I would like to thank the Committee for inviting the Canadian Medical Association to appear on this very important topic.
As a family physician in Saskatoon and the past president of the CMA, I can assure you that Canada's physicians have an acute interest in drawing attention to the health consequences of poor nutrition and lack of physical activity, and the challenge of obesity.
We know that obesity is a contributor to a number of chronic diseases, such as diabetes, cardiovascular disease, hypertension and liver disease, as well as breast, colon and prostate cancer.
We know that over-consumption of salt, sugars, and saturated and trans fats can be a factor in hypertension, cardiovascular disease and stroke, and kidney disease.
And we know that Canadians have become dramatically less physically fit in recent decades.
As a country, we need to espouse a culture of health and wellness, based on good nutrition and physical activity.
Finding solutions will require a collaborative, system-wide approach involving all levels of government, the health, education, industry, finance and transportation ministries, and the private sector.
We know that if provided with support when young, children can adopt healthy life styles. That is why the CMA continues to call on governments across the country to work with school boards to:
* provide at least 30 minutes of active daily physical education for all primary and secondary grades, given by trained educators in the field;
* provide access to attractive, affordable, healthy food choices and clearly post the nutrition content of the foods they sell; and
* ban junk food sales in all primary, intermediate and secondary schools in Canada.
The CMA has advocated policies and regulations for food safety, and promoted healthy eating and physical activity as key components of healthy living and the prevention of disease.
The CMA policy statement Promoting Physical Activity and Healthy Weights calls for a Canada-wide strategy for healthy living that includes:
* information and support for Canadians to help them make healthy choices;
* support for health professionals in counselling patients on healthy weight and in treating existing obesity;
* community infrastructure that makes healthy living choices easier; and
* public policies that encourage healthy eating and physical activity.
All Canadians need access to nutritious food at affordable prices. The price of milk, produce and other healthy foods varies greatly in different parts of Canada. In remote areas, they are even more expensive because of high transportation costs. In urban areas, nutritious food may be unaffordable for people on low incomes and unavailable as grocery stores move to the suburbs thus creating "food deserts". Among other strategies, governments should consider: implementing school meal programs; and taking into account the cost of nutritious food when setting social assistance rates.
The proliferation of packaged, prepared foods and fast foods has contributed to excess amounts of salt, sugar, saturated and trans fat and calories in our diet.
While we welcome the federal government's support for the reduction of trans fats and sodium levels in processed foods, reliance on the food industry to voluntarily reduce these ingredients has not been successful. We believe that regulation is needed to safeguard the health of Canadians.
Healthy living begins with an awareness of the impact of food and exercise on health. While individuals must take responsibility for making healthy choices, the CMA believes that governments have an obligation to provide guidance on healthy eating and physical activity that can be easily incorporated into daily lives.
We commend the federal and provincial/ territorial governments for their recent Framework for Action to Promote Healthy Weights. Physicians were also pleased to see the revised Canada's Food Guide in 2007, and the recent update to Canada's Physical Activity Guide.
The CMA supports nutrition and caloric labeling on packaged foods to help Canadians make informed food choices. The federal nutrition labeling awareness initiative is useful to consumers but we think information can be simplified. For example, the UK is testing front of pack 'traffic light' coding for fats, salt, sugar and calories. The CMA has also called for a clear display of caloric counts, and sodium, trans-fats and protein levels on restaurant and cafeteria menus.
The CMA believes encouragement of active transportation, that is walking and cycling, is a way to increase physical activity. Communities need to make it easier for Canadians to be physically active in their day-to-day life by providing sidewalks and pedestrian-friendly intersections; bike lanes, paths and parking spaces; and trails, parks and green spaces.
One area that we believe warrants further study is the use of incentives to promote healthy behaviours. By transferring funds or other benefits to an individual, incentives provide immediate rewards for behaviours that can lead to long-term health gains. An example in Canada is the Children's Fitness Tax Credit, which is intended to help children be more active by off-setting some of the costs incurred by families for sports and leisure programs.
Government disincentives largely involve the use of regulation and taxation in order to change individual behaviour. This helps to create an environment in which healthy choices are easier to make.
It is impossible to overstate the importance of nutrition and physical activity to our health. Encouraging Canadians to make healthy choices requires a wide ranging, long-term and collaborative approach.
The CMA believes this challenge should be met urgently. Canada's physicians are more than ready to work with governments to ensure that Canadians can improve and maintain their health.
Thank you very much for inviting the Canadian Medical Association back to this committee as you continue your study on healthy living.
A few weeks ago my colleague Dr. Doig was here to talk about the health consequences of poor nutrition and lack of physical activity and the policies CMA has advocated to promote healthy living.
Today I would like to expand upon nutrition labelling and health claims on foods, and on the labelling of foods regulated as natural health products.
Nutrition facts tables can be an important source of information, but many Canadians have difficulty interpreting them. A 2009 Health Canada review of research on nutrition labelling indicated that:
* those with little nutrition knowledge have difficulty using the tables and are unable to relate the information they contain to their own dietary needs; and that
* the concept of percentage of daily value is often misunderstood.
There has been an increase in the use of health claims on the front of packaging expressed as slogans or logos such as "healthy choice," as well as in disease reduction and nutrient content claims.
Studies have shown that foods carrying health-related claims are seen by consumers as healthier choices. But the myriad of different claims can be confusing and may, in fact, draw attention away from the less healthy characteristics of a food, or oversimplify complex nutritional messages.
We believe a standard consistent "at a glance" approach to front-of-package food labelling could reduce confusion and help consumers make informed dietary choices.
