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Position statement on bodychecking in youth ice hockey

https://policybase.cma.ca/en/permalink/policy10758
Last Reviewed
2020-02-29
Date
2013-05-25
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Last Reviewed
2020-02-29
Date
2013-05-25
Topics
Population health/ health equity/ public health
Text
Hockey is one of the most popular sports for Canadian children and youth. While the health benefits of physical activity and sport participation are well recognized, there is increasing concern around the frequency and severity of hockey-related injuries, particularly concussion. Studies consistently identify bodychecking as the primary mechanism associated with youth hockey injuries, including concussion. Policy to delay bodychecking until bantam league play (when participants are 13 to 14 years of age) will reduce the risks of injury and concussion in young ice hockey players. Bodychecking should be eliminated from non-elite youth ice hockey. The age at which bodychecking is introduced in competitive hockey leagues must be reconsidered. Both initiatives require policy change in many provinces/territories, and must be re-evaluated prospectively in light of emerging research. More than 4.5 million Canadians are involved in ice hockey, as coaches, officials, administrators or direct volunteers, and hockey is the most popular winter sport among Canadian children and youth.[1] Hockey Canada reported over 550,000 registered players under the age of 19 in 2008, and participation rates are increasing, especially among girls and young women.[1] While the health benefits of physical activity and sport participation are well recognized, there is increasing concern around the frequency and severity of hockey-related injuries in youth, particularly concussion. The American Academy of Pediatrics (AAP) classifies hockey as a collision sport because of unintentional and intentional body contact, including bodychecking.[2] The AAP published a policy statement on youth ice hockey in 2000, recommending that bodychecking not be allowed for children younger than 15 years of age.[3] There is passionate debate about the risk factors for injury in youth hockey and the relative merits of early or later introduction of bodychecking. Because bodychecking is not allowed in girls' or women's hockey in Canada, the present statement pertains to play in boys' and men's hockey leagues. It reviews the scientific literature on bodychecking injuries, outlines positions in the current debate and makes recommendations on when bodychecking should be introduced into the game. DEFINING BODY CONTACT AND BODYCHECKING Body contact is an individual defensive tactic designed to legally block or impede the progress of an offensive puck carrier. The defensive player moves to restrict action by the puck carrier anywhere on the ice, by skating, angling and positioning. The defensive player cannot hit the offensive player by travelling in an opposite direction to him or by physically extending toward him in an effort to initiate contact. There must be no action where the puck carrier is pushed, hit or shoved into the boards. In contrast, bodychecking is an individual defensive tactic designed to legally separate the puck carrier from the puck. The defensive player physically extends his body toward the puck carrier while moving in an opposite or parallel direction, a deliberate and forceful move not solely determined by the movement of the puck carrier.[1] Bodychecking is taught based on a four-step skill development program outlined by Hockey Canada, with progression through positioning and angling, stick checking, body contact and bodychecking skills.[4] Instruction in bodychecking includes techniques for receiving bodychecks, adhering to rules, and safe play. BODYCHECKING LEGISLATION Hockey Canada groups children and adolescents by age into six play levels: initiation (5 to 6 years of age), novice (7 to 8 years), atom (9 to 10 years), peewee (11 to 12 years), bantam (13 to 14 years), and midget (15 to 17 years). Historically, from the early 1980s until the 2002/2003 season, bodychecking was introduced at age 12 years in Canadian boys' ice hockey. In 2003, four of 13 provincial/territorial branches allowed checking for players as young as nine years old. Hockey Canada mandated the introduction of bodychecking in peewee leagues (ages 11 to 12) in 2009. Quebec has delayed bodychecking until bantam (age 14 from 1978 to 2002, then age 13 following an age change mandated nationally). THE DEBATE Despite lack of evidence, proponents of bodychecking argue that it is a fundamental skill which, learned early, may prevent future injuries. However, the evidence supports that bodychecking is the most common mechanism of injury. The Canadian Academy of Sports Medicine recommends that bodychecking be introduced only in boys' competitive hockey, and no earlier than the bantam (ages 13 to14) or midget (ages 15 to 17) level.[5] The AAP recommends a ban on bodychecking for male players younger than 15 years of age.