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All of them - Conservatives, New Democrats, Liberals, Greens, Bloc Quebecois - support universal, publicly funded health insurance. All of them believe Ottawa should transfer significant amounts of federal tax dollars to the provinces for health care. And all of the parties conveniently ignore that Canada has the least universal, most expensive, and least cost-efficient universal health system in the world, and that the provinces have almost no accountability for the federal money they receive. There are some differences among the parties, of course, but they are largely philosophical, and revolve around interpretations of the constitutional divisions of power - not very good fodder for sound bites. The Conservatives (at least under Stephen Harper) believe health is strictly a provincial responsibility and Ottawa should transfer money with no strings attached. The separatist Bloc has the same position.

The New Democrats, Liberals and Greens believe that Ottawa's role should be to create a semblance of a national health plan and show moral leadership (for lack of a better term). But to do so they need to, among other things, earmark money, to demand it be spent on specific programs. But the leaders don't want to say so out loud because no federal leader wants to pick a fight with the provinces during an election. NDP Leader Thomas Mulcair has made a number of healthcare promises aimed at specific demographic groups - such as home care and long-term care for seniors and a mental health plan for teens - but has been fuzzy on the details and an overall plan. Similarly, both the Liberals and the NDP promise to renew the health accord by holding talks with the premiers, but offer no hard numbers. (To refresh memories, in 2004, the Liberals unveiled the health care "fix for a generation," which principally involved increasing health transfers to the provinces by 6 per cent a year for 10 years. The Conservatives extended the 6-percent escalator to 2017; after that it will be tied to inflation, and no less than 3 per cent per annum.)

Pharmacare - providing affordable access to prescription drugs for all Canadians - is another hot topic in health circles, but not on the hustings. The Greens have a firm plan to implement pharmacare, saying it will save up to $11-billion annually, but promising a national plan is easy when you have little chance of winning power. Other parties are more circumspect about a topic whose details really matter. In fact, that's the overriding reason health care is difficult to discuss on the campaign trail: It's a sprawling, complex topic, with many potential pitfalls.

Health care is not one issue, it's 1,000 issues. The politician who wades too deeply into the morass risks bleeding support, suffering the proverbial death by a thousand cuts.

Underlying both reforms is a quiet resignation to the idea that two-tiered health care is inevitable. This sense of resignation is understandable, coming as it does on the heels of a decade-long void in federal leadership on health care. Throughout the Harper government's time in office, the Canada Health Act went substantially unenforced as private clinics popped up across the country. Even in its reduced role as a cheque-writer, the federal government took steps that undermined national unity on health care, switching the Canada Health Transfer to a strict per capita formula, which takes no account of a province's income level or health-care needs. If Canadians hope to reverse this trend, we cannot simply wage a rearguard battle for the enforcement of the Canada Health Act as it was enacted in 1984. Even if properly enforced, the act protects universal access only for medically necessary hospital and physician services. This is not the blueprint of a 21st-century public health-care system.

We desperately need universal coverage for a full array of health-care goods and services -- pharmaceuticals, mental-health services, home care and out-of-hospital diagnostics. Canada is unique among Organization for Economic Co-operation and Development countries in the paucity of what it covers on a universal basis despite falling in the top quartile of countries in levels of per capita health spending. Far from being our saviour, the Canada Health Act in its current incarnation is partly to blame -- not because of its restrictions on queue-jumping and private payment, but because it doesn't protect important modern needs, such as access to prescription drugs.

There are limits on what a public health system can provide, of course -- particularly as many provinces now spend nearly half of their budgets on health care. But fairness requires these limits be drawn on a reasoned basis, targeting public coverage at the most effective treatments. Under the current system, surgical removal of a bunion falls under universal coverage, while self-administered but life-saving insulin shots for diabetics do not. A modernized Canada Health Act would hold the provinces accountable for reasonable rationing decisions across the full spectrum of medically necessary care.

Instead of modernizing medicare, Saskatchewan and Quebec are looking to further privatize it. Experience to date suggests allowing two-tiered care will not alleviate wait times in the public system. Alberta has reversed course on its experiment with private-pay MRIs after the province's wait times surged to some of the longest in the country.

The current wisdom is long wait times are better addressed by reducing unnecessary tests. A 2013 study of two hospitals (one in Alberta, one in Ontario) found more than half of lower-back MRIs ordered were unnecessary. Skirmishes over privatization have to be fought, but they should not distract us from the bigger challenge of creating a modern and publicly accountable health system -- one that provides people the care they need, while avoiding unnecessary care.

Achieving that will make National Medicare Week a true cause for celebration. Bryan Thomas is a research associate and Colleen M. Flood is a professor at the University of Ottawa's Centre for Health Law, Policy and Ethics. Flood is also an adviser with EvidenceNetwork.ca.

