associated with SARS. This is a perfect example of what can be accomplished when our talented research teams work together. The recent announcement by the CIHR of an integrated national strategy for research on SARS reflects the intent of this recommendation for other public health challenges.
9. The CMA recommends
The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and interventions.
Public health surveillance is defined as the ongoing, systematic collection, analysis and interpretation of health data necessary for designing implementing and evaluating public health programs. It is an integral part of the public health system and performs an essential function in early detection and response to threats to human health.
Current surveillance systems for communicable and noncommunicable diseases are inadequate to allow public health professionals to detect and react to major health issues. For effective public health management, surveillance must be a continuous process covering a range of integrated data sources to provide useful and timely information.
10. The CMA recommends
The one-time infusion of $100 million, with an additional $2 million a year, for a “REAL” (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies.
In today’s world, international travel, business and migration can move infectious diseases around the world at jet speed. But during the SARS experience, governments and public health authorities were unable to communicate in real time with health professionals on the front lines. Gaps in the basic communication infrastructure prevent public health agencies from talking with each other in real time, and also hinder exchanges between public health staff, private clinicians and other sources of information about emerging new diseases.
In response to requests from both the Ontario Medical Association and Health Canada, the CMA mobilized its communication networks to provide physicians with critical information about public health management of SARS. In less than 48 hours, via email and fax, we reached over 45,000 physicians with authoritative information. Through the good offices of the Canadian Council of Health Services Accreditation, this information was also made available to over 1500 accredited health facilities across Canada.
Although necessity caused the limits of the system to be tested, SARS highlighted the fact that we do not have information systems in place to facilitate real-time communication with health professionals. Information is the key to effective response during times of emergency. Information in real time is also essential for effective day-to-day health care to provide, for example, information on adverse drug reactions.
SARS brought out the best in Canada and Canadians’ commitment to one another. It also turned a bright, sometimes uncomfortable spotlight on the ability of this country’s health care system to respond to a crisis, be it an emerging disease, a terrorist attack, a natural disaster or a large-scale accident. We must learn from the SARS experience and quickly move to rebuild the infrastructure of a strong public health system.
The CMA believes that this 10-point Public Health Action Plan will go a long way toward addressing shortfalls in the Canadian public health system. Action now will help to ensure that Canadians can be confident once again that their governments are doing all they can to protect them from the threat of new infectious diseases.
We wish the advisory committee well in its deliberations and offer the CMA’s assistance at any time in clarifying the strategies set out in our submission.
APPENDIX 1: THE CMA’S PUBLIC HEALTH ACTION PLAN
[TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY]
APPENDIX 2: ESTIMATED COST OF IMPLEMENTING THE RECOMMENDATIONS
[TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY]
Estimated cost over 5 years
Legislative and institutional reform
1. Canada Emergency Health Measures Act
2. Canadian Office for Disease Surveillance and Control (CODSC)
3. Chief Public Health Officer of Canada
4. Canadian Centre of Excellence for Public Health
5. Canadian Public Health Emergency Response Service
6. Canadian Institute for Health Information and Statistics Canada
7. Surge capacity
Research, surveillance and communications
8. Canadian Institutes of Health Research
9. Mandatory reporting
Included under 2 and 3 above
10. Enhanced reporting
a. Work is currently underway to break-out public health from the current category of “public health and administration.”
b. This is an incremental investment in addition to funding currently available under Health Canada’s Health Promotion and Prevention Strategic Outcome area.
c. Funding must be sequestered specifically for new initiatives related to public health. Additional money could also be acquired through funding from the Canadian Foundation for Innovation, which received an additional $500 million in 2002–2003 (announced in the 2003 federal budget) to enhance the Foundation’s support of public health infrastructure.
APPENDIX 3: CHRONOLOGY OF THE CMA’S RESPONSE TO SARS
* First known case of atypical pneumonia (SARS) occurs in Guangdong province, China
* World Health Organization (WHO) receives reports from the Chinese Ministry of Health about SARS; 305 persons affected and 5 deaths
* Canadian index case arrives in Hong Kong for a family visit
* Canadian index case is a guest at the Metropole hotel in Kowloon
* A medical doctor from Guangdong checks into Metropole hotel in Kowloon. The physician, who became ill a week before staying at the hotel, is considered to be the original source of the infection
* This leads subsequently to outbreaks in Vietnam, Hong Kong, Singapore and Canada after guests leave the hotel and return home
* Canadian index case returns home to Toronto
* Canadian index patient dies in Toronto, 9 days after the onset of her illness
* WHO issues global alert about SARS
* National and international media reports begin appearing about SARS
* The Canadian index patient’s son, Canada’s second SARS victim, dies 15 days after the onset of his illness
* First reports from Toronto about deaths from SARS
* Health Canada receives notice of SARS patients in Ontario and British Columbia; begins regular updates on SARS on its website
* Health Canada initiates its pan-Canadian communication infrastructure, based on its pandemic influenza contingency plans
* CMA calls Health Canada to offer assistance and request “real time information.” CMA immediately placed on list of participants in daily pan-Canadian teleconferences.