[3] The present statement marks the first CPS position on this issue. BODYCHECKING AND INJURY Hockey is recognized as a high-risk sport. The speed of play, body contact and bodychecking all contribute to injury risk.[6][7] The injury rate is also high, with Canadian data suggesting that hockey injuries account for 8% to 11% of all adolescent sport-related injuries.[8][10] Unfortunately, serious injuries such as concussion, other brain injuries and spinal cord trauma are not uncommon in hockey.[6][11] The incidence of traumatic brain injury appears to be rising.[12][13] Ice hockey-related fatality rates are double those reported in American football, and catastrophic spinal cord and brain injury rates are almost four times higher for high school hockey players than for high school and college football players.[14][15] Bodychecking is the predominant mechanism of injury among youth hockey players at all levels of competition where it is permitted, accounting for 45% to 86% of injuries.[8][16]-[18] Several published studies, including two recent systematic reviews, reported on risk factors for injury (including bodychecking) in youth hockey.[19][20] Emery and colleagues conducted a systematic review of 24 studies and a meta-analysis including only studies which examined policy allowing bodychecking as a risk factor for injury. Policy allowing bodychecking was found to be a risk factor for all hockey injuries, with a summary incidence rate ratio (IRR) of 2.45 (95% CI 1.7 to 3.6). Furthermore, policy allowing bodychecking was found to be a risk factor for concussion, with a summary OR of 1.71 (95% CI 1.2 to 2.44). These data confirm that bodychecking increases the risk of all injuries and the risk of concussion specifically.[20] Nine of ten studies examining policy allowing bodychecking provided evidence to support a greater risk in bodychecking leagues.[20] The second systematic review found the RR of injury associated with policy allowing bodychecking ranged from 0.6 to 39.8; all but one of these studies found an increased risk of injuries associated with bodychecking.[19] Since the publication of these systematic reviews there have been five additional studies. A Canadian prospective cohort study compared injury rates between peewee ice hockey players in a league where bodychecking is permitted at age 11 years (Alberta) versus players in a league where bodychecking is not permitted until age 13 (Quebec).[21] During the 2007/2008 season, a validated injury surveillance system was used to capture all injuries requiring medical attention and/or time loss from hockey (ie, time between injury and return to play) in 2154 players. There was a threefold increased risk of all game-related injuries (IRR =3.26 [95% CI; 2.31 to 4.60]) and of injury resulting in >7 days time lost from sport (IRR=3.30 [95% CI; 1.77 to 6.17]) in 11- to 12- year-old peewee players from Alberta when compared with Quebec. There was also an almost fourfold increased risk of game-related concussion (IRR=3.88 [95% CI; 1.91 to 7.89]) in Alberta peewee players.[21] Further evidence was reported in a five-year cohort study (2002 to 2007) including all age groups, which demonstrated that injury risk increases 3.75 times (IRR=3.75 [95% CI; 1.51 to 9.74]) in leagues that allow bodychecking compared with those that do not.[22] A second prospective cohort study by Emery et al examined whether the introduction of bodychecking at 11 years of age (Alberta) or 13 years of age (Quebec) affected injury rates in later years (at 13 to 14 years of age).[23] During the 2008/09 season, the same injury surveillance system cited above was used to study 1971 bantam players (13- to 14-year-olds). There was no reduction in game-related injury risk (all injuries) for this age group (IRR=0.85 [95% CI 0.63 to 1.16]), of concussion specifically (IRR=0.84 [95% CI 0.48 to 1.48]), or of concussions resulting in >10 days time lost from sport (IRR=0.6 [95% CI 0.26 to 1.41]) in the Alberta league, compared with Quebec. In fact, the concussion rate found in Alberta peewee players was higher than in bantam players in either province.[22][23] Injuries to bantam players resulting in >7 days time lost from sport were reduced by 33% (IRR=0.67 [95% CI 0.46 to 0.99]) in the Alberta league, where players had had two years of bodychecking experience. However, these findings must be interpreted in light of the three- to fourfold greater injury and concussion risk among peewee players in Alberta, along with a possibly higher 'survival effect' among peewee players moving on to bantam in Quebec when compared with Alberta, where bodychecking is allowed in peewee league play. Recent retrospective studies have examined the influence of policy change based on the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) surveillance data. Injury rates among boys presenting to emergency departments in the Kingston, Ontario area both before and after the 2002 rule change to allow bodychecking in younger players, were reported. There was no change between bodychecking injury rates in 1997 to 2002 (with bodychecking introduced at 11 years of age) and 2003 to 2007 (when bodychecking was introduced at nine years of age).