Arbitrator Jim Hayes found the "vaccinate or mask" policy was unreasonable, and "a coercive tool" to force heath-care workers to get the flu shot. Experts testified that it was illogical to force healthy nurses to wear masks, and Hayes concluded the masks were not protecting patients or nurses from the flu.

"The sad part about it is it was giving our patients a false sense of security, and we knew that," said Haslam-Stroud. The Ontario Hospital Association said it was disappointed in the arbitrator's ruling. "In light of the arbitrator's decision we are considering a number of options," said OHA president Anthony Dale. "In addition, we will continue to work with government and our partners on best practices for the upcoming flu season."

The influenza vaccine is only about 40 to 60 per cent effective even in good years, said Gardam, which means all hospital workers should wear masks all the time if they were actually effective at preventing the spread of the flu. "So the only way you can really explain that argument is to say 'well, it's not really that the masks are working,' " he said. "It's because the masks are a way of driving you towards vaccination."

The policy "was symbolic rather than a scientifically based tool in the fight against influenza," and amounted to a "draconian shaking of the finger at nurses," said Haslam-Stroud. The ONA said there are provisions in its agreements with hospitals that require a non-vaccinated nurse to move to another ward if the medical officer of health determines there is a flu outbreak in the area where he or she works. "I am not going to suggest that anyone should be forced to take the vaccine," said Haslam-Stroud. "I personally take it, but it is an individual right as a nurse." The "vaccinate or mask" policy started in B.C. hospitals before moving to some health-care facilities in New Brunswick and Ontario.

FRANK GUNN/CANADIAN PRESS FILES • The Ontario Nurses Association says hospitals will no longer be allowed to shame health-care workers into getting a flu shot following an arbitrator's ruling striking down a "vaccinate or mask" policy.

For decades, the Ontario health-care system has been planned, operated and overseen by doctors, hospital administrators, health ministry bureaucrats and executives in agencies such as the Local Health Integration Networks and Community Care Access Centres (CCACs) responsible for home care. What's been missing is the voice of patients and caregivers. That's inexcusable, given that some 400,000 people are employed in the Ontario health system and several million patients are treated in hospitals, at home and in community settings each year.

Until now, those patients have had few places to turn when they ran into roadblocks in the system, or have been frustrated trying to find their way through the layers of bureaucracy and in getting anyone in authority to deal with their issues. As health ombudsman, Elliott is to work with patients and caregivers to resolve complaints about their health-care experience. She will also investigate health-sector organizations on her own initiative, make recommendations for improvements and make annual reports to the minister.

Although her five-year appointment doesn't come into effect officially until July 1, 2016, she will start preliminary work on recruiting a staff of 12-15 people early next year. She will earn about $220,000 a year. Elliott quit provincial politics in August, three months after losing the Tory leadership race to Patrick Brown. Hoskins said Elliott was chosen from more than 400 candidates. Her "advocacy for vulnerable people, extensive knowledge of the health-care system and commitment to the betterment of this province make her the perfect choice for Ontario's first patient ombudsman," he said. While some people question the ombudsman's independence because the post reports to the minister, patient advocate groups are delighted with Elliott's appointment, suggesting she will be taken seriously at Queen's Park. As an MPP, she fought for better treatment for stroke victims and people with disabilities, and was a driving force behind a legislative committee's push for the auditor general to review the operations of the troubled CCACs.

There is much to be done in alerting the public and the minister to where patients fall through the cracks and get bad outcomes," says Michael Decter, a former Ontario deputy health minister and chair of Patients Canada, a national advocacy group. "For example, transitions from hospital to home are a major area of problems for patients." As encouraging as this move is, there is still more the government can do to give patients a true voice in health care. One suggestion circulating in the upper levels of the health ministry is to appoint an assistant deputy minister for patient experience. The proposal was first revealed in a blog by Steve Paikin, host of The Agenda on TVO.

The health ministry now has 16 assistant deputy ministers or their equivalents. Their areas of responsibilities range from provider agencies to doctors and pharmaceuticals. Although they may not realize, such bureaucrats can sometimes get captured by and become advocates for those interests over time. None of them, however, have prime responsibility for patients. That means there is no voice for patients or caregivers around the table when the top bureaucrats meet to formulate future policies and procedures or to assess how existing programs are working. It's a stunning absence, given that many universities, such as the University of Toronto, have created positions in recent years to deal specifically with student experiences.

Also, some hospitals have established jobs to deal with patient experience and many private companies have executives assigned to customer care. Naming a health ombudsman is a positive first step in giving patients a voice. Appointing such an assistant deputy minister, though, could be exactly what's needed to shake up the health ministry and focus its attention laser-like on where it should be - the patients and caregivers of Ontario. Bob Hepburn's column appears Sunday. bhepburn@thestar.ca

Christine Elliott is a good choice for the position of patient ombudsman, but there is more that Queen's Park can do to ensure that patients' concerns and needs are put first, Bob Hepburn writes.