The "traffic light" front-of-pack labelling currently in voluntary use in the UK is an example. The front-of-pack labels on composite processed foods use green, amber and red to indicate low, medium or high levels of the nutrients most strongly associated with diet-related health risks: fat, saturated fat, sugars and salt. Also included is calorie count per serving and percentage daily amount information.
Research in the UK has shown that consumers generally understand these labels. Shoppers are most likely to use them when buying a product for the first time; to compare different products; when shopping for children; when trying to control intake of certain ingredients such as fat or salt, for health reasons; or when trying to lose weight.
Not surprisingly, research in the UK and Canada also shows that those most likely to read nutrition labels are those who are already interested in healthy eating.
For this reason, labelling policy must be embedded in a broader nutrition policy that uses multiple instruments to foster education and interest in healthy eating, and helps ensure that Canadians have healthy food choices by, for example, regulating amounts of salt in processed food.
In addition, physicians have become quite concerned about a recent tendency toward regulating 'fortified foods 'as Natural Health Products.
The Food and Drugs Act effectively prevents products classified as foods from being marketed as having medicinal benefits unless there is compelling scientific evidence that the claims are true and the products are safe. The same strong legislation does not apply to Natural Health Products (NHPs), which are regulated under a different act.
This is a concern because a trend is emerging whereby manufacturers of products normally sold as foods fortify their products with approved natural health products such as vitamins or minerals. Examples of these are energy drinks and vitamin-enhanced juice, power bars, gums and candy.
The manufacturer can then request federal approval to market the product as a 'health product in food format.' If approved, food labelling requirements no longer apply and health claims that would not be allowed under the Food and Drugs Act can be made.
Without proper nutrition labelling, it is difficult, if not impossible, for consumers to make informed food choices. This can be particularly troubling for those with special diets or health concerns. Further, those misled by dubious health claims might be consuming empty calories or high amounts of fat or sodium, with no corresponding benefit. The result is that the health of Canadians may be compromised.
The CMA has called on Health Canada to require compelling evidence of health benefits before changing a product's regulatory status from food to natural health product, and nutrition labelling for all foods regulated as a natural health product.
Faced with an array of products and health claims, and a barrage of advertising extolling their benefits, Canadians can find it challenging to make healthier food choices.
To find our way through to the right choice, we need good nutritional information, and the ability to access and understand this information.
Governments and health care providers share a responsibility to help Canadians make choices that will help them achieve and maintain good health. Canada's doctors are partners in healthy living and are ready to work with governments and others toward a healthy population.
I welcome your questions.
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.
The Canadian Medical Association wishes to commend the House of Commons Standing Committee on Health for undertaking this study of the issue of chronic diseases related to aging.
It is a timely issue, since the first members of the Baby Boom generation turned 65 in 2011 and it's predicted that by 2031 a quarter of Canada's population will be 65 or older. Though chronic disease is not exclusive to seniors, its prevalence does rise with age: according to Statistics Canada, about 74% of Canadians over 65 have at least one chronic condition such as diabetes, high blood pressure, arthritis or depression and nearly 25% have three or more. The proportion is higher among people 85 years old and over.
What are the causes of chronic disease? There are many. Some of them are rooted in unhealthy behaviour: smoking, poor nutrition and, in particular, lack of physical activity. Physicians are concerned about rising obesity rates in Canada, for example, because obesity increases one's risk of developing chronic diseases later in life.
But there is more to chronic disease than unhealthy behaviour. It is also affected by a person's biological and genetic makeup, as well as by his or her social environment. Lower income and educational levels, poor housing, and social isolation, which is a greater problem for seniors than for other populations, are all associated with poorer health status.
Now the good news: chronic disease is not an inevitable consequence of aging. We can delay the onset of chronic disease, and perhaps even reduce the risk that it will occur. Patients who do have existing chronic disease, their conditions can often be controlled successfully through appropriate health care and disease management, so that they can continue to lead active, independent lives.
Thus the CMA supports initiatives promoting healthy aging - which the Public Health Agency of Canada defines as "the process of optimizing opportunities for physical, mental and social health as people age." Healthy lifestyles should be encouraged at any age.
For example, the Canadian Physical Activity Guidelines, which CMA supports, recommend that people 65 or older accumulate at least two-and-a-half hours per week of aerobic activity such as walking, swimming or cycling. Experts believe that healthy aging will compress a person's period of illness and disability into a short period just prior to death, enabling a longer period of healthy, independent and fulfilling life.
For those who are already affected with chronic diseases, treatment is long term and can be very complex. People with diabetes, for example, need a continuous ongoing program to monitor their blood sugar levels and maintain them at an appropriate level; people with arthritis or other mobility problems may require regular physical therapy. For the patient, chronic disease means a long-term management that is much more complicated than taking antibiotics for an infection. People with two or more chronic conditions may be consulting a different specialist for each, as well as seeking support from nurse counsellors, dieticians, pharmacists, occupational therapists, social workers or other health professionals.
Often, management requires medication. The majority of Canadians over 65 take at least one prescription drug, and nearly 15% are on five drugs or more, which increases the possibility that, for example, two of those drugs could interact negatively with each other to produce unpleasant and possibly serious side effects.
Long-term, complex chronic disease care is in fact the new paradigm in our health care system. About 80% of the care now provided in the United States is for chronic diseases, and there is no reason to believe Canada is greatly different. Hence, it is worth considering what form, ideally, a comprehensive program of chronic disease management should take, for patients of any age.