[24] Overall rates of injury actually declined over the later period.[24] However, this retrospective study may also be biased by stronger rule enforcement, better coaching certification and temporal declines in emergency department use for this type of injury over that period. In contrast, retrospective research of CHIRPP data from 1994 to 2004 in five Ontario hospitals examined injury risk following a rule change in 1998 that allowed bodychecking in nine- and 10-year-old hockey players. A 2.2 times greater risk of injury in atom players (9 and 10 years of age) after the rule change was reported (OR=2.2 [95% CI 1.7 to 2.84]).[25] Another retrospective study using CHIRPP data (from 1995 to 2002) compared hockey injuries in children 10 to 13 years of age playing in Ontario, where bodychecking was allowed, with data from Quebec, where bodychecking was not allowed. There was a 2.6 times greater risk of bodycheck-related injuries reported for this age group when bodychecking was allowed (OR=2.65 [95% CI 2.21 to 3.18]).[26] OTHER RISK FACTORS After policy that permits bodychecking, the most commonly investigated risk factors for injury in the scientific literature are: age, session-type (ie, a practice versus a game), level of play, player position, physical size, and a previous history of injury and/or concussion. Most studies examining age found that injury risk increased with age;[8][20][27][29] others suggest no elevated injury risk in older age groups.[30]-[33] Relative age has been examined to "describe the potential advantages (or disadvantages) that result from age differences between peers within one age group".[31] One study examining relative age among hockey players found no evidence that younger (or older) players within a grouping were at elevated injury risk.[31] Additional research supports this finding at the peewee level, where no increased risk was found in first-year players. In bantam leagues, however, there was a 40% greater risk of injury in first-year players when compared with players in their second year.[21][23] Based on session-type, injury risk is reported to be consistently higher in games than in practices, with RR estimates ranging from 2.45 to 6.32.[16][18][27][34] One study also indicated that injury rates were higher in regular season play than during preseason, postseason or tournament games.[30] In general, studies examining level of play have found that injury risks rise with increasing skill levels across all age groups.[31][35][36] However, one study reported that only peewee players in the highest skill division were at the greatest risk of injury, with no significant increase by skill level in other age groups.[8] Larger cohort studies confirmed a consistently greater risk of injury among peewee players who were more highly skilled, but this trend was not observed in the bantam age group.[21][23] When examining player position, some researchers found that forwards were at higher risk of injury than defencemen or goalies, [30][32] while others reported the relative risk of injury was 2.18 times higher for defencemen than forwards.[27] In all three studies, goalies were shown to be at much lower risk than other players. Additional research shows a consistent protective effect for goalies at both the peewee and bantam levels.[21][23] Research on player size has shown conflicting results, with some studies citing increased risk for smaller players in some age groups. Prospective Canadian data show a significantly greater risk of injury in peewee players in the lowest 25th percentile by weight, [21] though this finding was not reflected in the bantam cohort.[23] However, additional research has found lighter bantam players to be at greater risk, while other studies report a significant weight difference, at all levels, between players who sustained a bodychecking-related injury and those who did not.[16][30] Other research examining body weight as a risk factor for shoulder injuries found that heavier players were at greater risk for these injuries.[37] One study looked at height as a possible risk factor for injury and found no evidence of effect among bantam players.[16] By contrast, a history of previous injury or concussion is consistently reported as a significant risk factor for reinjury and further concussion, respectively.[20] One recent Canadian peewee cohort study showed that the risk of injury doubled for players who reported being injured within the past year (IRR=2.07 [95% CI 1.49 to 2.86]), while the risk of concussion tripled for players reporting any previous concussion (2.76 [95% CI 1.1 to 6.91]).[21] The bantam cohort also showed greater risk of reinjury and concussion in players reporting previous injury within the past year (IRR=1.39 [95% CI 1.13 to 1.71]) or any previous concussion (IRR=1.87 [95% CI 1.19 to 2.94]), respectively.