The CMA appreciates the opportunity to appear before this committee as part of your review of the 10-Year Plan to Strengthen Health Care. An understanding of what has worked and what hasn't since 2004 is critical to ensuring the next accord brings about necessary change to the system.
Overview of 2004 Accord
On the positive side of the ledger, the 2004 accord provided the health care system with stable, predictable funding for a decade - something that had been sorely lacking. It also showed that a focused commitment, in this case on wait times, can lead to improvements.
However, little has been done on several other important commitments in the Accord, such as the pledge that was also made in 2003 to address the significant inequity among Canadians in accessing prescription drugs.
Along with the lack of long-term, community and home-based care services, this accounts for a major gap in patient access along the continuum of care.
We also know that accountability provisions in past accords have been lacking in several ways. For instance, there has been little progress in developing common performance indicators set out in previous accord. i The 2004 accord has no clear terms of reference on accountability for overseeing its provisions.
Vision and principles for 2014
What the 2004 accord lacked was a clear vision. Without a destination, and a commitment to getting there, our health care system cannot be transformed and will never become a truly integrated, high performing health system.
The 2014 Accord is the perfect opportunity to begin this journey, if it is set up in a way that fosters the innovation and improvements that are necessary. By clearly defining the objectives and securing stable, incremental funding, we will know what changes we need to get us there.
Now is the time to articulate the vision- to say loudly and clearly that at the end of the 10-year funding arrangement, by 2025, Canadians will have the best health and health care in the world. With a clear commitment from providers, administrators and governments, this vision can become our destination.
As a first step to begin this long and difficult journey, the CMA has partnered with the Canadian Nurses Association, and together we have solicited support from over 60 health care organizations for a series of "Principles to Guide Health Care Transformation in Canada."
These principles define a system that would provide equitable access to health care based on clinical need; care that is high quality and patient-centred; and that focuses on empowering patients to attain and maintain wellness.
They call for a system that provides accountability to those who use it and those who fund it; and that is sustainable - by which I mean adequately resourced in terms of financing, infrastructure and human resources, and measured against other high-performing systems, with cost linked to outcomes.
Based on our experience working within the provisions of the 2004 accord, we would like to suggest three strategies to ensure the next accord leads to a sustainable, high-performing health care system.
They are: a focus on quality; support for system innovation; and the establishment of an accountability framework and I will touch briefly on each one.
Focus on quality
First, the crucial need to focus on improving the quality of health care services. The key dimensions of quality, and by extension, the areas that need attention are: safety, effectiveness, patient-centredness, 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. What is missing and urgently needed is an integrated, pan-Canadian approach to quality improvement in health care that can begin to chart a course to ensure 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 fund the establishment and resource 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.
To help expand quality improvement across the country, the Institute for Healthcare Improvement's Triple Aim provides the solid framework. Our health care systems will benefit inordinately from a simultaneous focus on providing better care to individuals and better health to populations, while reducing the per-capita cost. There is ample evidence that quality care is cost effective care. This approach, when adopted and applied as the pan-Canadian framework for any and all structural changes and quality improvement initiatives, will not only serve patients well, but will also enhance the experience of health care providers on the front lines.
The second strategy revolves around system innovation. Innovation and quality improvement initiatives are infinitely more likely to be successful and sustained if they arise out of a commitment by frontline providers and administrators to the achievement of a common goal. We need to shift away from compliance models with negative consequences that have little evidence to support their sustainability.
Innovative improvements in health care in Canada are inadequately supported, poorly recognized, and constrained from being shared and put into use more widely. This needs to change. The 2014 accord, with a focus on improving Canadians' health and health care, can facilitate the transformation we all seek.
Building on the success of the 2004 Wait Times Reduction Fund and the 2000 Health Accord Primary Health Care Transition Fund, the CMA proposes the creation of a Canada Health Innovation Fund that would broadly support the uptake of health system innovation initiatives across the country.
A Working Accountability Framework
And, third, there needs to be a working accountability framework. This would work three ways.
To provide accountability to patients - the system will be patient-centred and, along with its providers, will be accountable for the quality of care and the care experience.
To provide accountability to citizens - the system will provide and, along with its administrators and managers, will be accountable for delivering high quality, integrated services across the full continuum of care.
And to provide accountability to taxpayers - the system will optimize its per-capita costs, and along with those providing public funding and financing, will be accountable for the value derived from the money being spent.
We have done all of this because of our profound belief that meaningful change to our health care system is of the essence, and that such change can and must come about through the next health accord.
Therefore I thank this committee for your efforts on this important area. I would be happy to answer your questions.
Issues identified in 2004 Accord and Current Status
[NOTE: see PDF for correct dispaly of table]
Annual 6% escalator in the CHT to March 31, 2014
Has provided health care system with stable, predictable funding for a decade.
Adoption of wait-time benchmarks by December 2005 for five procedural areas
Largely fulfilled. However, no benchmarks were set for diagnostic imaging. The Wait Time Alliance is calling for benchmarks for all specialty care.
Release of health human resource (HHR) action plans by December 2005
Partially fulfilled. Most jurisdictions issued rudimentary HHR plans by the end of 2005; F/P/T Advisory Committee on Health Delivery and Human Resources issued a paper on a pan-Canadian planning HHR framework in September 2005.
First-dollar coverage for home care by 2006
Most provinces offer first-dollar coverage for post-acute home care but service varies across the country for mental health and palliative home care needs.