Three countries we have written about in a new paper for the Macdonald-Laurier Institute - Japan, Korea and Taiwan - are not typically where Canadians look for public policy solutions. They are far away and have very different cultures and histories. But they, like other developed countries, face similar health care challenges.

apan, Korea and Taiwan are leading users of health-care technologies. Their overall health outcomes are comparable to, if not better than, those in Canada, and they do this spending a lower percentage of their GDP on health care than we do. These countries have universal public health care - something Canadians are justifiably proud of - though Japan achieved this about a decade before Canada. These countries' plans cover physician visits and hospitalization, but also dental care and outpatient prescription drugs.

What are the lessons for Canada? First, the countries' policy-makers actively learned from abroad. Japan looked to Germany as it started modernizing nearly 150 years ago; recently Korea and Taiwan studied what worked, or not, elsewhere as they developed their systems. More importantly, politicians and bureaucrats had the fortitude to implement necessary reforms. Changes were made often in the face of protests by entrenched stakeholders, including physicians. And programs were reviewed soon after implementation, making modifications when problems arose. This is in stark contrast to Canada's embrace of the status quo.

More specifically, the systems in Japan, Korea and Taiwan suggest that copayments may be useful to help moderate demand and help fund care. They can be applied and properly designed to recognize income disparities. In Canada's case, they could increase equity if used to help extend coverage to drugs and dental care for more people. Unlike in Canada, where most hospitals are de facto public, in these countries privately-owned hospitals, many of them non-profit, compete with public hospitals, creating dynamism in the sector.

Finally, and most significantly, these proactive governments have moved to introduce Long-Term Care Insurance (LTCI) to address a very predictable problem. Very few people buy LTCI on their own, mostly because they can't predict their future needs and expect long-term care be covered by public funds. However, estimates suggest that about 70 per cent of people who reach 65 will need LTC at some time. In Japan and Korea, and likely soon in Taiwan, LTCI creates distinct insurance funds devoted to supporting appropriate care at home and in institutions.

Asia deserves the attention it is getting. As we build economic links, we should also look for the good ideas of our new partners that can make our health and long-term-care systems better. Ito Peng is Director of the Centre for Global Social Policy at the University of Toronto. James Tiessen is director of the School of Health Services Management at the Ted Rogers School of Management at Ryerson University. They are co-authors of the MLI report An Asian Flavour for Medicare (macdonaldlaurier.ca).

And one to which many family doctors, struggling to help mentally ill patients, can attest. After months of research, and as detailed in our Open Minds series, The Globe and Mail identified some of the top evidence-based approaches to building a mental health system that will work for Canadians. These are changes that would move the country beyond its patchwork, fragmented mental health system in which the care patients receive is too often determined by what they can afford, or where they live or what they are savvy enough to cobble together on their own. These initiatives abide by the principals of Medicare and good science, and treat the disorders of the mind as diligently as the diseases of the body.

Expanding access to publicly funded therapy One in five Canadians will be affected by mental illness in their lifetimes. The cost to the country's economy is staggering: $50billion a year in health care and social services, lost productivity and decreased quality of life, estimates the Mental Health Commission of Canada. The personal costs are more devastating - unemployment, family breakup, suicide. Canadians who seek help for a mental illness will most often be prescribed medication, even though research shows that psychotherapy works just as well, if not better, for the most common illnesses (depression and anxiety) and does a better job at preventing relapse. According to a 2012 Statistics Canada study, while 91 per cent of Canadians were prescribed the medication they sought, only 65 per cent received the therapy they felt they needed. Access to evidencebased psychotherapy, which experts say should be the front-line medical treatment, is limited and wait-lists are long.

No provinces cover therapy delivered in private practice by a psychologist, social worker or psychotherapist, creating a twotier system, which means families without coverage through work - those more likely to be low-income - often either pay out of pocket or go without or, if they are lucky, rely on a non-profit group working to fill a gaping hole in a flawed health-care system. Even Canadians with coverage rarely have enough for a proper dose that meets treatment guidelines. This kind of inconsistent, unequal and scientifically flawed approach to care would be untenable for diabetes, cancer or heart disease. Yet it persists for some of the most debilitating illnesses suffered by Canadians. "Clearly this is the biggest gap we have, and the one that most needs to be fixed," says psychiatrist Elliot Goldner, director of the Centre for Applied Research in Mental Health and Addiction. Psychotherapy is a medically necessary treatment, he argues, that should be publicly funded. The question is not whether Canadians need it, but how to deliver it.

With no history of care, Dr. Cookson had no way to know for sure. She advised him to make sure he told his mom if he had suicidal thoughts again and wrote a referral to see a psychiatrist, though even an urgent request would take weeks. Other than that, she had little to offer. They had no coverage for psychotherapy, which ideally, she would have prescribed. Since the young man was a walk-in patient, there is no guarantee she will see him again. "I want to be able to give them the care they deserve, and I know will benefit him, and I have no way of arranging that," she says. "It's a pretty helpless feeling."