[21] INJURY PREVENTION AND RISK REDUCTION Injury prevention and risk reduction programs have been implemented but have not been evaluated rigorously. The STOP (Safety Towards Other Players) program (www.safetytowardsotherplayers.com) is supported by the Ontario Minor Hockey Association (www.omha.net), and includes an education component and the "STOP patch", which is sewn on the back of players' uniforms to remind opponents not to hit from behind. A study evaluating another injury prevention program, "Fair Play", which awards points for sportsmanlike play (based on penalty minutes), suggests an approximate 60% reduction in the risk of injury (OR=0.41 [95% CI 0.11 to 1.47]) where the program is in effect, but the results were not statistically significant.[38] EDUCATION Players, parents, coaches, officials and trainers must be mindful of the potential risks of playing hockey. Hockey Canada has player development, coaching, education and safety promotion programs and resources for coaches, officials, players and parents at www.hockeycanada.ca. Concussion awareness is vital. Athletes and all those involved in their care need to know about the risks, symptoms/signs and how to manage concussive injuries. The CPS statement on concussion evaluation and management is essential reading [39], with additional information available from the Canadian Academy of Sport and Exercise Medicine (www.casm-acms.org), ThinkFirst Canada (www.thinkfirst.ca) and the US Centers of Disease Control and Prevention (www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm). CONCLUSION Studies consistently identify bodychecking as the primary mechanism of hockey-related injuries, including concussion. It is expected that delaying the introduction of bodychecking until the bantam level and restricting bodychecking to elite leagues for older age groups will reduce the risks of injury and concussion substantially. Delaying bodychecking until bantam will have a clear benefit in reducing the risks of injury and concussion in young ice hockey players. Bodychecking should be eliminated from recreational youth ice hockey and the age at which it is introduced in competitive hockey leagues should be reconsidered. Both initiatives require policy change in many provinces/territories in Canada, and policy changes will need to be evaluated on a regular basis in light of emerging research. RECOMMENDATIONS The Canadian Paediatric Society recommends the following: * Eliminating bodychecking from all levels of organized recreational/non-elite competitive male ice hockey. (Grade II-2A evidence) * * Delaying the introduction of bodychecking in elite male competitive leagues until players are 13 to 14 years of age (bantam level) or older. (Grade III-C evidence)* * Implementing Hockey Canada's four-stage skill development program for bodychecking (body positioning, angling, stick checking and body contact) for all leagues. * Educating coaches and trainers, schools, and policy-makers in sport about the signs and symptoms of common hockey injuries, especially concussion. * Improving injury surveillance to better identify the risk factors for, and mechanisms of, hockey injuries. * Policies to reduce injury and promote fair play in hockey, for all age groups and league levels. Clinicians who see young hockey players in their practice should offer the following advice: * Girls and young women should continue participating in non-bodychecking leagues. * Boys should play in recreational/non-elite hockey leagues that do not allow bodychecking. * Elite male players should play in hockey leagues that introduce bodychecking later, when players are 13 to 14 years of age (bantam level) or older. * All players should adhere to fair play and a non-violent sport culture. * Parents and caregivers should learn injury prevention and risk reduction strategies, including concussion prevention, recognition and management. *The levels of evidence and strength of recommendations are based on the Canadian Task Force on Preventive Health Care (See Table 1). [40][41] TABLE 1: [SEE PDF] Levels of evidence and strength of recommendations Level of evidence Description I Evidence obtained from at least one properly randomized controlled trial. II-1 Evidence obtained from well-designed controlled trial without randomization. II-2 Evidence obtained from well-designed cohort or case-controlled analytical studies, preferably from more than one centre or research group. II-3 Evidence obtained from comparisons between times and places, with or without the intervention. Dramatic results in uncontrolled experiments could also be included in this category. III Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees. Grade Description A There is good evidence to recommend the clinical preventive action. B There is fair evidence to recommend the clinical preventive action. C The existing evidence is conflicting and does not allow a recommendation to be made for or against use of the clinical preventive action; however, other factors may influence decision-making. D There is fair evidence to recommend against the clinical preventive action. E There is good evidence to recommend against the clinical preventive action. F There is insufficient evidence to