The CMA believes it should include the following four elements:
* First, access to a primary care provider who has responsibility for the overall care of the patient. For more than 30 million Canadians, that primary care provider is a family physician. Family physicians who have established long-standing professional relationships with their patients, can better understand their needs and preferences. They can build a relationship of trust, so that patients are comfortable in discussing frankly how they want to treat their conditions: for example, whether to take medication for depression or seek counselling with a therapist. The family physician can also serve as a co-ordinator of the care delivered by other providers. This leads to our second recommended element:
* Collaborative and coordinated care. The CMA believes that, given the number of providers who may be involved in the care of chronic diseases, the health care system should encourage the creation of interdisciplinary teams or, at minimum, enable a high level of communication and coordination among individual providers. We believe all governments should support:
o Interdisciplinary primary care practices, such as Family Health Networks in Ontario, which bring a variety of different health professionals and their expertise into one practice setting;
o Widespread use of the electronic health record, which can facilitate information sharing and communication among providers; and
o A smooth process for referral: for example, from family physician to specialists, or from family physician to physiotherapist. The CMA is working with other medical stakeholders to create a referral process tool kit that governments, health care organizations and practitioners can use to support the development of more effective and efficient referral systems.
The patient may also need non-medical support services to help cope with disability related to chronic disease. For example, a person with arthritis who wants to remain at home may need to have grab bars, ramps or stair lifts installed there. Ideally, a coordinated system of chronic disease management would also include referral to those who could provide these services.
* The third necessary element is support for informal caregivers. These are the unsung heroes of elder care. An estimated four million Canadians are providing informal, unpaid care to family members or friends. About a quarter of these caregivers are themselves 65 or older. Their burden can be a heavy one, in terms of both time and expense. Stress and isolation are common among caregivers.
The federal government has taken steps to provide much-needed support to informal caregivers. The most recent federal budget, for example, increased the amount of its Caregiver Tax Credit. We recommend that the government build on these actions, to provide a solid network of support, financial and otherwise, to informal caregivers.
* The fourth and final element is improving access to necessary services. Only physician and hospital services are covered through the Canada Health Act, and many other services are not. All provinces have pharmacare programs for people over 65, but coverage varies widely between provinces and many, particularly those with lower incomes, find it difficult to pay for their necessary medications. Seniors who do not have post-retirement benefit plans - and these are the majority - also need to pay out of pocket for dental care, physiotherapy, mental health care and other needed supports. We recommend that all levels of government explore adjusting the basket of services provided through public funding, to make sure that it reflects the needs of the growing number of Canadians burdened by chronic disease. In particular, we recommend that the federal government negotiate a cost-shared program of comprehensive prescription drug coverage with provincial/territorial governments.
In conclusion, the CMA believes the committee is wise to consider how we might reduce the impact - on individual patients, the health care system and society - of chronic disease related to aging. Chronic disease management is a complex problem, but warrants close attention as it is now the dominant form of health care in Canada. We look forward to the results of the Committee's deliberations.
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.
The Canadian Medical Association (CMA) is pleased to provide this response to Health Canada's Proposed Order Amending the Schedule to the Tobacco Act (Menthol), as found in the Canada Gazette, Part I, on November 5, 2016.
The CMA believes that the federal government has an important role in prevention and smoking cessation, particularly among youth, to end smoking within Canada. As early as 2008, the CMA called for the federal government to ban menthol in tobacco products. In 2014, the CMA submitted a brief to Health Canada on the proposal to amend the Tobacco Act to restrict the use of additives in tobacco products. One of the CMA's concerns at that time was that the Act excluded menthol as a flavouring agent in tobacco products.
Therefore, the CMA strongly supports Health Canada's proposed order to prohibit menthol in cigarettes, blunt wraps and cigars. The proposed order has the ability to deter youth from smoking since menthol makes smoking more palatable by masking the harshness of tobacco smoke. This may lead to not only a decline in youth smokers but a decline in the number of smokers in the overall Canadian population as well.
The CMA issued its first warning to the public about the dangers of tobacco in 1954, and we continue to advocate for stronger measures to control smoking. Banning the use of menthol is one step towards achieving this goal.
Jeff Blackmer, MD, MHSc, FRCPC
Vice-President, Medical Professionalism
Canadian Medical Association
The Canadian Medical Association is pleased to present its views to the study on poverty reduction strategies by the House of Commons Standing Committee on Human Resources, Skills and Social Development and the Status of Persons with Disabilities.
The focus of the Committee’s study on improving the delivery of federal resources and services for the Canadian Poverty Reduction Strategy is of profound interest to the CMA, given our concerns about the need to address the social determinants of health. It is that perspective from which this paper will approach the Committee’s areas of interest.
Social Determinants of Health
The consequences of poverty on health are well established and include lower life expectancy, higher disease burden, and poorer overall health. Research suggests that 15% of population health is determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.1 Many studies show that people low on the socioeconomic scale are likely to carry a higher burden of just about any disease.2
1 Keon, WJ, Pépin L. (2008) Population Health Policy: Issues and Options. Ottawa: The Senate of Canada; 2008. Available at: https://sencanada.ca/content/sen/Committee/392/soci/rep/rep10apr08-e.pdf
2 Op cit. Dunn JR. The Health Determinants Partnership Making Connections Project
3 Munro D. Healthy People, Healthy Performance, Healthy Profits: The Case for Business Action on the SocioEconomic Determinants of Health. The Conference Board of Canada, Ottawa (ON); 2008.
Reducing inequities and thereby improving population health should be an overall objective for all governments in Canada.
The societal cost of poor health extends beyond the cost to the health care system: healthier people lose fewer days of work and contribute to overall economic productivity.3 Those living in the most disadvantaged neighbourhoods experience almost 20 years less disability-free life.
It is fundamental that the health impact of social and economic decisions be part of the policy development and decision-making process.
1. The CMA recommends that health impact assessments be included as part of the policy development and decision-making process in poverty reduction strategies, including in the development of legislation and regulations.