Using technology to deliver therapy into the homes of Canadians It can be hard enough to get timely treatment if you only have to drive a few blocks to find it. But what if access to care for, say, an anxiety disorder requires traversing a sprawling wilderness, for hours by car, sometimes through a blizzard? These were the stories that Fern Stockdale Winder heard often from Saskatchewan patients, as the psychologist charged with developing the province's new mental health strategy. Even when mental health care was available, reaching treatment was often one more layer of stress. It doesn't have to be this way. Chief among the strategy's recommendations: a provincewide online therapy system. The evidence for tech-delivered therapy, with support over the phone, is strong - for many patients with depression and anxiety, it can be just as effective as face-to-face sessions. It allows patients to manage care around their work and school schedules, to maintain privacy and to take control of their own recovery in a way less likely to happen with medication.

And it's cost-effective, says Dr. Stockdale Winder, potentially reducing appointment no-shows and cutting down on travel time for patients and therapists to and from remote communities. Canadians have ready access to medication for mental illness not because it's the best option, but because it's the easiest - even though psychotherapy works as an effective early intervention, a standalone treatment or in combination with drugs, and to prevent relapse. This front-line treatment can also be delivered in a modern and increasingly convenient way that gives patients more choice in how they receive their care.

It's very much about how people like to learn. Whether for reasons of stigma or personal preference, many people like to work on life challenges by themselves," says Chris Williams, a psychiatrist at the University of Glasgow, whose self-guided program is used as a first-stage treatment in Britain's publicly funded psychotherapy system. It has also been adapted in British Columbia and is being piloted in other provinces by the Canadian Mental Health Association. Self-guided therapies vary - some use DVDs or booklets, others are delivered online - but the evidence is strongest for ones that also link patients to therapists, either by e-mail or with brief phone calls.

A separate online program at the University of Regina has already had promising results. (Even so, the government is taking a wait-and-see attitude: Health Minister Dustin Duncan said last week that the government is keeping an eye on the project and will consider whether to expand the service after the pilot concludes next year.) What Dr. Stockdale Winder envisions is a system in which family doctors could use depression and anxiety screening to easily steer appropriate patients away from medication and toward accessible, online therapy.

"She clicks a button, and the patient is in," she says. Such a system would also monitor the progress of participants and direct them into more intensive care if their conditions worsened. The need for early intervention is pressing, and the evidence for online therapy is already convincing. In a country of wide open spaces, with remote communities difficult to reach even in the best weather, it's necessary. What are policy-makers waiting for? Teaching the next generation about mental health

Justice Slatter clearly had issues with the majority judgment in Chaoulli. He highlighted that section 7 is a notoriously unsettled and controversial Charter provision, and the “drafters of the Charter never intended it to be applied to the review of social and economic policies” (para 33).

first year enrolment in Canadian medical schools is now 80 per cent higher than a decade ago.

Scopes of practice, coordinated management, and CPGs have all come under a variety of committee, task force, working group, and Royal Commission lenses over the past two decades. As important as that work has been, there has been a frustrating lack of follow through or haphazard implementation on what are often a series of well crafted, evidence-based recommendations.

huge potential for nurse practitioners in primary care. Yet, implementation of this single evidence-based policy recommendation continues to be hamstrung by a maddening mix of professional resistance and lack of political will.

There is now a chorus of voices highlighting the need for better health workforce policy and planning

a pan-Canadian health workforce observatory.

an organization that would assemble health workforce data, information, and expertise to inform more rational approaches to policy development and health workforce deployment

Several other developed and developing countries have created such organizations

the standing committee supported the call for an observatory in its recommendations but, sadly, the federal government response did not even acknowledge that the recommendation had been made

Boudreau has said the move will save the province millions of dollars through efficiencies brought in by a private company. However, the union's document paints a poor picture of privatization of services in health-care facilities in other jurisdictions. "We believe it is important for New Brunswickers to understand the impact of such a move, especially when it comes to the cleanliness of a building which the public relies on everyday," Robinson said. Last year, the Horizon Health Network started a regular audit of the cleanliness of hospitals being serviced by unionized public sector workers. Auditor General Kim MacPherson reported that health-care workers weren't cleaning their hands as required and that the standards to do so weren't even the same within the two regional health authorities.

Robinson said Friday that policies have been established and changes made that are addressing cleanliness concerns. "And they have improved on their targets of cleaning in the hospital sector," she said. The union claims its research into the three companies they believe are being considered to take over those services - Sodexo, Aramark and Compass - shows a poor track record. The union said it's also concerned about the quality of food declining. The union wants to keep the management of hospital environmental services in-house. It also wants fair wages and benefits for cleaning and food services staff to ensure against high turnover and gaps in training. The union also stated lay-offs and staff reductions would be a poor way to balance the budget.