make a recommendation; however, other factors may influence decision-making. ACKNOWLEDGEMENTS This statement was reviewed by the Community Paediatrics and Injury Prevention Committees of the Canadian Paediatric Society. Thanks to Drs. Claire MA LeBlanc, Stan Lipnowski, Peter Nieman, Christina G Templeton and Thomas J Warshawski for their input as past members of the CPS Healthy Active Living and Sports Medicine Committee. HEALTHY ACTIVE LIVING AND SPORTS MEDICINE COMMITTEE Members: Catherine Birken MD; Tracey L Bridger MD (Chair); Mark E Feldman MD (Board Representative); Kristin M Houghton MD; Michelle Jackman MD; John F Philpott MD Liaison: Laura K Purcell MD, CPS Paediatric Sports and Exercise Medicine Section Principal authors: Kristin M Houghton MD; Carolyn A Emery PT PhD May 2013 REFERENCES 1. Hockey Canada, Annual report 2008: www.hockeycanada.ca/index.php/ci_id/55192/la_id/1.htm (Accessed July 4, 2012). 2. Rice SG; American Academy of Pediatrics, Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics 2008;121(4):841-8. 3. American Academy of Pediatrics, Committee on Sports Medicine and Fitness. Safety in youth ice hockey: The effects of body checking. Pediatrics 2000;105(3 Pt 1):657-8. 4. Hockey Canada. Teaching checking: A progressive approach. 2002: www.omha.net/admin/downloads/Teaching%20Checking.pdf (Accessed July 4, 2012). 5. Canadian Academy of Sport Medicine. Position Statement: Violence and injuries in ice hockey. 1988. www.casm-acms.org/forms/statements/HockeyViolEng.pdf (Accessed July 4, 2012). 6. Emery CA, Risk factors for injury in child and adolescent sport: A systematic review of the literature. Clin J Sport Med 2003;13(4):256-68. 7. Caine D, Caine C, Maffulli N. Incidence and distribution of pediatric sport-related injuries. Clin J Sport Med 2006;16(6):500-13. 8. Emery CA, Meeuwisse WH. Injury rates, risk factors, and mechanisms of injury in minor hockey [comment]. Am J Sports Med 2006;34(12):1960-9. 9. Emery CA, Meeuwisse WH, McAllister JR. Survey of sport participation and sport injury in Calgary and area high schools. Clin J Sport Med 2006;16(1):20-6. 10. Emery C, Tyreman H. Sport participation, sport injury, risk factors and sport safety practices in Calgary and area junior high schools. Paediatr Child Health 2009;14(7):439-44. 11. Tator CH, Carson JD, Cushman R. Hockey injuries of the spine in Canada, 1966-1996 [comment]. CMAJ 2000;162(6):787-8. 12. Proctor MR, Cantu RC. Head and neck injuries in young athletes. Clin Sports Med 2000;19(4): 693-715. 13. Kelly KD, Lissel HL, Rowe BH, Vincenten JA, Voaklander DC. Sport and recreation-related head injuries treated in the emergency department. Clin J Sport Med 2001;11(2):77-81. 14. Mueller FO, Cantu RC. Catastrophic injuries and fatalities in high school and college sports, fall 1982-spring 1988. Med Sci Sports Exerc 1990;22(6):737-41. 15. Cantu RC, Mueller FO. Fatalities and catastrophic injuries in high school and college sports, 1982-1997: Lessons for improving safety. Phys Sportsmed 1999;27(8):35-48. 16. Brust JD, Leonard BJ, Pheley A, Roberts WO. Children's ice hockey injuries. Am J Dis Child 1992;146(6):741-7. 17. Bernard D, Trudel P. Marcotte G. The incidence, types, and circumstances of injuries to ice hockey players at the bantam level (14 to 15 years old). In: Hoerner E, ed. Safety in Ice Hockey. Philadephia: American Society for Testing and Materials, 1993:44-55. 18. Benson B, Meeuwisse WH. Ice hockey injuries. In: Maffulli N, Caine DJ, eds. Epidemiology of Pediatric Sports Injuries: Team Sports. Basel: S Karger AG, 2005:86-119. 19. Warsh JM, Constantin SA, Howard A, Macpherson A. A systematic review of the association between body checking and injury in youth ice hockey. Clin J Sport Med 2009;19(2):134-44. 20. Emery CA, Hagel B, Decloe M, Carly M. Risk factors for injury and severe injury in youth ice hockey: A systematic review of the literature. Inj Prev 2010;16(2):113-8. 21. Emery CA, Kang J, Shrier I, et al. Risk of injury associated with body checking among youth ice hockey players. JAMA 2010;303(22):2265-72. 22. Darling, SR, Schaubel DE, Baker JG, Leddy JJ, Bisson LJ, Willer B. Intentional versus unintentional contact as a mechanism of injury in youth ice hockey. Br J Sports Med 2011;45(6):492-7. 23. Emery C, Kang J, Shrier I, et al. Risk of injury associated with bodychecking experience among youth hockey players. CMAJ 2011;183(11):1249-56. 24. Kukaswadia A, Warsh J, Mihalik JP, Pickett W. Effects of changing body-checking rules on rates of injury in minor hockey. Pediatrics 2010;125(4):735-41. 25. Cusimano M, Taback N, McFaull S, Hodgins R, Tsegaye B; Canadian Research Team in Traumatic Brain Injury and Violence. Effect of bodychecking on rate of injuries among minor hockey players. Open Medicine 2011;5(1):e59: www.openmedicine.ca/article/view/246/389 (Accessed July 4, 2012). 26. Macpherson A, Rothman L, Howard A. Body-checking rules and childhood injuries in ice hockey. Pediatrics;117(2):e143-7 [Erratum in Pediatrics. 2006;117(6):2334-6]. 27. Stuart MJ, Smith AM, Nieva JJ, Rock MG. Injuries in youth ice hockey: A pilot surveillance strategy. Mayo Clin Proc 1995;70(4): p. 350-6. 