Neighbourhoods and Housing
Mounting evidence suggests that the built environment can play a significant role in our state of health. The literature indicates that the following connections between the built environment and public health are possible:
o Decreased physical activity;
o Increased prevalence of obesity;
o Increased prevalence of asthma and other respiratory diseases;
o Injuries and unintended fatalities;
o Heat exposure.4
4 Frank , L., Kavage S, & Devlin A. (2012). Health and the Built Environment: A Review. World Medical Association
5 Canadian Society of Exercise Physiology. (2011). Canadian Physical Activity Guidelines. Canadian Society of Exercise Physiology
6 CMA. Active Transportation http://policybase.cma.ca/dbtw-wpd/Policypdf/PD09-04.pdf 2009
7 Statistics Canada. (2006, June 28). Childhood Obesity: A Troubling Situation. Retrieved July 15, 2012, from StatsCan: http://www41.statcan.ca/2006/2966/ceb2966_004-eng.htm
Canada's physical activity guidelines recommend that children ages 5 to 11 should be active for at least 60 minutes a day; those 18 and over should be active for at least 150 minutes per week.5 However, physical activity includes more than exercise and leisure time activity, it also includes active transportation such as walking to school, work or errands as part of daily living. CMA’s policy on Active Transportation recommends that all sectors (physicians and other health professionals, government, business and the public) work together, as a matter of priority, to support and encourage active transportation and physical activity.6 Urban planners must work together with health professionals to understand the impact on health.
Research shows that specific populations, such as children, the elderly, and low-income populations, are more affected.
Children: Obesity is an issue for Canadians nationwide, but particularly so for children. Between 1978 and 2004 there was a 70% increase in overweight and obese children aged 12-17.7 Obesity in children can lead to health issues such as hypertension, glucose intolerance, and orthopaedic complications.8 Furthermore it has a high likelihood of carrying over into adulthood and may result in further health problems such as diabetes and heart disease.9 Environments that promote physical activity are
especially important, including mixed use communities with walkable destinations, parks and recreational facilities.10
10 Dannenberg, A., Frumkin, H., & Jackson, R. J. (2011). Making Healthy Places Designing and Building for Health, Well-Being and Sustainability. Island Press.
11 Vogel, T., Brechat, P., Lepetre, P., Kaltenbach, G., Berthel, M., & Lonsdorfer, J. (2009). Health Benefits of Physical Activity in Older Patients: A Review. The International Journal of Clinical Practice, 63(2), 303-320.
12 Centre for Chronic Disease Prevention and Control. . (2002). Diabetes in Canada, 2nd Edition. Ottawa: Health Canada
13 Statistics Canada. (1996-97, May 29). National Population Health Survey, Cycle 2. Canada: The Daily.
14 Creatore, M., Gozdyra, P., Booth, G., & Glazier, R. (2007). Chapter 1: Setting the Context. In M. Creatore, P. Gozdyra, G. Booth, R. Glazier, & M. Tynan, Neighbourhood Environments and Resources for Healthy Living - A Focus on Diabetes in Toronto: ICES Atlas. Toronto: Institute for Clinical Evaluative Sciences.
15 Op cit Dunn JR. The Health Determinants Partnership Making Connections Project
16 Raphael D. Addressing The Social Determinants of Health In Canada: Bridging The Gap Between Research Findings and Public Policy. Policy Options. March 2003 pp.35-40.
Elderly: The elderly population is generally less physically robust and more prone to chronic illnesses, which make them especially vulnerable to air pollution and heat exposure. Physical activity is an important aspect of daily life for this age group as it has been shown to reduce the negative health impacts of aging.11 Being physically active, however, requires accessible and safe streets, and transportation systems that cater to the needs of individuals with mobility issues. Special consideration is required when constructing the built environment to ensure the needs of this growing population.
Low Income Populations: Low income populations are at higher risk for chronic illnesses such as high blood pressure and diabetes, and have a lower overall survivability for major heart attacks.12,13 They are also more likely to smoke, be overweight or obese, and are less likely to be physically active.14 Many of these factors can be linked to limited access to stable housing, housing location (normally close to highways or industrial zones with high pollution exposure), neighbourhood safety, and lack of access to or affordability of healthy food options.
2. The CMA recommends that the federal government work with all sectors to create a culture within communities that supports and encourages active transportation and physical activity.
Hundreds of research papers have confirmed that people in the lowest socio-economic groups carry the greatest burden of illness.15 Studies also suggest that adverse socio-economic conditions in childhood can be a greater predictor of cardiovascular disease and diabetes in adults than later life circumstances and behavioural choices.16 Finally,
the countries reporting the highest population health status are those with the greatest income equality, not the greatest wealth.17
17 Hofrichter R ed. Tackling Health Inequities Through Public Health Practice: A Handbook for Action. The National Association of County and City Health Officials & The Ingham County Health Department. Lansing (USA); 2006.
18 Bierman AS, Angus J, Ahmad F, et al. Ontario Women’s Health Equity Report : Access to Health Care Services : Chapter 7. Toronto (ON) Project for and Ontario Women’s Health Evidence-Based Report; 2010.
19 Bierman AS, Johns A, Hyndman B, et al. Ontario Women’s Health Equity Report: Social Determinants of Health & Populations at Risk: Chapter 12. Toronto (ON) Project for and Ontario Women’s Health EvidenceBased Report; 2010.; Williamson DL, Stewart MJ, Hayward K. Low-income Canadians’ experiences with health-related services: Implications for health care reform. Health Policy 2006; 76:106-121.