* CMA adds a SARS page to its website home page (cma.ca) with CMA Shortcuts to expert information and daily updates
* CMA alerts all its divisions and affiliates to the Health Canada and CMA SARS web pages
* eCMAJ includes SARS updates on its website
* CMA divisions add a link to SARS information for health professionals to their websites
* Health Canada requests CMA’s assistance to inform physicians of the public health management guidelines for SARS
* CMA sends an email to 33,000 members (copied to divisions and affiliated societies) to alert them to Health Canada’s SARS public health management documents and SARS web page
* CMA CEO initiates cross-directorate task force and deploys dedicated staff resources. Some other CMA programs deferred/delayed. Task force begins daily staff SARS Working Group meetings
* CMA communicates with the Ontario Medical Association on a daily basis
* CMA holds teleconference with divisional communication directors re: SARS
* CMA contacts the British Medical Association to establish whether we can secure a supply of masks from European sources
* CMA organizes a teleconference among national health care organizations to discuss SARS developments
* CMA posts electronic grand rounds on SARS for clinicians on cma.ca;
* CMA sends email and fax communication to physicians to raise awareness of SARS e-grand rounds on cma.ca
* Working with the Mental Health Support Network of Canada, CMA prepares and posts on cma.ca, fact sheets for health professionals and the public on coping with the stress caused by SARS
* CMA hosts second teleconference among national health care organizations to discuss SARS developments
* Electronic grand rounds on SARS updated and promoted through cma.ca
* CMA sends email to membership requesting volunteers for the CMA Volunteer Emergency SARS Relief Network
* CMA consults with the American Medical Association regarding the possibility of US physicians volunteering for the relief network
* CMA CEO sends letter to deputy minister of health about the urgent need to create a national ministerial SARS task force
April 30-May 1
* CMA participates in Health Canada-sponsored international SARS conference in Toronto
* Health Canada announces the National Advisory Group on SARS and Public Health, headed by Dr. David Naylor
* Opinion editorial by Dr. Dana Hanson, CMA president, on SARS and public health surge capacity published in The Ottawa Citizen;
* CMA organizes a meeting of national health care organizations to discuss lessons learned from SARS
* CMA receives an invitation to submit a brief to the National Advisory Group on SARS and Public Health
* CMA sends e-mail to targeted segment of its membership (community medicine, public health, infectious disease and medical microbiology) requesting volunteers for the CMA Volunteer Emergency SARS Relief Network
* CMA president outlines the CMA’s Public Health Action Plan during a speech at the Canadian Club in Toronto
* CMA submission to the National Advisory Committee on SARS and public health
APPENDIX 4: CMA’S PROPOSED HEALTH EMERGENCY ALERT SYSTEM
[TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY]
Health alert may be declared in:
* Any area under federal jurisdiction
* Any community or province/territory with a risk of transmission to other provinces/territories or countries
* Any community or province/territory with insufficient resources to manage the public health emergency within the capacity of the local public health authorities
Definition of the area of concern
Voluntary quarantine for individuals or property
Chief public health officer takes the lead in coordinating the response
Regulation or prohibition of travel
Reviewing and updating health emergency procedures
Determination of local capacity to lead and respond
Coordinating necessary response efforts with national disaster relief agencies, armed forces or law enforcement agencies at the federal–provinical–territorial level
Medium to significant limitations of civil rights and freedoms
Assessing future resource requirements
Deployment of a national response team
Medium to significant limitations of civil rights and freedoms
Evacuation of persons and the removal of personal property
Providing the public with necessary information.
Discretionary deployment of the national response team or on request of local authorities
Quarantine of individuals and/or property with enforcement by law
Implementing interventions, as appropriate, and emergency response actions
Regulation of the distribution and availability of essential goods, services and resources
Assessing further refinement of actions
Restricting access to the area of concern
Requisition, use or disposition of property
Required consent of governor in council
Lead response team
1. Garrett, L. Betrayal of trust: the collapse of global public health. New York: Hyperion; 2000.
2. Health Canada. National consultations, summary report: renewal of the federal health protection legislation. Ottawa: Health Canada; 1999.
3. Federal, Provincial and Territorial Advisory Committee on Population Health. Survey of public health capacity in Canada: highlights. Ottawa: The Committee; 2001.
4. Canadian Institutes for Health Information. National health expenditure trends: 1975–2002. Ottawa: CIHI; 2002.
5. Lévesque M. The economic impact of SARS. TD Economics Topic Paper. TD Bank Financial Group; 6 May 2003. Available: http://www.td.com/economics/topic/ml0503_sars.html (viewed: 20 June 2003).
1 Many countries (e.g., United States, United Kingdom, Norway and the Netherlands) have developed critical masses of public health expertise at the national level. The Centers for Disease Control and Prevention in the United States, which has a critical mass, great depth of scientific expertise and the tools and fiscal resources to fund public health programs at both state and local levels through demonstration projects, is a sterling example of the effectiveness of such a central agency.
2 A review by the Canadian Institute for Health Information recognizes the problem with current expenditure tracking systems and has recommended separating public health from government administrative costs and prepayment administration in future health system cost estimates.
3 On 6 May, the TD Bank released a paper<5> suggesting that the cost of SARS to the Canadian economy may be between $1.5 and $2.1 billion.
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.
Re: Future Mandate of the Health Care Innovation Working Group (the Council of the Federation)
On behalf of the Canadian Nurses Association (CNA) and the Canadian Medical Association (CMA), I am writing in advance of the meeting of the Council of the Federation later this month regarding the future mandate of the Health Care Innovation Working Group with respect to seniors care.
The CNA and CMA welcomed the Council of the Federation's prioritization of seniors care as an area of focus of the Health Care Innovation Working Group. Already, seniors and their families in communities across Canada face significant challenges accessing social supports and health services. These challenges will only intensify as the demographic shift progresses. Based on current trends and approaches, the proportion of provincial/territorial health spending associated with seniors care is forecast to grow by over 15% to almost 62% of health budgets by 2036.
Recognizing the significant pressure this will present for health care systems and provincial/territorial budgets moving forward, it is critical that the Council of the Federation maintain its prioritization of seniors care and meeting the needs of an aging population. As such, we respectfully encourage you in your capacity as Co-Chairs of the Health Care Innovation Working Group to ensure the future mandate of the working group on seniors care be included as part of the agenda at the January 30, 2015 meeting of the Council of the Federation.
The CNA and CMA are actively engaged on this issue and welcome the opportunity to meet with each of you to discuss how we may collaborate to ensure improved health outcomes for seniors, now and in the future.
Christopher S. Simpson, MD, FRCPC, FACC, FHRS
Karima Velji, RN, PhD, CHE
That the government create a one-time Health Care and Innovation Fund to resume health care services, bolster public health capacity and expand primary care teams, allowing Canadians wide-ranging access to health care.
That the government recognize and support the continued adoption of virtual care and address the inequitable access to digital health services by creating a Digi-Health Knowledge Bank and by expediting broadband access to all Canadians.
That the government act on our collective learned lessons regarding our approach to seniors care and create a national demographic top-up to the Canada Health Transfer and establish a Seniors Care Benefit.
That the government recognize the unique risks and financial burden experienced by physicians and front line health care workers by implementing the Frontline Gratitude Tax Deduction, by extending eligibility of the Memorial Grant and by addressing remaining administrative barriers to physician practices accessing critical federal economic relief programs.
Five months ago COVID-19 hit our shores. We were unprepared and unprotected. We were fallible and vulnerable. But, we responded swiftly.
The federal government initiated Canadians into a new routine rooted in public health guidance.