"The cost associated with treating hospital-acquired infections, managing public relations fiascoes and defending lawsuits would defeat any possible savings while destroying the public trust." The Province of New Brunswick expects to have completed talks with a private contractor for the management of health-care cleaning and food services before the end of the year.

Bruce McFarlane, Health Minister Victor Boudreau's director of communications, said Friday that the province is "still in current discussions with the preferred proponent and we hope to have completed the process sometime this fall." McFarlane sent The Daily Gleaner an email statement Friday afternoon after the New Brunswick Council of Hospital Unions CUPE local 1252 released a 20-page document critical of the government's plan to privatize housekeeping, food services and porter services at hospitals. "We want to clarify that we are only outsourcing the management of the services," said McFarlane, who added that the ministry had not yet received the document.

"CUPE staff will remain in their union and will continue to be employees of the Province of New Brunswick." Norma Robinson, president of CUPE Local 1252, said she is "very concerned that the Liberal government is negotiating with a private firm to take over the management of food and cleaning services in the province's hospitals." Robinson said she's worried the move could lead to further privatization. In an interview with Brunswick News in April, Boudreau said the government wants to give the private sector a greater role in the province's health-care system.

Boudreau has said the move will save the province millions of dollars through efficiencies brought in by a private company. However, the union's document paints a poor picture of privatization of services in health-care facilities in other jurisdictions. "We believe it is important for New Brunswickers to understand the impact of such a move, especially when it comes to the cleanliness of a building which the public relies on everyday," Robinson said. Last year, the Horizon Health Network started a regular audit of the cleanliness of hospitals being serviced by unionized public sector workers. Auditor General Kim MacPherson reported that health-care workers weren't cleaning their hands as required and that the standards to do so weren't even the same within the two regional health authorities.

Robinson said Friday that policies have been established and changes made that are addressing cleanliness concerns. "And they have improved on their targets of cleaning in the hospital sector," she said. The union claims its research into the three companies they believe are being considered to take over those services - Sodexo, Aramark and Compass - shows a poor track record. The union said it's also concerned about the quality of food declining. The union wants to keep the management of hospital environmental services in-house. Calls made to Sodexo, Aramark and Compass were not returned by press time.

"I work with a lot of new staff in my role and they tell me, ""It's different here," she says. "Employees go above and beyond; they will do whatever it takes to make that difference in people's lives, whether it is a patient or a co-worker." Successfully recruiting employees who embrace Covenant Health's compassionate goals and values is no accident but, rather, it is the result of a careful process, says Dumelie. "We spend a considerable amount of effort and energy ensuring that, as we attract people to our organization, we attract people who want to be part of our mission." Attracting and retaining the right people is critical for the organization, which has 15,000 physicians, employees and volunteers, given the steady population growth of increasing demands for health care as the average age of Albertans rises. "We are a large organization that is growing rapidly," says Dumelie. "Population growth, demographic shifts and the rising need for seniors care has meant that the demands for our services continue to grow."

Engagement is a well-worn buzzword among employers that are focused on issues such as employee morale, motivation and job satisfaction. Covenant Health has an established engagement program and also measures its employee engagement every two years to ensure that staff not only share and live the organization's values but see a continuing or growing role with the healthcare provider. "We spend time with our employees to make sure that we provide them the opportunity to learn and grow, contribute to our culture and also be leaders within it," says Dumelie. The organization-wide engagement program "on all accounts improves quality," says the Covenant Health chief executive. "It improves retention, it improves every dimension of the workplace. Ultimately, it benefits those that we serve." © 2015 Postmedia Network Inc. All rights reserved. Illustration: • / Body, mind and soul: Covenant Health employees live its values every day - at the bedside, in decision-making and in how colleagues treat one another.

Philpott said one of the misconceptions about the future of health care is that demographics - a silver tsunami related to an aging population - is going to bankrupt government coffers. While she acknowledged that seven per cent of $1,000-a-day hospital beds are taken up by seniors and 14 per cent of beds are occupied by patients who should be in alternate levels of care, Philpott threw cold water on the "doom and gloom" forecasts that an aging population means "massive infusions of cash" are needed to sustain public health care. Sticking to the federal government's commitment to inject another $3 million over four years into home care, she noted it's not only cost effective but preferred by patients and their families.

Federal health minister Jane Philpott said Tuesday a national pharmacare program is likely years away because of more pressing priorities like primary care, improved health for indigenous people, better care for those with mental illness, and more home care for seniors. "I do not want to promise anything I don't know I can deliver on," she told about 600 delegates and observers at the annual Canadian Medical Association meeting in Vancouver.