20 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status for Males and Females. Ottawa(ON); 2010. Available: https://secure.cihi.ca/free_products/disparities_in_hospitalization_by_sex2010_e.pdf (accessed 2017 Jan 5)
21 Canadian Institute for Health Information. Hospitalization Disparities by Socio-Economic Status…;Roos LL, Walld R, Uhanova J, et al. Physician Visits, Hospitalizations, and Socioeconomic Status: Ambulatory Care Sensitive Conditions in a Canadian Setting. HSR 2005; 40(4): 1167-1185.
22 Canadian Medical Association. Policy resolution GC15-70 - Basic income guarantee. Approved August 26, 2015
Income plays a role in access to appropriate health care as well. Individuals living in lower income neighbourhoods, are less likely to have primary care physicians18, and are more likely to report unmet health care needs.19 They are more likely to be hospitalized for conditions which could potentially be avoided with appropriate primary care.20,21
In 2015, the CMA passed a resolution endorsing the concept of a basic income guarantee”22, which is a cash transfer from government to citizens not tied to labour market participation. It ensures sufficient income to meet basic needs and live with dignity, regardless of employment status. A basic income guarantee has the potential to alleviate or even eliminate poverty. It has the potential to reduce the substantial, long-term social consequences of poverty, including higher crime rates and fewer students achieving success in the educational system.
In addition, resources and supports are needed to assist low-income Canadians regarding diet, shelter, skills development and other needs..
3. The CMA urges the Government of Canada to prioritize consideration of a basic income guarantee as a policy option for reducing poverty.
Prenatal and Early Childhood
Research suggests that 90% of a child’s brain capacity is developed by age five.23 High quality early childhood programs including programs to nurture and stimulate children and educate parents are highly correlated with the amelioration of the effects of disadvantage on cognitive, emotional and physical development among children.24,25
23 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014.
24 Braveman P, Egerter D & Williams DR. The Social Determinants of Health: Coming of Age. Annu Rev Publ Health. 32:3.1-3.18. 2011.
25 European Union. Commission Recommendation of 20.2.2013: Investing in children: breaking the cycle of disadvantage. Brussels (Belgium); 2013.
26 Canadian Medical Association, Canadian Paediatric Society, College of Family Physicians of Canada. Child and Youth Health: Our Challenge: Canada’s Child and Youth Health Charter. Ottawa October 9, 2007.
In 2007, the Canadian Medical Association, the Canadian Paediatric Society and the College of Family Physicians of Canada released Canada’s Child and Youth Health Charter.26 To reach their potential, children and youth need to grow up in a place where they can thrive — spiritually, emotionally, mentally, physically and intellectually — and get high-quality health care when they need it. That place must have three fundamental elements: a safe and secure environment; good health and development; and a full range of health resources available to all. Children and youth of distinct populations in Canada, including First Nations, Inuit and Métis, must be offered equal opportunities as other Canadian children and youth through culturally appropriate resources.
Our children and youth must have a safe and secure environment where they can access clean water, air and soil; be protected from injury, exploitation and discrimination; and live in healthy family, homes and communities. Further, to ensure good health and development there must be access to prenatal and maternal care for the best possible health at birth and access to quality nutrition for proper growth, development and long-term health.
As well, early learning opportunities and high-quality care, at home and in the community must be accessible. Opportunities and encouragement for physical activity are crucial as well as access to high-quality primary and secondary education. Finally, affordable and available post-secondary education and a commitment to social well-being and mental health are paramount.
4. The CMA recommends that the federal government and the provinces and territories work to ensure that poverty does not continue to be a barrier to the healthy development of Canadian children, particularly in their first five years.
Socio-economic factors play a larger role in creating (or damaging) health than either biological factors or the health care system. Health equity is increasingly recognized as a necessary means by which we will make gains in the health status of all Canadians. Despite a commitment to equal access to health care for all Canadians there are differences in access and quality of care for many groups. For those that are most vulnerable, this lack of access can serve to further exacerbate their already increased burden of illness and disease. Action is still required by the federal government to tackle the underlying social and economic factors which lead to the disparities in the health of Canadians.
With the advent of technology allowing for the extension of life, and as a result of the increasing importance of personal autonomy, decisional capacity, and informed consent and the growing awareness of issues related to quality of life and dying, Canadians have become increasingly interested in expressing their wishes regarding their health care and having more input into decisions about their care should they become incapable. Advance care planning (ACP) can help patients to achieve these goals.
The CMA supports development of a strategy for ACP1 in all provinces and territories. ACP leads to better concordance between patients' wishes and treatments provided,2,3 decreased anxiety for families,4 decreased moral distress for health care providers,5 decreased hospitalization rates of nursing home residents3 and fewer unnecessary medical treatments.3,6,7
ACP is at the intersection of the provision of health care, ethical values and legal rights and duties. In particular, it involves the acknowledgement of essential aspects of autonomy, informed consent, and respect of patients' care wishes now and in the future, and their intentions if they become incapable.8,9
The balancing of the need to obtain informed consent for a treatment option in the present with the need to respect health care preferences that were stated in the past has been addressed using various clinical, legal and institutional approaches across Canadian jurisdictions."
Physicians10 can play a significant role in ACP throughout the course of the patient-physician relationship, including in the pediatric setting. At any time, outcomes of the planning process can be documented and/or the patient can appoint a substitute decision-maker in writing. These documents can be identified as advance directives, personal directives or powers of attorney for personal care11 (hereinafter all will be referred to as advance directives). An advance directive does not remove the need for a physician to obtain consent before providing a treatment to a patient, except in an emergency. As stated in the Canadian Medical Protective Association's consent guide: "[U]nder medical emergency situations, treatments should be limited to those necessary to prevent prolonged suffering or to deal with imminent threats to life, limb or health. Even when unable to communicate in medical emergency situations, the known wishes of the patient must be respected."12
While much of the focus of ACP is on making care decisions and nominating proxy decision-makers in case the patient becomes incapable of making decisions in the future, ACP has much more utility. ACP conversations13 can assist patients in determining treatment trajectories and making decisions about the intensity level of interventions in their current care. Providers can have discussions with patients and their families about proposed treatments in the context of the patient's communicated goals and wishes. The process of ACP also helps patients and their families to become familiar with the language and processes used to make cooperative health care decisions.