It struggled to outfit the front line workers. It anchored quick measures to ensure some financial stability.
Canadians tuned in to daily updates on the health crisis and the battle against its wrath.
Together, we flattened the curve… For now.
We have experienced the impact of the first wave of the pandemic. The initial wake has left Canadians, and those who care for them, feeling the insecurities in our health care system.
While the economy is opening in varied phases – an exhaustive list including patios, stores, office spaces, and schools – the health care system that struggled to care for those most impacted by the pandemic remains feeble, susceptible not only to the insurgence of the virus, but ill-prepared to equally defend the daily health needs of our citizens.
The window to maintain momentum and to accelerate solutions to existing systemic ailments that have challenged us for years is short. We cannot allow it to pass. The urgency is written on the faces of tomorrow’s patients.
Before the onset of the pandemic, the government announced intentions to ensure all Canadians would be able to access a primary care family doctor. We knew then that the health care system was failing.
The pandemic has highlighted the criticality of these recommendations brought forward by the Canadian Medical Association. They bolster our collective efforts to ensure that Canadians get timely access to the care and services they need. Too many patients are succumbing to the gaps in our abilities to care for them. Patients have signaled their thirst for a model of virtual care. The magnitude of our failure to meet the needs of our aging population is now blindingly obvious. Many of the front line health care workers, the very individuals who put themselves and their families at risk to care for the nation, are being stretched to the breaking point to compensate for a crumbling system.
The health of the country’s economy cannot exist without the health of Canadians.
Long wait times have strangled our nation’s health care system for too long. It was chronic before COVID-19. Now, for far too many, it has turned tragic.
At the beginning of the pandemic, a significant proportion of health care services came to a halt. As health services are resuming, health care systems are left to grapple with a significant spike in wait times. Facilities will need to adopt new guidance to adhere to physical distancing, increasing staff levels, and planning and executing infrastructure changes. Canada’s already financially atrophied health systems will face significant funding challenges at a time when provincial/territorial governments are concerned with resuscitating economies.
The CMA is strongly supportive of new federal funding to ensure Canada’s health systems are resourced to meet the care needs of Canadians as the pandemic and life continues. We need to invigorate our health care system’s fitness to ensure that all Canadians are confident that it can and will serve them.
Creating a new Health Care and Innovation Fund would focus on resuming the health care system, addressing the backlog, and bringing primary care, the backbone of our health care system, back to centre stage.
The CMA will provide the budget costing in follow-up as an addendum to this submission.
RECOMMENDATION 1 Creating a one-time Health Care and Innovation Fund
It took a global pandemic to accelerate a digital economy and spark a digital health revolution in Canada. In our efforts to seek medical advice while in isolation, Canadians prompted a punctuated shift in how we can access care, regardless of our location or socio-economic situation. We redefined the need for virtual care.
During the pandemic, nearly half of Canadians have used virtual care. An incredible 91% were satisfied with their experience. The CMA has learned that 43% of Canadians would prefer that their first point of medical contact be virtual.
The CMA welcomes the $240 million federal investment in virtual care and encourages the government to ensure it is linked to a model that ensures equitable access.
A gaping deficit remains in using virtual care. Recently the CMA, the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada established a Virtual Care Task Force to identify digital opportunities to improve health care delivery, including what regulatory changes are required across provincial/territorial boundaries. To take full advantage of digital health capabilities, it will be essential for the entire population, to have a functional level of digital health literacy and access to the internet.
The continued adoption of virtual care is reliant on our ability to educate patients on how to access it. It will be further contingent on consistent and equitable access to broadband internet service.
Create a Digi-Health Knowledge Bank
Virtual care can’t just happen. It requires knowledge on how to access and effectively deliver it, from patients and health care providers respectively. It is crucial to understand and promote digital health literacy across Canada. What the federal government has done for financial literacy, with the appointment of the Financial Literacy Leader within the Financial Consumer Agency of Canada, can serve as a template for digital health literacy.
We recommend that the federal government establish a Digi-Health Knowledge Bank to develop indicators and measure the digital health of Canadians, create tools patients and health care providers can use to enhance digital health literacy, continually monitor the changing digital divide that exists among some population segments.
Pan-Canadian broadband expansion
It is critical to bridge the broadband divide by ensuring all those in Canada have equitable access to affordable, reliable and sustainable internet connectivity. Those in rural, remote, Northern and Indigenous communities are presently seriously disadvantaged in this way. With the rise in virtual care, a lack of access to broadband exacerbates inequalities in access to care. This issue needs to be expedited before we can have pride in any other achievement.
RECOMMENDATION 2 Embedding virtual care in our nation’s health care system
Some groups have been disproportionately affected by the COVID-19 crisis. Woefully inadequate care of seniors and residents of long-term care homes has left a shameful and intensely painful mark on our record. Our health care system has failed to meet the needs of our aging population for too long.
The following two recommendations, combined with a focus on improving access to health care services, will make a critical difference for Canadian seniors.
A demographic top-up to the Canada Health Transfer
The Canada Health Transfer (CHT) is the single largest federal transfer to the provinces and territories. It is critical in supporting provincial and territorial health programs in Canada. As an equal per-capita-based transfer, it does not currently address the imbalance in population segments like seniors.
The CMA, hand-in-hand with the Organizations for Health Action (HEAL), recommends that a demographic top-up be transferred to provinces and territories based on the projected increase in health care spending associated with an aging population, with the federal contribution set to the current share of the CHT as a percentage of provincial-territorial health spending. A top-up has been calculated at 1.7 billion for 2021. Additional funding would be worth a total of $21.1 billion to the provinces and territories over the next decade.
Seniors care benefit
Rising out-of-pocket expenses associated with seniors care could extend from 9 billion to 23 billion by 2035. A Seniors Care Benefits program would directly support seniors and those who care for them. Like the Child Care Benefit program, it would offset the high out-of-pocket health costs that burden caregivers and patients.
RECOMMENDATION 3 Ensuring that better care is secured for our seniors
The federal government has made great strides to mitigate the health and economic impacts of COVID-19. Amidst the task of providing stability, there has been a grand oversight: measures to support our front line health care workers and their financial burden have fallen short.