The reality is I don't know how this is going to end up. A lot of this will come down to basic principles of fairness." While Canada spends more per capita than many other countries, Philpott said she's concerned about international rating systems that show Canada gets poorer outcomes compared to countries such as Australia, the United Kingdom, France and Germany. During a press scrum, a journalist noted that all those other countries have parallel public/private systems. But Philpott insisted the federal government is only interested in how those other countries deliver care within the publicly funded realm. "Our government is firmly committed to upholding the Canada Health Act. That act has principles around accessibility and universality and it means Canadians have access to care based on need, not on ability to pay," she said. "You cannot have a growing, thriving middle class unless you have a publicly funded universal health care system."

Philpott attempted to dissuade doctors of the notion that the federal role is merely to transfer money to the provinces ($36 billion this year), maintaining that the government and "this minister of health" is determined to be engaged in health system transformation. The provinces have begun the slow process of negotiations with the federal government on a renewal of the Canada Health Accord to be signed sometime next year. But some health ministers have complained that the feds have given no indication about how much money they can expect. It's been more than a decade since the provinces and the federal government negotiated transfer payments and Philpott said that while the last round led to improvements like shorter waiting times in some surgical areas, "it did not buy change. So we should use this opportunity to trigger innovation."

Philpott said real change will incorporate digital health records and the banishment of anachronisms like fax machines. Patients should be seamlessly connected, in real time, to their health care providers, hospital, home care, pharmacy and lab. "What is it going to take to get there? Pragmatism, persistence and partnership. Changes require courage and practicality." Doctors gave her enthusiastic applause for stating that low socioeconomic status represents one of the greatest barriers to good health and "that is why this government believes that the economy and jobs and a stronger middle class will reduce social inequity." She said in 2016, the federal government has earmarked $8.4 billion in spending on social and economic conditions for indigenous communities. Earlier Tuesday, on the second day of the three-day annual meeting, doctors passed numerous motions that will now go to their board for further discussion before becoming official policy.

Delegates passed a motion introduced by Ontario doctor Stephen Singh of the Canadian Society of Palliative Care Physicians that aims to distinguish between palliative care ("neither to hasten or postpone death") and medical assistance in dying. Most palliative care doctors don't want to serve as gatekeepers to doctor-assisted dying, but they do want to consult with patients who have life-limiting illnesses in order to help mitigate their suffering.

the deal offered by Mr. Harper’s government is reasonable. It is fiscally responsible, tying spending increases to inflation

It is also politically astute, for a host of reasons:

* It avoids the sordid scene we saw in 2004 when provincial premiers ganged up on prime minister Paul Martin and extorted $41-billion in additional health dollars and a spendthrift 6-per-cent escalator clause on transfers.

* It is a 10-year deal, just as the provinces demanded, allowing some certainty in budgeting.

* It respects Mr. Harper’s election promise to maintain 6-per-cent increases beyond 2014 – at least nominally. (Those who wanted 6 per cent per annum were dreaming in Technicolor.)

* It puts the onus on the provinces to justify why health-care spending should exceed inflation, something they have never been able to do.

* It places no restrictions on how the provinces spend the $40-billion a year they receive in federal health transfers (along with another $20-billion in social transfers for education and welfare programs.)

It should be an instrument for improving health-care delivery, and in that regard, Mr. Flaherty’s offer fails miserably

What the public should expect from Ottawa is that federal funds be used to exercise leadership and foster innovation

The reason Ottawa transfers money to the provinces in the first place (because health is a provincial responsibility constitutionally) is to ensure some semblance of equity coast-to-coast-to-coast. But there are areas, such as catastrophic drug coverage and homecare, where there are gross regional disparities.

This accord will force the provinces to rein in health spending, which is not a bad thing in itself. But one of the consequences will likely be greater disparities in the quality of care and breadth of coverage between the have and have-not provinces.

The great failure here is not refusing to increase transfers by 6 per cent, it is failing to attach strings to the monies.

With this deal, Mr. Harper has shown himself to be politically astute and fiscally prudent, but he has failed to show a commitment to strengthening health care, and medicare more specifically.

the impact of Liberal health-care policy in southern Ontario is "bad enough." The model Mehra said the province is using to centralize services into fewer communities is especially detrimental to the North. "That doesn't work for the south," she added. "It definitely, in no way, works for Northern Ontario." The state of Northern health care was brought to the floor of Queen's Park this week when, on Wednesday during Question Period, NDP health critic France Gélinas called on the government to stop continued cuts to care in the region. Funding based on volumes doesn't jibe with regional population distributions, Mehra said. "It just doesn't make any sense at all," she said, adding Northern Ontario has many common complaints with small, rural southern Ontario communities.