SCOPE OF POLICY
This policy aims to provide guidance on key considerations pertinent to ACP in a way that is consistent with a physician's ethical, professional and legal obligations. This is a complex subject: physicians should be aware of the legislation in the jurisdiction in which they practise, the standards and expectations specified by their respective regulatory authority, as well as the policies and procedures of the setting(s) in which they practise (e.g., regional health authority, hospital).
1. ACP is a process of (a) respecting patients' wishes through reflection and communication, (b) planning for when the patient cannot make health care decisions and (c) discussion with friends, family and professionals; (d) it may result in a written document.5 It informs the substitute decision-maker and provides information for the clinician to consider in the provision of care within the bounds of the law.
2. Although often associated with the end of life, ACP represents the expression of a patient's wishes for any future health care when the patient is incapable. It expresses the patient's values and beliefs regarding current care decisions and provides information that can inform any decisions that must be made during an emergency when the patient's consent cannot be obtained. For these reasons, ACP should occur throughout a person's lifetime.
3. Respect for patients' dignity and autonomy is a cornerstone of the therapeutic physician-patient relationship. Patients' right to autonomous decision-making has become embedded in ethical frameworks, consent legislation and case law.14 Respect for the wishes of an incapable patient constitutes a preservation of autonomy and promotes trust between the physician and patient.15
4. The way in which the act of obtaining consent is weighed against the patient's stated wishes as outlined during the ACP process varies according to the jurisdiction in which the patient and physician are located.
1. Given the practical, ethical and legal complexities of ACP, physicians, medical learners should be supported in becoming familiar with ACP and comfortable in engaging in the process with their patients. To this end, CMA supports the development of training in ACP and efforts to make it available to all physicians and medical learners.16 For practising physicians and residents, many resources are available, for example:
a. Advance Care Planning in Canada: A National Framework
b. Facilitating Advance Care Planning: An Interprofessional Educational Program
c. Information from the Health Law Institute of Dalhousie University on the regulatory policies and legislation of individual provinces and territories
d. A comprehensive collection of Canadian resources compiled by the Speak Up campaign of the Advance Care Planning in Canada initiative
e. Pallium Canada's Learning Essential Approaches to Palliative Care module on ACP
In the case of medical students, the CMA supports the position of the Canadian Federation of Medical Students that end-of-life training is an essential facet of undergraduate medical education.
2. The issue of the supervision of medical learners practising ACP should be clarified, as considerable ambiguity currently exists.17 Medical learners would benefit from unified national guidelines concerning the nature of their participation in ACP, especially regarding end-of-life care. In the case of medical students, the CMA agrees with the recommendation of the Canadian Federation of Medical Students that supervision be mandatory during conversations about end-of-life care.
3. The CMA calls for more research on the outcomes associated with the provision of ACP training to physicians and medical learners.
4. The CMA recommends that governments and institutions promote information and education on ACP to patients and their substitute decision-makers.
PROFESSIONAL AND LEGAL RESPONSIBILITY
1. While respecting patients' values, all physicians are expected to encourage their patients to engage in ACP with them. ACP is not a one-time event. The nature of the conversation between the physician and the patient and the regularity with which they discuss the subject will depend on the patient's health status. Family physicians and physicians have ongoing care relationships with chronically ill patients are particularly well placed to have regular discussions with their patients about their beliefs, values and wishes. An effective exchange of information between family physicians (and other physicians who work in the community with outpatients) and acute or tertiary care physicians would assist in ensuring patient's wishes are considered.
2. ACP, in particular advance directives, are at the intersection of medicine and the law. Physicians should recognize this and ask patients whether they have an advance directive or have done any ACP.
3. There is wide variation across jurisdictions in terms of the requirements and procedures for ACP; therefore, physicians should inform themselves about any relevant legislation and the scope of the requirement to obtain consent within that jurisdiction when carrying out ACP.
1. The CMA supports institutional processes that recognize and support ACP. Support for ACP includes developing a consistent process for the exchange of information about patients' wishes and advance directives among health care providers, as patients traverse sectors and locations of care. Patients with a written advance directive must be identified and the advance directive integrated fully within the patient's records18 so that it is available across the institution (and ideally the health care system). The CMA advocates for the inclusion of advance care directive functionality as a conformance and usability requirement for electronic medical record vendors.19 Provinces and territories should be encouraged to establish robust organizational processes and resources for patients in all locations of care and strong province- or territory-wide policy, such as in Alberta.20
2. Institutions and other organizations should encourage health care providers to ask patients to bring their advance directive to appointments at the same time they ask them to bring a list of their medications or other medical information.
3. The CMA supports institutional/organizational audits of structures, processes and outcomes related to ACP as an important step in improving the quality and frequency of ACP activities.
ROLE FOR GOVERNMENTS
1. The CMA supports infrastructures enabling ACP, including funding that will support ACP and other end-of-life discussions.
2. The CMA promotes the incorporation of ACP into future federal and provincial/territorial senior strategies and dementia and/or frailty strategies.