The CMA recommends the following measures:
1. Despite the significant contribution of physicians’ offices to Canada’s GDP, many physician practices have not been eligible for critical economic programs. The CMA welcomes the remedies implemented by Bill C-20 and recommends the federal government address remaining administrative barriers to physicians accessing federal economic relief program.
2. We recommend that the government implement the Frontline Gratitude Tax Deduction, an income tax deduction for frontline health care workers put at risk during the COVID-19 pandemic. In person patient care providers would be eligible to deduct a predetermined amount against income earned during the pandemic. The Canadian Armed Forces already employs this model for its members serving in hazardous missions.
3. It is a devastating reality that front line health care workers have died as a result of COVID-19. Extending eligibility for the Memorial Grant to families of front line health care workers who mourn the loss of a family member because of COVID-19, as a direct result of responding to the pandemic or as a result of an occupational illness or psychological impairment related to their work will relieve any unnecessary additional hardship experienced. The same grant should extend to cases in which their work contributes to the death of a family member.
RECOMMENDATION 4 Cementing financial stabilization measures for our front line health care workers
Those impacted by COVID-19 deserve our care. The health of our nation’s economy is contingent on the health standards for its people. We must assert the right to decent quality of life for those who are most vulnerable: those whose incomes have been dramatically impacted by the pandemic, those living in poverty, those living in marginalized communities, and those doubly plagued by experiencing racism and the pandemic. We are not speaking solely for physicians. This is about equitable care for every Canadian impacted by the pandemic.
Public awareness and support have never been stronger. We are not facing the end of the pandemic; we are confronting an ebb in our journey. Hope and optimism will remain elusive until we can be confident in our health care system.
The Canadian Medical Association (CMA) welcomes the opportunity to appear before the Sub-Committee on the Status of Persons with Disabilities to discuss issues related to the Disability Tax Credit (DTC). This tax measure, which is recognition by the federal government that persons with a severe disability may be affected by having reduced incomes, increased expenses or both, compared to those who are not disabled i, helps to account for the intangible costs associated with a severe and prolonged impairment. It also takes into account disability-related expenses that are not listed in the medical expense deduction or which are excluded by the 3% threshold in the Medical Expense Tax Credit.
Physicians are a key point of contact for applicants of the DTC and, given the way the program is structured, a vital participant in its administration. It is for these reasons that we come before you today to address specific concerns related to the program’s performance. In addition, we would like to discuss the broader issue of developing a coherent set of tax policies in support of health and social policy.
The Integration of Tax Policy with Health Policy and Social Policy
The federal government, through a variety of policy levers such as taxation, spending, regulation and information, has played a key role in the development of our health care and social systems. To date however, discussion about the federal role in these areas has centered largely on federal transfers to the provinces and territories and the Canada Health Act.
However, in looking at how to renew Canada’s health and social programs, we should not limit ourselves to these traditional instruments. Today we have a health system that is facing a number of pressures that will challenge its sustainability. These pressures range from an aging and more demanding population in terms of the specialty care services and technology they will seek; the cry for expanding the scope of medicare coverage to include homecare and pharmacare; and a shortage of health personnel. These are only some of the more immediate reasons alternative avenues of funding health care, and thus ensuring the health and well-being of our citizens, must be explored.
In our pre-budget consultation document to the Standing Committee on Finance ii, the CMA recommended that the federal government establish a blue ribbon National Task Force to study the development of innovative tax-based mechanisms to synchronize tax policy with health policy. Such a review has not been undertaken in over 25 years since the Royal Commission on Taxation in 1966 (Carter Commission).
The CMA is echoing its call for a National Task Force to develop new and innovative ways to synchronize tax policy with health policy and social policy. A study of this nature would look at all aspects of the taxation system, including the personal income tax system, in which the DTC is a component.
The remainder of our brief addresses issues specific to the DTC.
Physician Involvement in the DTC Program
The CMA has in the past provided input with respect to the DTC program. Our working relationship on the DTC program with the Canada Customs and Revenue Agency (CCRA) has been issue-specific, time-limited and constructive.
Our first substantive contact in regard to the DTC program was in 1993 when the CMA provided Revenue Canada with a brief review of the program and the T2201form. It is interesting to note what our observations were in 1993 with regard to this program because many of them still hold true today.
Here are just some of the issues raised by the CMA in 1993 during our initial review of the program:
* The tax credit program may not address the needs of the disabled, it is too hit and miss. The DTC program should be evaluated in a comprehensive way to measure its overall effectiveness in meeting the needs of persons with disabilities.
* The program should be called the “Severe Disability Tax Credit Program” – or something equivalent to indicate that not everyone with a disability is eligible.
* The program puts physicians in a potential conflict with patients—the responsibility of the physician to advocate for the patient vs. gate-keeper need for Revenue Canada. The physician role should be to attest to legitimate claims on the patients’ behalf.
* Revenue Canada should clarify the multiplicity of programs. There are numerous different federal programs and all appear to have varying processes and forms. These overlapping efforts are difficult for patients and professionals.
* A major education effort for potential claimants, tax advisers and physicians should be introduced.
* A suitable evaluation of claimant and medical components of the process should be undertaken.
The CMA does not have a standardized consultative relationship with the CCRA in regard to this program. An example of this spotty relationship is the recent letter sent by the CCRA Minister asking current DTC recipients to re-qualify for the credit. The CMA was not advised or consulted about this letter. If we had been advised we would have highlighted the financial and time implications of sending 75 to 100 thousand individuals to their family physician for re-certification. We also would have worked with the CCRA on alternative options for updating DTC records. Unfortunately, we cannot change what has happened, but we can learn from it. This clearly speaks to the need to establish open and ongoing dialogue between our two organizations.
Policy Measure: The CMA would like established a senior level advisory group to continually monitor and appraise the performance of the DTC program to ensure it is meeting its stated purpose and objectives. Representation on this advisory group would include, at a minimum, senior program officials preferably at the ADM level; those professional groups qualified to complete the T2201 Certificate; various disability organizations; and patients’ advocacy groups.
We would now like to draw the Sub-committee’s attention to three areas that, at present, negatively impact on the medical profession participation in the program, namely program integrity, program standardization (e.g., consistency in terminology and out-of-pocket costs faced by persons with disabilities) and tax advisor referrals to health care providers.
A primary concern and irritation for physicians working with this program is that it puts an undue strain on the patient-physician relationship. This strain may also have another possible side effect, a failure in the integrity of the DTC program process.