The coalition argues the entire Ontario system has received short shrift for years and is below the Canadian per capita average by about $350 per person. The provincial Liberals ended a four-year hospital base funding freeze in its latest budget, pledging to spend $60 million on hospital budgets, along with $75 million for palliative care and $130 million for cancer care. The Ontario Health Coalition - and Sault and Area Health Coalition - are not impressed. The local group argues on a regular bases, 22 admitted patients often wait in SAH's Emergency Department for inpatient beds and admitted patients stay in emergency for as long as five days. Patients are lined along hallways on the floors or put in areas that were designed to be stretcher storage areas or lounges with no call buttons, oxygen, out of the nurses' usual treatment areas. Late last month, the Ontario Health Coalition launched an Ontario-wide, unofficial referendum to raise awareness about what it contends is a system in critical condition. The unofficial referendum asks Ontarians if they're for or against the idea: "Ontario's government must stop the cuts to our community hospitals and restore services, funding and staffto meet our communities' needs for care." Ballot boxes will be distributed to businesses, workplaces and community

centres across the province before May 28, when votes will be tallied and presented to Premier Kathleen Wynne. "We have to make it so visible, and so impossible to ignore, the widespread public opposition to the cuts to local public hospitals so the province cannot continue to see all those cuts through," Mehra said. Similar public OHC-led lobbying helped limit and "significantly" change policy in a past Sault Area Hospital bid to usher in publicprivate partnerships (P3s), she added. "The referendum is a way to make that so visible, so impossible to ignore by the provincial government, that we actually stop the cuts," Mehra said. Other speakers Thursday included Sault coalition member Peter Deluca, who spoke of the many challenges his elderly parents have endured thanks to what he dubbed less-than-stellar hospital experiences. "We deserve the truth, we deserve answers, not just political talk," said Deluca, adding concerned citizens must band together in order to prompt change and halt healthcare cuts.

Sharon Richer, of Ontario Council of Hospital Unions/CUPE, said as a Health Sciences North employee, she's seen "first-hand" how cuts affect health care. "There won't be change if we don't make a ripple," she said. Laurie Lessard-Brown, president of Unifor Local 1359, told the meeting of how SAH's recent "wiping out" of the personal support worker classification is wreaking havoc on staff and patients, alike. Registered nurses and registered practical nurse must now pick up the slack, she added. "Morale is lowest I've ever seen," Lessard-Brown said. And, as recent as last Tuesday, Unifor learned of a further four full-time RPN positions being cut while supervisor positions were being added. "Cutting front-line workers is not acceptable," Lessard-Brown said. jougler@postmedia.com On Twitter: @JeffreyOugler © 2016 Postmedia Network Inc. All rights reserved.

Natalie Mehra, Ontario Health Coalition executive director, decries what she describes as the profound lack of funding being divvied out to Ontario hospitals during a town hall meeting Thursday evening, hosted by the Sault and Area Health Coalition at Royal Canadian Legion, Branch 25.

To shed new empirical light on this old debate, we quantified the impacts of demographic and non-demographic determinants of healthcare expenditure using data for British Columbia (BC) over the period 1996 to 2006. Using linked administrative healthcare data, we quantified the trends in and the determinants of expenditures on hospital care, physician services and pharmaceuticals. To our knowledge, this is the first time that all three of these major components of healthcare costs have been analyzed in a single Canadian study.

our study cohort included 3,159,900 residents in 1996 and 3,662,148 residents in 2006

We found that population aging in British Columbia contributed less than 1% per year to total growth of expenditures on hospital, medical and pharmaceutical care from 1996 to 2006. We also found that changes in age-specific mortality rates reduced (albeit modestly) per capita healthcare costs over time, confirming what other researchers have suggested (Fries 1980; Breyer and Felder 2006). With rigorous analysis of recent healthcare data, we can therefore confirm what studies spanning earlier decades for British Columbia, elsewhere in Canada and other comparable health systems have found: the net impact of demographic factors on major components of the healthcare system is moderate (Denton and Spencer 1983; Fuchs 1984; Barer et al. 1987, 1995; Gerdtham 1993; Evans et al. 2001; McGrail et al. 2001). Moreover, when we forecasted the effects of expected demographic changes in British Columbia through 2036, we found that the future effects of population aging on healthcare spending will continue to be modest (1% or less per year).

Our findings also indicated that average payment per unit of hospital care increased over the period. The increase in hospital unit costs may have been an appropriate policy response to increases in age-adjusted clinical complexity per patient remaining in care following reductions in the average length of stay

After taking into account population aging, the average number of days of prescription drug therapy received by British Columbia residents grew more than 5% per year during the first half of our study period and plateaued in the latter half of the period (data not shown)

Despite popular claims about population aging and the sustainability of healthcare in Canada, demographic changes exert steady, predictable and modest forces on the cost of major components of our healthcare system. This is likely to remain true for the foreseeable future.

Doctors have already made it clear that they don’t want centralization of services to detract from the needs of local communities. “Physicians want administrative feet on the ground. They want local support,” says Harrigan. “Any model we come up with will have to reflect this.”

The government has made four commitments, including developing a multi-year health plan for the province that will set targets for improvement. There is also a legal requirement for the IWK Health Centre in Halifax and the provincial health board — the two authorities created by the new legislation — to prepare annual public-engagement plans to ensure community voices are heard.