28. Mölsä, J, Kujala U, Myllynen P, Torstila I, Airaksinen O. Injuries to the upper extremity in ice hockey: Analysis of a series of 760 injuries. Am J Sports Med 2003;31(5):751-7. 29. Björkenheim JM, Syvähuoko I, Rosenberg PH. Injuries in competitive junior ice-hockey. 1437 players followed for one season. Acta Orthop Scand 1993;64(4):459-61. 30. Wiggins W. Implication of introducing body checking in ice hockey at different ages. OpenThesis. Lakehead University, 1998: www.openthesis.org/documents/Implication-introducing-body-checking-in-182710.html (Accessed July 4, 2012). 31. Wattie N, Cobley S, Macpherson A, Howard A, Montelpare WJ, Baker J. Injuries in Canadian youth ice hockey: The influence of relative age. Pediatrics 2007;120(1):142-8. 32. Roberts WO, Brust JD, Leonard B. Youth ice hockey tournament injuries: Rates and patterns compared to season play. Med Sci Sports Exerc 1999;31(1):46-51. 33. Williamson IJS. An epidemiological investigation of concussion in youth ice hockey. Simon Fraser University: MSc thesis, 2006. 34. Smith AM, Stuart MJ, Wiese-Bjornstal DM, Gunnon C. Predictors of injury in ice hockey players. A multivariate, multidisciplinary approach. Am J Sports Med 1997;25(4): 500-7. 35. McKay C, Emery CA, Campbell T, Meeuwisse W. The effect of premature return to play on re-injury risk in elite adolescent ice hockey and associated psychosocial predictors [Abstract]. Br J Sport Med 2008;42(6):532-3. 36. Willer B, Kroetsch B, Darling S, Hutson A, Leddy J. Injury rates in house league, select, and representative youth ice hockey. Med Sci Sports Exerc 2005;37(10):1658-63. 37. Finke RC, Goodwin Gerberich S, Madden M, et al. Shoulder injuries in ice hockey. J Orthop Sports Phys Ther 1988;10(2):54-8. 38. Brunelle JP, Goulet C, Arguin H. Promoting respect for the rules and injury prevention in ice hockey: Evaluation of the fair-play program. J Sci Med Sport 2005;8(3):294-304. 39. Canadian Paediatric Society, Healthy Active Living and Sports Medicine Committee. Identification and management of children with sport related concussion (Principal author Laura K Purcell). Paediatr Child Health 2012;17(1):31 www.cps.ca/en/documents/position/concussion-evaluation-management. 40. Canadian Task Force on Preventive Health Care, New grades for recommendations from the Canadian Task Force on Preventive Health Care for specific clinical preventive actions. CMAJ 2003;169(3):207-8. 41. Canadian Task Force. Quality of Published Evidence. www.canadiantaskforce.ca/_archive/index.html (Accessed July 19, 2012). Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.
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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. Program Integrity 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. 2) Remuneration 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. Conclusion 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.
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Consensus Guideline for Health Professionals Working with First Nations, Inuit and Metis

https://policybase.cma.ca/en/permalink/policy10741
Last Reviewed
2019-03-03
Date
2013-03-02
Topics
Population health/ health equity/ public health
Resolution
BD13-05-132
The Canadian Medical Association endorses the Consensus Guideline for Health Professionals Working with First Nations, Inuit and Metis developed by the SOGC outlined in Appendix A to BD 13-99.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2013-03-02
Topics
Population health/ health equity/ public health
Resolution
BD13-05-132
The Canadian Medical Association endorses the Consensus Guideline for Health Professionals Working with First Nations, Inuit and Metis developed by the SOGC outlined in Appendix A to BD 13-99.
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The Canadian Medical Association endorses the Consensus Guideline for Health Professionals Working with First Nations, Inuit and Metis developed by the SOGC outlined in Appendix A to BD 13-99.
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Better health, better care and better value

https://policybase.cma.ca/en/permalink/policy10960
Last Reviewed
2019-03-03
Date
2013-05-25
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
BD13-06-209
The Canadian Medical Association will continue to collaborate with the Council of the Federation – Health Care Innovation Working Group to help ensure that Canada delivers on better health, better care and better value.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2013-05-25
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
BD13-06-209
The Canadian Medical Association will continue to collaborate with the Council of the Federation – Health Care Innovation Working Group to help ensure that Canada delivers on better health, better care and better value.
Text
The Canadian Medical Association will continue to collaborate with the Council of the Federation – Health Care Innovation Working Group to help ensure that Canada delivers on better health, better care and better value.