3. The CMA supports the development of ACP metrics and their future inclusion in Accreditation Canada standards.
Advance care planning (ACP)
Advance care planning is a term used to describe a process of reflection, communication, conversation and planning by a capable individual with family, friends and professionals about their beliefs, values and wishes for a time when they no longer have the mental capacity to make decisions about their health care. ACP can also involve the naming of a substitute decision-maker.8
The legislated term "advance directive" has different names, definitions and legal authority across the country. For example, in British Columbia an advance directive is a written legal document that provides a mechanism for capable patients to give directions about their future health care once they are no longer capable. 21 As such, in BC an advance directive may, under certain circumstances, be considered "equivalent to consent to treatment and may be acted upon directly by a health care provider without consultation with an SDM [substitute decision-maker]." 8 In Alberta it is called a personal directive. In Ontario, "advance directive" is a generic non-legal term and refers to communications that may be oral, written or in other forms.8
In Quebec, advance care directives are legally binding, as set out in the Act respecting end-of-life care, which recognizes "the primacy of freely and clearly expressed wishes with respect to care. . ."22
Current legislation does not allow for medical assistance in dying to be requested by an advance directive.23 The CMA acknowledges that considerable public, expert and legal debate exists around the issue.
To obtain informed consent, physicians must provide adequate information to the patient or capable decision-maker about the proposed procedure or treatment; the anticipated outcome; the potential risks, benefits and complications; and reasonable available alternatives, including not having the treatment; and they must answer questions posed by the patient. Consent is only informed if there is disclosure of matters that a reasonable person in the same circumstances would want to know.24 Consent must be given voluntarily, must not be obtained through misrepresentation or fraud, must relate to the treatment and must be informed.
Substitute decision-maker (SDM or agent or proxy)
A substitute decision-maker is a capable person who will make health care decisions on behalf of an incapable individual. In all jurisdictions the health care provider must take reasonable steps to become aware of whether or not there is a substitute decision-maker before providing health treatment to an incapable patient. Legally there are implementation differences across the country. For example, in BC a substitute decision-maker is appointed through a representation agreement, in Alberta through a personal directive and in Ontario through a power of attorney for personal care.
Approved by the CMA Board of Directors May 2017
1 Canadian Medical Association. Policy resolution GC14-25 - strategy for advance care planning, palliative and end-of-life care. Ottawa (ON): The Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 Oct 17)
2 Houben CHM, Spruit MA, Groenen MTJ, et al. Efficacy of advance care planning: a systematic review and meta-analysis. J Am Med Dir Assoc 2014;15:477-89.
3 Martin RS, Hayes B, Gregorevic K, et al. The effects of advance care planning interventions on nursing home residents: a systematic review. J Am Med Dir Assoc 2016;7:284-93.
4 Mack JW, Weeks JC, Wright AA, et al. End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol 2010;28(7):1203-8.
5 Canadian Hospice Palliative Care Association. Advance care planning in Canada: national framework. Ottawa; The Association; 2010.
6 Teo WSK, Raj AG, Tan WS, et al. Economic impact analysis of an end-of-life programme for nursing home residents. Palliat Med 2014;28(5):430-7.
7 Zhang B, Wright AA, Huskamp HA, et al. Health care costs in the last week of life: associations with end-of-life conversations. Arch Intern Med 2009;169(5):480-8.
8 Wahl J, Dykeman MJ, Gray B. Health care consent and advance care planning in Ontario. Toronto (ON): Law Commission of Ontario; 2014.
9 Canadian Medical Association. CMA Code of Ethics (update 2004). Ottawa: The Association; 2004.
10 Physician involvement is not mandatory in the process. However, it is important for physicians to engage with their patients in ACP as this can facilitate change in patients' ACP behaviour and understanding.
11 Wahl JA, Dykeman MJ, Walton T. Health care consent, advance care planning, and goals of care practice tools: the challenge to get it right. Improving the last stages of life. Toronto (ON): Law Commission of Ontario; 2016.
13 Frank C, Puxty J. Facilitating effective end-of-life communication - helping people decide. CJS Journal of CME 2016;6(2). Available: http://canadiangeriatrics.ca/wp-content/uploads/2017/02/Facilitating-Effective-End-of-Life-Communication---Helping-People-Decide.pdf (accessed 2017 April 25).
14 Fleming v Reid (1991) 82 DLR (4th) 298 (CA ON); Cuthbertson v Rasouli, 2013 SCC 53; Malette v Shulman (1990), 72 OR (2d) 417; Starson v Swayze (2003) 1 SCR 722.
15 Harmon SHE. Consent and conflict in medico-legal decision-making at the end of life: a critical issue in the Canadian context. University of New Brunswick Law Journal 2010;60(1):208-29.
16 Canadian Medical Association. Policy resolution GC13-69 - training in advance care planning. Ottawa (ON): The Association; 2013. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 May 26).
17 Touchie C, De Champlain A, Pugh D, et al. Supervising incoming first-year residents: faculty expectations versus residents' experiences. Med Educ 2014;48(9):921-9.
18 Canadian Medical Association. Policy resolution GC14-19 - advance care plans. Ottawa (ON): The Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 May 26).
19 Canadian Medical Association. BD14-05-163 Advance care directive functionality. Ottawa (ON): The Association; 2014. Available: policybase.cma.ca/dbtw-wpd/CMAPolicy/PublicB.htm (accessed 2016 May 26).
20 Conversations matter. Edmonton (AB): Alberta Health Services. Available: http://goals.conversationsmatter.ca.s3-website-us-east-1.amazonaws.com/ (accessed 2017 May 19).
21 Health Care (Consent) and Care Facility (Admission) Act, RSBC 1996, c 181, s.3
22 Act respecting end-of-life care, S-32.0001. Government of Quebec. Available : http://legisquebec.gouv.qc.ca/en/ShowDoc/cs/S-32.0001
23 An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) S.C. 2016, c.3. Ottawa: Government of Canada; 2016. Available: http://canlii.ca/t/52rs0 (accessed 2016 Oct 17)
24 Riebl v Hughes,  2 SCR 880; Hopp v Lepp,  2 SCR 192.
The Canadian Medical Association (CMA) is pleased to submit this brief to the Senate Standing Committee on Social Affairs, Science and Technology in support of Bill S-228, An Act to Amend the Food and Drugs Act (prohibiting food and beverage marketing directed at children). The CMA has over 85,000 physician-members; our mission is empowering and caring for patients and its vision is a vibrant profession and a healthy population.