Under the current structure of the DTC program, physicians evaluate the patient, provide this evaluation back to the patient and then ask the patient for remuneration. This process is problematic for two reasons. First, since the patient will receive the form back immediately following the evaluation, physicians might receive the blame for denying their patient the tax credit—not the DTC program adjudicators. Second, physicians do not feel comfortable asking for payment when he or she knows the applicant will not qualify for the tax credit.
For the integrity of the DTC program, physicians need to be free to reach independent assessment of the patient’s condition. However, due to the pressure placed by this program on the patient-physician relationship, the physician’s moral and legal obligation to provide an objective assessment may conflict with the physician’s ethical duty to “Consider first the well-being of the patient.
There is a solution to this problem it’s a model already in use by government, the Canadian Pension Plan (CPP) Disability Program. Under the CPP Disability Program, the evaluation from the physician is not given to the patient but, it is sent to the government and the cost to have the eligibility form completed by a physician is subsumed under the program itself. Under this system, the integrity of patient-physician relationship is maintained and the integrity of the program is not compromised.
Policy Measure: The CMA recommends that the CCRA take the necessary steps to separate the evaluation process from the determination process. The CMA recommends the CPP Disability Program model to achieve this result.
Fairness and Equity
The federal government has several programs for people with disabilities. Some deal with income security (e.g., Canada Pension Plan Disability Benefits), some with employment issues (e.g., Employability Assistance for People with Disabilities), and some through tax measures (e.g., Disability Tax Credit). These government transfers and tax benefits help to provide the means for persons with disabilities to become active members in Canadian society.
However, these programs are not consistent in terms of their terminology, eligibility criteria, reimbursement protocols, benefits, etc. CMA recommends that standards of fairness and equity be applied across federal disability benefit programs, particularly in two areas: the definition of the concept of “disability”, and standards for remuneration to the physician. These are discussed in greater detail below.
1) Defining “disability”
One of the problems with assessing disability is that the concept itself is difficult to define. In most standard definitions the word “disability” is defined in very general and subjective terms. One widely used definition comes from the World Health Organization’s International Classification of Impairments, Disabilities and Handicaps (ICIDH) which defines disability as “any restriction or inability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being.”
The DTC and other disability program application forms do not use a standard definition of “disability”. In addition to the inconsistency in terminology, the criteria for qualification for these programs differ because they are targeted to meet the different needs of those persons with disabilities. To qualify for DTC, a disability must be “prolonged” (over a period of at least 12 months) and “severe” i.e. “markedly (restrict) any of the basic activities of daily living” which are defined. Though CPP criteria use the same words “severe” and “prolonged” they are defined differently (i.e., “severe” means “prevents applicant from working regularly at any job” and “prolonged” means “long term or may result in death”). Other programs, such as the Veterans Affairs Canada, have entirely different criteria.
This is confusing for physicians, patients and others (e.g., tax preparers/advisors) involved in the application process. This can lead to physicians spending more time than is necessary completing the form because of the need to verify terms. As a result if the terms, criteria and the information about the programs are not as clear as possible this could result in errors on the part of physicians when completing the forms. This could then inadvertently disadvantage those who, in fact, qualify for benefits.
Policy Measures: The CMA would like to see some consistency in definitions across the various government programs. This does not mean that eligibility criteria must become uniform.
In addition, the CMA would like to see the development of a comprehensive information package for health care providers that provides a description of each program, its eligibility criteria, the full range of benefits available, copies of sample forms, physical assessment and form completion payment information, etc.
The remuneration for assessment and form completion is another area where standardization among the various government programs would eliminate the difficulties that some individuals with disabilities currently face. For example, applicants who present the DTC Certificate Form T2201 to their physicians must bear any costs associated with its completion out of their own pockets. On the other hand, if an individual is applying to the CPP Disability Program, the cost to have the eligibility form completed by a physician is subsumed under the program itself.
Assessing a patient’s disabilities is a complex and time-consuming endeavour on the part of any health professional. Our members tell us that the DTC Certificate Form T2201 can take as much time and effort to complete as the information requested for CPP Disability Program forms depending, of course, on the patient and the nature of the disability. In spite of this fact, some programs acknowledge the time and expertise needed to conduct a proper assessment while other programs do not.
Although physicians have the option of approaching the applicant for remuneration for the completion of the DTC form, they are reluctant to do so because these individuals are usually of limited means and in very complex cases, the cost for a physician’s time for completing the DTC Form T2201 can reach as much as $150. In addition, physicians do not feel comfortable asking for payment when he/she knows the applicant will not qualify for the tax credit. Synchronizing funding between all programs would be of substantial benefit to all persons with disabilities, those professionals completing the forms and the programs’ administrators.
Policy Measure: We strongly urge the federal government to place disability tax credit programs on the same footing when it comes to reimbursement of the examining health care provider.
Tax Advisor Referrals
With the complexity of the income tax system today, many individuals seek out the assistance of professional tax advisors to ensure the forms are properly completed and they have received all the benefits they are entitled to. Tax advisors will very often refer individuals to health professionals so that they can be assessed for potential eligibility for the DTC. The intention of the tax advisors may be laudable, but often, inappropriate referrals are made to health professionals. This not only wastes the valuable time of health care professionals, already in short supply, but may create unrealistic expectations on the part of the patient seeking the tax credit.
The first principle of the CMA’s Code of Ethics is “consider first the well-being of the patient.” One of the key roles of the physician is to act as a patient’s advocate and support within the health care system. The DTC application form makes the physician a mediator between the patient and a third party with whom the patient is applying for financial support.
This “policing” role can place a strain on the physician-patient relationship – particularly if the patient is denied a disability tax credit as a result a third-party adjudicator’s interpretation of the physician’s recommendations contained within the medical report. Physicians and other health professionals are not only left with having to tell the patient that they are not eligible but in addition advising the patient that there may be a personal financial cost for the physician providing this assessment.
Policy Measure: Better preparation of tax advisors would be a benefit to both patients and their health care providers. The CMA would like CCRA to develop, in co-operation with the community of health care providers, a detailed guide for tax preparers and their clients outlining program eligibility criteria and preliminary steps towards undertaking a personal assessment of disability. This would provide some guidance as to whether it is worth the time, effort and expense to see a health professional for a professional assessment.