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The health of Aboriginal peoples 2002

https://policybase.cma.ca/en/permalink/policy163
Last Reviewed
2019-03-03
Date
2002-12-07
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2002-12-07
Topics
Population health/ health equity/ public health
Text
HEALTH OF ABORIGINAL PEOPLES 2002 A CMA Policy Statement Recommendation #1 That the federal government adopt a comprehensive strategy for improving the health of Aboriginal peoples that involves a partnership among governments, non-governmental organizations, universities and the Aboriginal communities. 2) The Need to Address Health Determinants The health status of Canada’s Aboriginal peoples is a result of a broad range of factors: social, biological, economic, political, educational and environmental. The complexity and interdependence of these health determinants suggest that the health status of Aboriginal peoples is unlikely to be improved significantly by increasing the quantity of health services. Instead, inequities within a wide range of social and economic factors should be addressed; for example: income education employment interactions with the justice system racism and social marginalization environmental hazards water supply and waste disposal housing quality and infrastructure cultural identity, (for example, long-term effects of the residential school legacy.) Recommendation #2 That all stakeholders work to improve provision for the essential needs of Aboriginal peoples and communities that affect their health (e.g. housing, employment, education, water supply). 3) The Importance of Self-Determination One characteristic of successful Aboriginal communities is a high degree of self-efficacy and control over their own circumstances. This empowerment can take many forms, from developing community-driven health initiatives to determining how to use lands. It is increasingly recognized that self-determination in cultural, social, political and economic life improves the health of Aboriginal peoples and their communities, and that Aboriginal peoples can best determine their requirements and the solutions to their problems. Therefore, the CMA encourages and supports the Aboriginal peoples in their move toward increasing self-determination and community control. A just and timely settlement of land claims is one means by which Aboriginal communities can achieve this self-determination and self-sufficiency. Recommendation #3 That governments and other stakeholders: Settle land claims and land use issues expeditiously; Work toward resolving issues of self-determination for Aboriginal peoples and their communities in areas of cultural, social, political and economic life. 4) Community Control of Health Services Control by Aboriginal peoples of health and social services is increasing across Canada as part of a broader transfer of control of political power, resources and lands. This transfer has not progressed at the same pace across all Aboriginal communities; the needs of Urban Aboriginal peoples, for example, are only beginning to be addressed. CMA supports the development of community-driven models for delivery of health care and health promotion, responsive to the culture and needs of individual communities. Successful community-driven models of health care delivery generally recognize that the Aboriginal concept of health is holistic in nature, incorporating mental, emotional and spiritual as well as physical components. Translating this concept into practice may involve: Development of primary care models that are grounded within Aboriginal culture at a local level; Integration of disease treatment services with health promotion and health education programs, and with traditional healing practices; Integration of health and social services; Interprofessional collaboration within a multi-disciplinary team. CMA also supports programs to increase the involvement of Aboriginal peoples in professional and other decision-making roles affecting the health of their community – for example, increased representation in health-care management positions, and on health facility boards where there is a significant Aboriginal population. Recommendation #4 That all stakeholders actively encourage the development of integrated, holistic primary care service delivery relevant to the needs and culture of Aboriginal communities and under community control. 5) Cultural Responsiveness in the Patient/Physician Relationship As mentioned above, the concept of “health” in Aboriginal culture is holistic and incorporates many components. The concepts of continuity, wholeness and balance within and among people are important to Aboriginal culture, as is a close affinity with the natural environment – both in practical and spiritual senses , which emphasises the importance of stewardship of the land as a component of individual and community health maintenance for present and future generations. Physicians should work in collaboration with Aboriginal peoples and groups to promote a greater understanding and acceptance of their respective philosophies and approaches. This could include: an openness and respect for traditional medicine and traditional healing practices (e.g. sweat lodges, herbal medicines, healing circles). This should be balanced with a recognition that not all Aboriginal people, whether First Nation, Métis or Inuit, adhere to or understand their traditional ceremonial practices. improved cross-cultural awareness in physicians, which could be facilitated by greater contact with their local Aboriginal communities, better understanding of local Aboriginal cultures, history and current setting, development of cross-cultural patient-physician communication skills. Recommendation #5 a) That educational initiatives in cross-cultural awareness of Aboriginal health issues be developed for the Canadian population, and in particular for health care providers, b) that practice tools and resources be developed to support physicians (Aboriginal and non-Aboriginal) and other health care professionals practicing in Aboriginal communities. 