The CMA is encouraged that the Senate is considering legislation that will protect children by prohibiting marketing of food and beverages directed to those under 13 years of age. We applaud Senator Nancy Greene Raine for sponsoring this important bill.
Obesity rates among children and youth in Canada have nearly tripled in the last 30 years. Obesity is of particular concern to Canada’s physicians because it increases a person’s risk of developing a number of serious health problems: high blood pressure, high blood cholesterol, heart disease and stroke, type 2 diabetes, osteoarthritis, lower back pain and other musculoskeletal disorders, and many types of cancer. Type 2 diabetes, once found only in adults, is now being seen in children.
Health advocates are concerned that because of obesity, today’s generation of children will have a shorter life expectancy than their parents. Children and youth who are obese are at higher risk of developing a range of health problems, and weight issues in childhood are likely to persist into adulthood. Diet-related chronic disease risk stems from long-term dietary patterns which start in childhood. Canadian statistics reveal children, consume too much fat, sodium and sugars (foods that cause chronic disease) and eat too little fiber, fruits and vegetables (foods that prevent chronic disease). The current generation of Canadian children is expected to live shorter less healthy lives as a result of unhealthy eating.1
CMA’s Cautions against Marketing
Children and youth in Canada are exposed to a barrage of marketing and promotion of unhealthy foods and beverages through a variety of channels and techniques – tactics which undermine and contradict government, health care professional and scientific recommendations for healthy eating. Research undertaken for the Heart and Stroke Foundation found that kids see over 25 million food and beverage ads a year on their favourite websites and that over 90% of the food and beverage product ads viewed online are unhealthy.2
Unhealthy food and beverage advertising influences children’s food preferences, purchase requests, and consumption patterns and has been identified as a probable cause of childhood overweight and obesity by the World Health Organization.3
The CMA has long been calling on governments to explore ways to restrict the advertising and promotion of high-calorie, nutrient-poor foods. In 2006 CMA recommended that media advertising of high-calorie, nutrient-poor "junk" food in children's television programs be banned altogether. As the ways and means of advertising have expanded so too has our thinking, and in 2012 CMA adopted a policy on Restricting Marketing of Unhealthy Foods and Beverages to Children and Youth in Canada which called for the restriction of all marketing to children under 13 years of age of unhealthy foods and beverages. In 2014, CMA endorsed the Ottawa Principles and the Stop Marketing to Kids Coalition. The Ottawa Principles went further to help refine the definitions, scope and principles meant to guide marketing to kids (M2K) policy-making in Canada.4 They recommend the restriction of commercial marketing of all food and beverages to children and youth age 16 years and younger. Restrictions would include all forms of marketing with the exception of non-commercial marketing for public education.
At present, Canada relies on voluntary industry codes to govern advertising and marketing practices. However, recent Canadian research into industry self-regulation has shown no reduction in children’s exposure to ads for unhealthy foods.5 The CMA believes that for maximum efficacy, regulatory measures are required to minimize the negative effect of food marketing on health. Only legally enforceable regulations have sufficient authority and power to ensure high-level protection of children from marketing and its persuasive influence over food preference and consumption.
Not only health organizations are in favour of restrictions on the marketing to children. Recent public opinion polling from Heart and Stroke’s 2017 Report on the Health of Canadians highlights that 72% believe the food and beverage industry markets its products directly to children, 78% believe the food and beverages advertised to children are unhealthy and 70% feel that children are exposed to too much advertising by the food and beverage industry.
In her introduction of Bill S-228, Senator Raine noted that this is not the first time that that legislation on this issue has come before the Canadian Parliament. The CMA sincerely believes that now is the time for action. We cannot delay any longer. Canadian children and parents need an environment free from the influence of food and beverage marketing in which to make health nutritious food choices.
Childhood obesity and overweight are serious health problems in Canada, and as such are of great concern to the country’s physicians and to the Canadian Medical Association. The causes, CMA believes, are rooted mainly in changes in our environment and their effect on our eating and physical activity habits. The consequences are extremely serious, both for individual Canadians’ health and for the sustainability of Canada’s health care system.
CMA believes that the way forward requires a number of different interventions, on many levels. The prohibition of the marketing of foods and beverages directed to children is one element of a wider healthy eating strategy that supports Canadians.
Once again, CMA commends the Senate of Canada on conducting this study. We urge support of the Child Health Protection Act and believe that it can assist in creating a social environment that supports healthy eating and healthy weight.
1 Canadian Medical Association, Restricting Marketing Of Unhealthy Foods And Beverages To Children And Youth In Canada, A Canadian Health Care And Scientific Organization Consensus Policy Statement, December 2012
2 Heart & Stroke (2017). The kids are not alright. How the food and beverage industry is marketing our children and youth to death. 2017 Report on the Health of Canadians.
3 World Health Organization. Set of recommendations on the marketing of foods and non-alcoholic beverages to children. Geneva: World Health Organization, 2010.
4 The Ottawa Principles, Stop Marketing to Kids Coalition, accessed at https://foodsecurecanada.org/sites/foodsecurecanada.org/files/ottawaprinciples.pdf, June 7, 2017.
5 Heart & Stroke (2017). The kids are not alright. How the food and beverage industry is marketing our children and youth to death. 2017 Report on the Health of Canadians.