As raised in a previous meeting with CCRA, the CMA is once again making available a physician representative to accompany DTC representatives when they meet the various tax preparation agencies, prior to each tax season, to review the detailed guide on program eligibility criteria and initial assessment, and to highlight the implications of inappropriate referral.
The DTC is a deserving benefit to those Canadians living with a disability. However, there needs to be some standardization among the various programs to ensure that they are effective and meet their stated purpose. Namely, the CMA would like to make the following suggestions:
1. The CMA would like established a senior level advisory group to continually monitor and appraise the performance of the DTC program to ensure it is meeting its stated purpose and objectives. Representation on this advisory group would include, at a minimum, senior program officials preferably at the ADM level; those professional groups qualified to complete the T2201 Certificate; various disability organizations; and patient advocacy groups.
2. The CMA recommends that the CCRA take the necessary steps to separate the evaluation process from the determination process. The CMA recommends the CPP Disability Program model to achieve this result.
3. That there be some consistency in definitions across the various government programs. This does not circumvent differences in eligibility criteria.
4. That a comprehensive information package be developed, for health care providers, that provides a description of each program, its eligibility criteria, the full range of benefits available, copies of sample forms, physical assessment and form completion payment information, etc.
5. That the federal government applies these social programs on the same footing when it comes to their funding and administration.
6. That CCRA develop, in co-operation with the community of health care providers, a detailed guide for tax advisors and their clients outlining program eligibility criteria and preliminary steps towards undertaking a personal assessment of disability.
7. That CCRA employ health care providers to accompany CCRA representatives when they meet the various tax preparation agencies to review the detailed guide on program eligibility criteria and personal assessment of disability, and to highlight the implications of inappropriate referral.
These recommendations would certainly be helpful to all involved - the patient, health care providers and the programs’ administrators, in the short term. However what would be truly beneficial in the longer term would be an overall review of the taxation system from a health care perspective. This could provide tangible benefits not only for persons with disabilities but for all Canadians as well as demonstrating the federal government’s leadership towards ensuring the health and well being of our population.
i Health Canada, The Role for the Tax System in Advancing the Health Agenda, Applied Research and Analysis Directorate, Analysis and Connectivity Branch, September 21, 2001
ii Canadian Medical Association, Securing Our Future… Balancing Urgent Health Care Needs of Today With The Important Challenges of Tomorrow”, Presentation to the Standing Committee on Finance Pre-Budget Consultations, November 1, 2001.
The Canadian Medical Association (CMA) submission to the House of Commons Standing Committee on Finance examines how increasing retirement income saving options, improving access to prescription drugs, and planning for a Canadian Health Quality Alliance to promote innovation in the delivery of high quality health care can enhance our health care system and, in turn, make our economy more productive. Higher quality health care and expanded options for meeting the needs of retired and elderly Canadians will contribute to the ultimate goals of better patient care, improved population health and help our country reach its full potential.
Polls show that Canadians are becoming increasingly concerned about the future of their health care system, particularly in terms of their ability to access essential care. The CMA's 2011 pre-budget submission responds to these concerns and supports a healthy population, a healthy medical profession and a healthy economic recovery. Our recommendations are as follows:
Recommendation # 1
The federal government should study options to expand the current PRPP definition beyond defined contribution pension plans. Also, the federal government should expand the definition of eligible administrators of PRPPs beyond financial institutions to include organizations such as professional associations.
Recommendation # 2
Governments, in consultation with the life and health insurance industry and the public, should establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies.
Recommendation # 3
The federal government should convene a time-limited national steering committee that would engage key stakeholders in developing a proposal for a pan-Canadian Health Quality Alliance with a mandate to work collaboratively towards integrated approaches for a sustainable health care system through innovative practices in the delivery of high quality health care.
Over the past year, the CMA has engaged Canadians across the country in a broad-based public consultation on health care and heard about their concerns and experiences with the system. This exercise was undertaken as part of the CMA's Health Care Transformation (HCT) initiative, a roadmap for modernizing Canada's health care systemi so that it puts patients first and provides Canadians with better value for money.
We have heard through these consultations that Canadians do not believe they are currently getting good value from their health care system, a feeling borne out by studies comparing Canada's health care system to those in leading countries in Europe. We also heard that Canadians are concerned about inequities in access to care beyond the basic medicare basket, particularly in the area of access to prescription drugs. While all levels of government need to be involved, it is the federal government that must lead the transformation of our most cherished social program.
1. Retirement Income Improvement
Issue: Increasing retirement savings options for Canadians with a focus on improving their ability to look after their long-term care needs.
The CMA remains concerned about the status of Canada's retirement income system and the future ability of Canada's seniors to adequately fund their long-term and supportive care needs. The proportion of Canadian seniors (65+) is expected to almost double from its present level of 13% to almost 25% by 2036. Statistics Canada projections show that between 2015 and 2021 the number of seniors will, for the first time, surpass the number of children under 14 years of age.ii
The CMA has been working proactively on this issue in several ways, including through the recently created Retirement Income Improvement Coalition (RIIC), a broad-based coalition of 11 organizations representing over one million self-employed professionals.
The coalition has previously recommended to the federal government the following actions:
* increased retirement saving options for all Canadians, particularly the self-employed;
* changes to the Income Tax Act, Income Tax Regulations and the Employment Standards Act to enable the self-employed to participate in pension plans;
* the approval of Pooled Retirement Pension Plans (PRPP) as a retirement savings program for the self-employed;
* changes to the current tax-deferred income saving options (increase the percentage of earned income or the maximum-dollar amount contribution limit for RRSPs);
* a requirement that registration to all retirement saving options be voluntary (optional); and
* opportunities for Canadians to become better educated about retirement saving options (financial literacy).iii
The CMA appreciates that federal, provincial and territorial finance ministers are moving ahead with the introduction of Pooled Registered Retirement Plans (PRPPs). The CMA, as part of the RIIC, has been providing input into the consultation process. However, PRPPs represent only one piece of a more comprehensive retirement savings structure.
Recommendation # 1
The federal government should study options that would not limit PRPPs to defined contribution pension plans. Target benefit plans should be permitted and encouraged. Target benefit plans allow risk to be pooled among the plan members, providing a more secure vehicle than defined contribution plans.
Also, the administrators of PRPPs should not be limited to financial institutions. Well-governed organizations that represent a particular membership should be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members.