An objective of 50% of Canadians having 24/7 access to multidisciplinary primary care teams by 2011
Unfulfilled: Health Council of Canada reported in 2009 that only 32 per cent of Canadians had access to more than one primary health care provider.
A 5-year $150 million Territorial Health Access Fund
Fulfilled: Territorial Health System Sustainability Initiative (THSSI) funding extended until March 31, 2014.
A 9-point National Pharmaceuticals Strategy (NPS)
Largely unfulfilled: A progress report on the NPS was released in 2006 but nothing has been implemented.
Accelerated work on a pan-Canadian Public Health Strategy including goals and targets
F/P/T health ministers (except Quebec) put forward five high-level health goals for Canada in 2005, although they were not accompanied by operational definitions that would lend themselves to setting targets.
Continued federal investments in health innovation
Unknown-no specificity in the 2004 Accord.
Reporting to residents on health system performance and elements of the Accord
P/T governments ceased their public reporting after 2004, and only the federal government has kept its commitment (at least to 2008).
Formalization of the dispute advance/resolution mechanism on the CHA
Done but not yet tested.
i P/T governments ceased their public reporting after 2004, and only the federal government has kept its commitment (at least to 2008).Government of Canada. Healthy Canadians: a federal report on comparable health indicators 2008. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/system-regime/2008-fed-comp-indicat/index-eng.pdf. Accessed 06/21/11.
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.
We are very pleased to appear on behalf of the Canadian Medical Association before this Senate committee as part of your study of pandemic preparedness and the H1N1 experience in Canada.
Earlier this year, the CMA collaborated with the College of Family Physicians of Canada and the National Specialty Society of Community Medicine to present a picture of lessons learned from the frontlines of the pandemic.
Together we represent over 80,000 physicians engaged in all aspects of Canada's health care and public health systems.
The report includes recommendations that, if acted upon, would help ensure that a strong foundation is in place to protect Canadians from future health threats.
As President of the CMA and a practising physician, I am here to present my association's point of view.
Physicians have a unique and critical role to play during public health emergencies. Many people turn to their physician first for information and counseling. Physicians are the first line of defence.
This was certainly the case during the H1N1 pandemic. This role was intensified by the confusion created by the great variation in mass vaccination programs across the country.
Many physicians felt that their urgent need for clinically relevant information was not well recognized by the Public Health Agency of Canada, the Public Health Network and, in some cases, provincial, territorial, regional or local levels.
The lack of national leadership on clinical guidance led to delays and the proliferation of differing guidelines across the country.
Standard clinical guidance, adaptable to local circumstances, is the norm in medical practice. Nationally disseminated clinical practice guidelines on vaccine sequencing, use of anti-virals and hospital treatment would have created consistent clinical responses across the country.
We recommend that the Public Health Network seek advanced pan-Canadian commitment to a harmonized and singular national response to clinical practice guidelines, including mass vaccination programs, during times of potential public health crisis.
The CMA also recommends that the Public Health Agency of Canada work closely with the medical specialty societies, as it did successfully with Society for Obstetrics and Gynecology in the development of clinical guidance for the care and treatment of pregnant women.
Many physicians and public health workers have complained that multiple levels of government provided similar, but not identical, advice. The differences led to skepticism among both physicians and the public and the inundation of messages led to overload.
In situations where scientific evidence is rapidly changing, as was the case during the H1N1 pandemic, we need a national communication strategy, targeted to physicians that can build on communication processes already in place.
It is especially important during a health emergency to build on existing systems that work well and can minimize the chances of conflicting messages.
It is also important that two-way lines of communication between public health and primary care are established. Embedding primary care expertise into public health planning at all levels would help us avoid problems and improve our response.
We believe that the H1N1 immunization process did not adequately engage physicians in planning and delivery.
A number of difficulties, such as the impact of bulk packaging, the sequencing of patients and the logistics of inventory management, led to friction between front-line public health practitioners and family physicians.
These could have been avoided with strengthened consultation, interdependence and mutual understanding before the crisis.
A number of witnesses have noted the importance of surveillance. There is no doubt that greater use of electronic medical records - or EMRs - in primary care could have facilitated surveillance and communications.
Family practice clinics with EMRs were able to quickly identify high-risk patients, communicate with them to schedule vaccination appointments, and collect the required data for public health.
Another aspect of pandemic planning that cannot be ignored is the possibility that physicians themselves might fall ill.
Physicians have never hesitated to provide care to patients during times of crisis, but this obligation must be balanced by a reciprocal obligation of society to physicians.
Following the SARS outbreak, the CMA prepared Caring in a Crisis, a policy paper that addresses the need to take into account and plan for what would happen when health care providers become part of the statistics of those infected.
We urge the committee to consider this challenge in your deliberations.
My last point addresses the lack of surge capacity in Canada's health system.
To mount a response to H1N1, public health units pulled human resources from other programs and many critical services were delayed, suspended or cancelled altogether.
The resources of our critical care infrastructure were stretched to their limits in many hospitals and frontline health care providers were inundated with telephone calls and visits from the worried well and an increase in visits from those with flu symptoms.
If H1N1 had been the severe pandemic that was expected and for which Canada had been preparing, our health system would have been brought to its knees.
The CMA has been warning of the lack of surge capacity in our health system for over a decade.
Canada remains vulnerable to the risks presented by epidemics and pandemics. If we are to be prepared for the next emergency, a long-range plan to build our public health capacity and workforce and to address the lack of surge capacity in our health system must become a priority.
We therefore very much appreciate the review to Canada's response to the H1N1 pandemic that has been undertaken by this Committee, and we look forward to your report.