6) Access to Health Services Canada is often considered to have one of the best health care systems in the world and is typically described as providing “universal access”. However, our system does not provide equal access to services for all people living in Canada – the most underserviced being those in northern Canada, which contains many Aboriginal communities. Several kinds of access problems exist in Aboriginal communities: Lack of access to employment, adequate housing, nutritious food, clean water and other social or economic determinants of health. Factors that impede access to health care services, particularly in remote locations; for example, language and cultural differences, and the difficulty of transporting patients to tertiary centres. Lack of specific services (for example, mental health services) for Aboriginal peoples in many regions of Canada. Specific groups, such as women and the elderly, have unique and distinct needs that should be addressed. Program delivery that involves multiple federal, provincial and municipal funding agencies. Physicians and patients alike have trouble obtaining information about and entry into existing programs and funding for new programs because of jurisdictional confusion. CMA has previously recommended that the Canadian health system develop and apply agreed-upon standards for timely access to care. This includes the need to increase timely and appropriate access by Aboriginal peoples to health care and health promotion services, geared to different segments of the population according to their needs. Recommendation #6 a) That governments and other stakeholders simplify and clarify jurisdictional responsibilities with respect to Aboriginal health at the federal, provincial and municipal level, with a goal of simplifying access to service delivery. b) That strategies be explored to increase access to health services by remote communities; for example, through the use of technology (e.g. Web sites, telemedicine) to connect them with academic medical centres. 7) Health Human Resources There is an urgent need to increase the training, recruitment and retention of Aboriginal health care providers. The 1996 Royal Commission on Aboriginal Peoples recommended that a cadre of 10,000 Aboriginal health care and social service workers be trained to meet the needs of a complex and diverse community. While progress has been made in recent years, an intensive focus on recruitment, training and retention is required in order to achieve this goal. A comprehensive health human resource strategy should be developed, to increase the recruitment, training and retention of Aboriginal students in medicine and other health disciplines. Such a strategy could include: Outreach programs to interest Aboriginal young people in the health sciences. Access and support programs for Aboriginal medical students. Residency positions for recently graduated Aboriginal physicians or physicians wishing to practice in Aboriginal populations, including re-entry positions for physicians currently in practice. Mentoring and leadership-development programs for Aboriginal medical students, residents and physicians. Programs to counter racism and discrimination in the health-care system. Initiatives to recruit and train Community Health Representatives/ Workers, birth attendants and other para-professionals within Aboriginal communities. Recommendation #7 a) That CMA and others work to develop a health human resource strategy aimed at improving the recruitment, training, retention of Aboriginal physicians and other health-care workers; b) That medical and other health faculties increase access and support programs to encourage enrollment of Aboriginal students. 8) Health Information Information about the health status and health care experience of Aboriginal peoples, is essential for future planning and advocacy. For Aboriginal peoples to effectively develop self-determination in health care delivery, they should have access to data that can be converted into useful information on their population. The “OCAP” principle (ownership, control, access to and possession of health data) is seen as integral to First Nation community empowerment, but may prove acceptable to other Aboriginal groups as well. A considerable amount of data currently exists, though there are gaps in coverage, particularly regarding Métis, Inuit and urban and rural off-reserve First Nations populations. This data can come from a variety of federal and provincial/territorial sources, including periodic surveys, federal censuses, Aboriginal Peoples Survey data holdings, and also regional physician and hospital utilization statistics. However, jurisdictional and ownership issues have hindered Aboriginal people from accessing and making use of this data. CMA supports the development and maintenance of mechanisms to systematically collect and analyze longitudinal health information for Aboriginal people, and the removal of barriers that prevent Aboriginal organizations from fully accessing information in government databases. Aboriginal health information should be subject to guarantees of privacy and confidentiality. The CMA urges relevant government departments to ensure that revisions to the Indian Act do not infringe on the privacy of health information of Aboriginal peoples in Canada. Recommendation #8 That the Government of Canada support the First Nations and Inuit Regional Longitudinal Health Survey Process, and the First Nations and Inuit Health Information System, and parallel interests for the Métis and Inuit. These programs should be operated under the control of their respective Aboriginal communities 9) Research The CMA supports culturally relevant research into the determinants of Aboriginal health and effective treatment and health-promotion strategies to address them. Specifically, the CMA supports the efforts of the Institute of Aboriginal Peoples’ Health at the Canadian Institute for Health Research, in addressing the needs of Canada’s Aboriginal peoples. Aboriginal peoples should be involved in research design, data collection and analysis; research should support the communities as they build capacity and develop initiatives to address their health needs. Ideally, research should address not only determinants of ill health but also the reasons for positive health outcomes. The CMA also acknowledges the need to communicate research results to Aboriginal communities to help them develop and evaluate health programs. In particular there is an urgent need among Aboriginal communities for the sharing of successes. Recommendation #9 That government and other stakeholders Support Aboriginal peoples and communities in the development of Aboriginal research and the means of interpreting its findings. Make public communication of health research results a priority in order to facilitate its use by Aboriginal communities. CMA’S CONTINUED COMMITMENT The Canadian Medical Association, consistent with its mandate to advocate for the highest standards of health and health care in Canada, will continue to work with the Aboriginal community and other stakeholders on activities addressing the following issue areas: Workforce Enhancement: Research and Practice Enhancement:. Public and Community Health Programming:. Leadership Development:. Advocacy for healthy public policy. Page 5 November 15, 2002
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