The CMA also continues to be concerned about the ability of Canadians to save for their long-term health care needs. The Wait Time Alliance - a coalition of 14 national medical organizations whose members provide specialty care to patients - reported recently that many patients, particularly the elderly, are in hospital while waiting for more suitable and appropriate care arrangements. Mostly in need of support rather than medical care, these patients are hindered by the lack of options available to them, often due to limited personal income.
The CMA has previously recommended that the federal government should study options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance. This remains pertinent.
2. Universal access to prescription drugs
Issue: Ensuring all Canadians have access to a basic level of prescription drugs.
Universal access to prescription drugs is widely acknowledged as part of the "unfinished business" of medicare in Canada. In 1964 the Hall Commission recommended that the federal government contribute 50% of the cost of a Prescription Drug Benefit within the Health Services Program. It also recommended a $1.00 contributory payment by the purchaser for each prescription. This has never been implemented.iv
What has emerged since then is a public-private mix of funding for prescription drugs. The Canadian Institute for Health Information (CIHI) has estimated that, as of 2010, 46% of prescription drug expenditures were public, 36% were paid for by private insurance and 18% were paid for out-of-pocket.v
Nationally there is evidence of wide variability in levels of drug coverage. According to Statistics Canada, 3% of households spent greater than 5% of after-tax income on prescription drugs in 2008. Across provinces this ranged from 2.2% in Ontario and Alberta, to 5.8% in P.E.I. and 5.9% in Saskatchewan.vi
Moreover, there is significant variation between the coverage levels of the various provincial plans across Canada. For example, the Manitoba Pharmacare Program is based on total income, with adjustment for spouse and dependents under 18, while in Newfoundland and Labrador, the plan is based on net family income.vii,viii
The Commonwealth Fund's 2010 International Health Policy Survey found that 10% of Canadian respondents said they had either not filled a prescription or skipped doses because of cost issues.ix Moreover, there have been numerous media stories about inequities in access across provinces to cancer drugs and expensive drugs for rare diseases.
The high cost of prescription drugs was frequently raised during our public consultations this year. The need for a national drug strategy or pharmacare plan was mentioned by an overwhelming number of respondents, many of whom detailed how they had been affected by the high cost of drugs.
The cost to the federal government of a program that would ensure universal access to prescription drugs would depend on the threshold of out-of-pocket contribution and the proportion of expenses that it would be willing to share with private and provincial/territorial public plans. Estimates have ranged from $500 millionx, and $1 billionxi, to the most recent estimate from the provincial-territorial health ministers of $2.5 billion (2006).xii
Recommendation # 2
Governments, in consultation with the life and health insurance industry and the public, should establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies.
Such a program should include:
* a mandate for all Canadians to have either private or public coverage for prescription drugs;
* a uniform income-based ceiling (between public and private plans and across provinces/territories) on out-of-pocket expenditures, on drug plan premiums and/or prescription drugs;
* federal/provincial/territorial cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal/provincial/territorial sharing of reimbursement or by scaling the household income ceiling or both;
* a requirement for group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size; and
* a continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs).
3. Innovation for Quality in Canadian Health Care
Issue: Development of a proposal to establish a Canadian Health Quality Alliance to promote innovation in the delivery of high-quality health care in Canada.
There is general agreement that Canada's health care system is no longer a strong performer compared to similar nations. Clearly, we can do better. However, progress has been slow on a comprehensive quality agenda for our health care system. At the national level, there is no coordination or body with a mandate to promote a comprehensive approach to quality improvement.
Over the past two decades, health care stakeholders in Canada have gradually come to embrace a multi-dimensional concept of quality in health care encompassing safety, appropriateness, effectiveness, accessibility, competency and efficiency. The unilateral federal funding cuts to health transfers that took effect in 1996 precipitated a long preoccupation with the accessibility dimension that was finally acknowledged with the Wait Time Reduction Fund in the 2004 First Ministers Accord. The safety dimension was recognized with the establishment of the Canadian Patient Safety Institute (CPSI) in 2003. Competence has been recognized by health professional organizations and regulatory bodies through the development of peer-review programs and mandated career-long professional development.
While six provinces have established some form of health quality council (B.C., Alta., Sask., Ont., Que., N.B.), there is no national approach to quality improvement beyond safety. Given that health care stands as Canadians' top national priority and that it represents a very large expenditure item for all levels of government, the lack of a national approach to quality improvement is a major shortcoming.
In the U.S., the Institute for Healthcare Improvement is dedicated to developing and promulgating methods and processes for improving the delivery of care throughout the world.xiii England's National Health Service (NHS) has also created focal points over the past decade to accelerate innovation and improvement throughout their health system.
Canadian advancements in the health field have occurred when the expertise and perspective of a range of stakeholders have come together. The CPSI, for example, was established following the deliberations and report of the National Steering Committee on Patient Safety.xiv
It is estimated that it would cost less than $500,000 for a multi-stakeholder committee to develop a proposal for a national alliance for quality improvement, including the cost of any commissioned research.
Recommendation # 3
The federal government should convene a time-limited national steering committee that would engage key stakeholders in developing a proposal for a pan-Canadian Health Quality Alliance with a mandate to work collaboratively towards integrated approaches for a sustainable health care system through innovative practices in the delivery of high quality health care.
This alliance would be expected to achieve the following in order to modernize health care services:
* Promote a comprehensive approach to quality improvement in health care;
* Promote pan-Canadian sharing of innovative and best practices;
* Develop and disseminate methods of engaging frontline clinicians in quality improvement processes; and
* Establish international partnerships for the exchange of innovative practices.