Physicians’ response to the merger, which was a prominent 2013 election promise from the Liberal government, has been cautious but supportive. “We’re looking at it as an opportunity to work with government so patients are better served,” says Kevin Chapman, director of Health Policy and Economics with Doctors Nova Scotia.

The new physician bylaws, now being developed by the health department and Doctors Nova Scotia, are also expected to change credentialing and privileging in the province. “We want to streamline this,” says Patrick Lee, CEO of the Pictou County Health Authority who is currently serving as co-lead of the provincial consolidation project.

Privileging is not now required in Nova Scotia, and physicians who want to be credentialed to work in more than one health facility must repeatedly go through the administrative process. Under the consolidated system, all physicians will likely have to be privileged, and credentialing will be simplified. Doctors Nova Scotia applauds both approaches but expressed concerns these systems could be used to restrict physicians to specific geographical locations.

That worry is unfounded, says Lee. “We have no plans to make any of those changes.”

One of the major — and controversial — changes the government has made is to reorganize the way health care workers are unionized. Four existing unions will continue to represent health workers, but they will represent only one group each. The Nova Scotia Nurses’ Union, for example, will represent all nurses in the province. The move is intended to reduce the rounds of bargaining from 50 to 4, according to the government.

The implications are already significant for the health care system, says Joan Jessome, president of the Nova Scotia Government and General Employees Union, which stands to lose 10 000 members under the restructuring. “It’s affected patient care today. [Staff] are all distracted.”

Canada’s health system is not transparent enough, says a new report that calls for more public reporting on patient experience, such as in instances when they are harmed. Consideration should be given to publicly reporting physician-level outcomes, such as death rates for patients of individual cardiac surgeons, states the report published Thursday by the C.D. Howe Institute. More collection and public disclosure are critical to creating better value for the health system, it says, urging the federal and provincial governments to pave the way. “From a democratic perspective, publicizing outcome measures can empower patients, families and communities to engage in the policy debate about which outcomes matter most and at what cost — and in the ways health care should be delivered,” says the report, titled “Canadian Health Care Needs a Checkup, Here’s How.”

Health-care outcomes that could be measured and publicly reported include data about death, disease, disability, discomfort and dissatisfaction, it states. As well, there could be more transparency surrounding patient satisfaction and health-system responsiveness.

“Public reporting of any individual physician or health-care provider has not shown to improve patient outcomes or satisfaction levels,” a statement from the OMA said. “Our health-care system is made better through the collection and reporting of accurate and meaningful data that physicians use to innovate how they deliver care.”

Long-term care: Invest in infrastructure so there is an adequate number of beds, and so they are affordable, particularly for seniors with specialized needs, such as those with dementia. Palliative care: Promote advance-care planning and ensure everyone gets palliative care at the end of life. In a wide-ranging discussion, delegates to the CMA meeting identified a number of specific issues that are hampering the provision of care to seniors with chronic health conditions, such as the lack of electronic health records, the way health-care delivery is siloed in Canada, the absence of pharmacare, physician payment schemes that reward volume rather than quality of care, the lack of training in geriatrics and a lacklustre commitment to patient-centred care.

The overarching theme was that if care is going to be improved for the burgeoning population of seniors, it must begin with better co-ordination. Dr. David Naylor, who headed the federal Advisory Panel on Healthcare Innovation, also stressed this as an essential element of reform. In a keynote address to the CMA meeting, he said that while Canadians love their medicare system - at least in theory - the reality is that "the scope is narrow and performance is middling." Dr. Naylor said the main reason Canadians don't get good value for money when it comes to health spending is a lack of co-ordination of care. "The critical factor is integration of services," he said.

Right now, far too many patients, especially seniors with chronic conditions, are being cared for in hospitals rather than in the community and their care is disjointed, the CMA's report notes. Fixing that will, among other things, require a reorganization of roles between various health professions, including physicians, nurses and pharmacists. "All health-care professionals are going to have to do their bit to deal with this grey tsunami," he said, stressing that many innovative solutions have been put in place across the country, but they are too rarely scaled up.

Dr. Naylor said policy-makers, and federal politicians in particular, need to take a leadership role to ensure this happens. Dr. Simpson of the CMA also called for federal political parties to commit to a seniors' strategy during the current election campaign, and said he is confident they will. "We know they're thinking about it. We know their hearts are in the right place," he said. "Now we want them to start talking about seniors' health care in the context of the election campaign so people can cast their votes accordingly."

Brett J. Skinner is founder and CEO of the Canadian Health Policy Institute and author of "How to Grow the Economy by Liberating Healthcare" (forthcoming).

Canadians spent almost $200-billion on health care in 2010, equal to about 12% of GDP

The health-care industry is also a job-creation machine.

current market demand for health care exceeds the current market supply

economic growth in the industry, is artificially constrained by limited government resources and policy barriers to private-sector funding and delivery