Such an alliance could be established in a variety of ways:
* Virtually, using the Networks of Centres of Excellencexv approach;
* By expanding the mandate of an existing body; or
* Through the creation of a new body.
i Canadian Medical Association. Health Care Transformation in Canada. Change that Works. Care that Lasts. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Advocacy/HCT/HCT-2010report_en.pdf Accessed 13/07/11.
ii Statistics Canada. Population Projections for Canada, Provinces and Territories. http://www.statcan.gc.ca/pub/91-520-x/2010001/aftertoc-aprestdm1-eng.htm. Accessed 13/07/11.
iii Retirement Income Improvement Coalition. Letter to the federal Minister of Finance and the Minister of State (Finance). March 17, 2011.
ivHall, E. Royal Commission on Health Services. Volume 1. Ottawa: Queen's Printer, 1964.
vCanadian Institute for Health Information. Drug Expenditure in Canada, 1985 to 2010. Ottawa, 2010.
viStatistics Canada. CANSIM Table 109-5012 Household spending on prescription drugs as a percentage of after-tax income, Canada and provinces, annual (percent). http://www5.statcan.gc.ca/cansim/pick-choisir?lang=eng&searchTypeByValue=1&id=1095012. Accessed 05/29/11.
vii Manitoba Health. Pharmacare deductible estimator. http://www.gov.mb.ca/health/pharmacare/estimator.html. Accessed 07/28/11.
viii Newfoundland Department of Health and Community Services. Newfoundland and Labrador Prescription Drug Program (NLPDP). http://www.health.gov.nl.ca/health/prescription/nlpdp_application_form.pdf. Accessed 07/29/11.
ixCommonwealth Fund. International health policy survey in eleven countries. http://www.commonwealthfund.org/~/media/Files/Publications/Chartbook/2010/PDF_2010_IHP_Survey_Chartpack_FULL_12022010.pdf. Accessed 05/29/11.
x Senate Standing Committee on Social Affairs, Science and Technology. The health of Canadians - the federal role. Volume six: recommendations for reform. Ottawa, 2002.
xi Commission on the Future of Health Care in Canada. Building on values: the future of health care in Canada. Ottawa, 2002.
xii Canadian Intergovernmental Conference Secretariat. Backgrounder: National Pharmaceutical Strategy decision points. http://www.scics.gc.ca/english/conferences.asp?a=viewdocument&id=112. Accessed 23/07/11.
xiii http://www.ihi.org. Accessed 29/07/10.
xiv National Steering Committee on Patient Safety. Building a safer system: a national integrated strategy for improving patient safety in Canadian health care. http://rcpsc.medical.org/publications/building_a_safer_system_e.pdf. Accessed 23/07/11.
xv http://www.nce-rce.gc.ca/index_eng.asp. Accessed 29/07/10.
Thank you for the opportunity to appear before this committee.
Over the past year, the Canadian Medical Association has engaged in a wide-ranging public consultation on health care and heard from thousands of Canadians about their concerns and experiences with the system.
This exercise was undertaken as part of the CMA's Health Care Transformation initiative, a roadmap for modernizing our country's health care system so that it puts patients first and provides Canadians with better value for money.
The CMA found there is a groundswell of support for change among other health care providers, stakeholders and countless Canadians who share our view that the best catalyst for transformation is the next accord on federal transfers to provinces for health care.
That said, while looking ahead to what we would like to see in the next health care accord, we have identified immediate opportunities for federal leadership in making achievable, positive changes to our health care system that would help Canadians be healthier and more secure and help ensure the prudent use of their health care dollars.
During our consultation, we heard repeated concerns that Canada's medicare system is a shadow of its former self. Once a world leader, Canada now lags behind comparable nations in providing high quality health care.
Improving the quality of health care services is key if Canada is ever going to have a high performing health system. The key dimensions of quality, and by extension, the areas that need attention are: Safety, Effectiveness, Patient-Centeredness, Efficiency, Timeliness, Equitability and Appropriateness. Excellence in quality improvement in these areas will be a crucial step towards sustainability.
To date, six provinces have instituted health quality councils. Their mandates and their effectiveness in actually achieving lasting system wide improvements vary by province. What is missing, and urgently needed, is an integrated, Pan-Canadian approach to quality improvement in health care in Canada that can begin to chart a course that will ensure that Canadians ultimately have the best health and health care in the world. Canadians deserve no less and, with the resources at our disposal, there is no reason why this should not be achievable.
The CMA recommends that the Federal Government funds the establishment, and adequately resources the operations, of an arms length Canadian Health Quality Council with the mandate to be a catalyst for change, a spark for innovation and a facilitator to disseminate evidence based quality improvement initiatives so that they become embedded in the fabric of our health systems from coast to coast to coast.
Canadians are increasingly questioning whether they are getting value for the $190 billion a year that go into our country's health care system... with good reason as international studies indicate they are not getting good value for money.
Defining, promoting and measuring quality care are not only essential to obtaining better health outcomes, they are crucial to building the accountability to Canadians that they deserve as consumers and funders of the system.
We also heard during our consultation that Canadians worry about inequities in access to care beyond the hospital and doctor services covered within medicare, particularly when it comes to the high cost of prescription drugs.
Almost 50 years ago, the Hall Commission recommended that all Canadians have access to a basic level of prescription drug coverage, yet what we have now is a jumble of public and private funding for prescription drugs that varies widely across the country.
Last year, one in 10 Canadians either failed to fill a prescription or skipped a dose because they couldn't afford it.
Universal access to prescription drugs is widely acknowledged to be part of the unfinished business of medicare in Canada.
Our second recommendation, therefore, is that governments establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies.
This should be done in consultation with the life and health insurance industry and the public.
In the 21st century, no Canadian should be denied access to medically necessary prescription drugs because of an inability to pay for them.
Our third and final recommendation relates to our aging population and the concerns Canadians share about their ability to save for their future needs.
We recommend that the federal government study options that would not limit PRPPs to defined contribution pension plans. Target benefit plans should be permitted and encouraged as they allow risk to be pooled among the plan members, providing a more secure vehicle than defined contribution plans.
As well, the administrators of PRPPs should not be limited to financial institutions. Well-governed organizations that represent a particular membership should be able to sponsor and administer RPPs and PRPPs for their own members, including self-employed members.
The CMA appreciates that governments are moving ahead with the introduction of Pooled Registered Retirement Plans. However, we note that PRPPs represent only one piece of a more comprehensive saving structure.
We also continue to be concerned about the ability of Canadians to save for their long-term health care needs. Many patients, particularly the elderly, are in hospital waiting for more suitable care arrangement. These patients are hindered by a lack of available options, often because they lack the means to pay for long-term care. They and their families suffer as a result, and so, too, does our health care system.
While not in this pre-budget brief, the CMA holds to recommendations we have made in previous years that the federal government study options to help Canadians pre-fund long-term care.
In closing, let me simply say that carrying out these recommendations would make a huge and positive impact, soon and over the long term, in the lives of literally millions of Canadians from every walk of life.
Thank you for your time. I would be happy to answer your questions.