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The committee is one of the most well-respected human rights bodies in the world, comprised of independent and eminent international law experts from every continent. My experiences in Geneva affirmed my impression that the committee approaches the Herculean task of ensuring compliance with the International Covenant on Civil and Political Rights with professionalism and rigour. After reviewing thousands of pages of documentation, listening to hours of testimony from NGOs and the Canadian government, and grilling government representatives with insightful questions, on Thursday, the committee issued its final verdict.

The concluding observations for Canada are breathtaking in their scope, covering issues related to national security, Aboriginal Peoples' rights, prisoners' rights, and even freedom of expression and association for human rights defenders.

The document is a sobering reminder of how much Canada has changed in the 10 years since our last review and we should be outraged that, in such a short time, our international reputation has been so tarnished. We have gone from being a global leader in the protection of human rights - the gold standard, even - to a country that repeatedly ignores UN recommendations, engages in suppression of dissent, and enables cruel treatment of migrants. At seven pages in length, the UN's assessment of Canada is necessary pre-election reading for anyone wishing to chart the changes wrought to our society in the past nine years of Conservative government rule.

Of particular interest to me, of course, were the concluding observations and recommendations related to Canada's treatment of non-citizens, people like Hassan. The committee expressed grave concerns around laws that allow for the mandatory detention of asylum-seekers who arrive by boat, recent cuts to the interim federal health program for asylum-seekers, and indefinite detention of migrants.

The committee recommended that Canada ensure that there is proper oversight over CBSA, place time limits on immigration detention, and ensure there are viable alternatives to detention. It also recommended that those held in provincial jails be granted access to treatment centres for mental health issues.

These recommendations are an important vindication of the rights of non-citizens, thousands of whom are detained in maximum-security jails every year, including vulnerable migrants such as asylum-seekers, torture survivors and those with serious mental health issues, people like Hassan.

However, the UN's strong recommendations will quickly become cold comfort for Hassan's family if Canada does nothing to implement them. Despite the death of at least 11 immigration detainees held in CBSA custody since 2000, Canada has done nothing to end arbitrary detention and cruel treatment of non-citizens held without charge. Now that the UN has made recommendations to end rights violations against immigration detainees, we must press all the major political parties to commit to implementing the recommendations if elected. Renu J. Mandhane is executive director of the international human rights program at the University of Toronto's faculty of law.

An alliance of Canadians from coast to coast to coast is taking up that question, launching a homegrown initiative that day to promote a healthy environment for debate, dissent, diversity, and democracy in Canada.

In Zimbabwe, Honduras, China, and too many other countries the risks for those who speak out are huge. Freedom of expression and freedom of association are under attack. Human rights defenders are targeted.

Given this bleak backdrop, some might suggest we have little to complain about in Canada. But the past dismal decade is a sober reminder there’s no cause for complacency. On the contrary, citizens and organizations critical of the government were dismissed, dismantled, defamed, and defunded. Officers of Parliament were silenced as were scientists and public servants. Access to evidence was severely constrained and dissent increasingly criminalized.

If you were from an indigenous community or a Muslim or a climate activist, you were all the more vulnerable to drive-by smears—or worse.

Transformative change is required to our laws, institutions, priorities, and political culture. Respect for human rights—both charter rights and Canada’s international obligations—must serve as the bedrock upon which all policies and programs are founded. And the vital role of civil society organizations in informing public opinion, shaping public policy, and generating political will must be respected and promoted.

This is particularly true for groups that represent marginalized constituencies including women, racialized peoples and others who have borne the brunt of cuts, attacks, and discrimination. Critically, the Canadian government must build a new relationship with indigenous peoples based on rights, respect, co-operation, and partnership.

Parliamentary accountability must be strengthened, ending omnibus bills and improving oversight and independent review. Citizens must have ready access to information, including all publicly funded research. And public servants must be encouraged to provide independent advice based on evidence and respect for the constitution and human rights. The agenda for action is ambitious but vital if we are to have a healthy enabling environment for a flourishing Canadian democracy.

It’s also a living document. The public, parliamentarians, pundits, and public interest groups are all encouraged to contribute their ideas and to join in securing the essential reforms we so urgently need. In its first six months, we’ve seen encouraging signals the government is following through on commitments to increase transparency and accountability. Renewed funding for the Court Challenges program, for example, is a welcome show of good faith.

But we’ve also seen troubling lapses where human rights have taken a back seat and alternative views have been censured, in particular in relation to the Middle East. And there are major files that remain open, including replacing Bill C-51 with legislation that respects rights and complies with the Charter of Rights and Freedoms.

The signal we send and the example we set for advocates of freedom of expression and association around the world are critical if the phrase “Canada’s back” is to have any substance and sunny ways are to prevail—let alone if we are to reinforce these rights so they are stronger here than ever before. There is no better time for bold action to bolster respect for rights and civic engagement than now. Robert Fox is a founding member of the Voices Coalition and a long-time social justice activist.

The Facts: In 2012, the Health Employers' Association of British Columbia introduced an Influenza Control Program Policy requiring health care workers to get a flu shot or wear a mask while caring for patients during flu season, which the union grieved. The employer, representing six Health Authorities in B.C., implemented the policy in response to low vaccine coverage rates of health care workers and an inability to achieve target rates of vaccination through campaigns promoting voluntary vaccination commencing in 2000. Acting on the advice of Dr. Perry Kendall, B.C.'s Provincial Health Officer, and relying on evidence suggesting that health care worker vaccination and masking reduce transmission of influenza to patients, the employer moved towards a mandatory policy. Asserting that members had the right to make personal health care decisions, the B.C. Health Sciences Association filed a policy grievance, contending that the policy violated the collective agreement, the Human Rights Code of British Columbia, privacy legislation, and the Canadian Charter of Rights and Freedoms. Extensive expert medical evidence during the hearing indicated that immunization was beneficial for the health care workers themselves, but was divided as to whether immunization of health care workers reduced transmission to patients. The evidence was similarly divided as to the utility of masking.

Comment:

Having determined that the policy was reasonable under the KVP test, Diebolt turned to the Irving test applicable to policies that affect privacy interests, which he characterized as requiring an arbitrator to balance the employer's interest in the policy as a patient safety measure against the harm to the privacy interest of the health care workers with respect to their vaccination status. Determining that the medical privacy right at stake in the annual disclosure of one's immunization status did not rise to the level of the right considered in Irving, which involved "highly intrusive" seizures of bodily samples, Diebolt further held that the employer's interest in patient safety related to a "real and serious patient safety issue" and that "the policy [was] a helpful program to reduce patient risk." Diebolt also considered that the employer had chosen the least intrusive means to advance its interest in light of the unsuccessful voluntary programs and in providing the alternative of masking. To quote the arbitrator: "[W]eighing the employer's interest in the policy as a patient safety measure against the harm to the privacy interest of the health care workers and applying a proportionality test respecting intrusion, based on the considerations set out above I am unable to conclude that the policy is unreasonable."

Diebolt also upheld the masking component of the policy as reasonable, finding on the evidence that masking had a "patient safety purpose and effect" by inhibiting the transmission of the influenza virus, and an "accommodative purpose" for health care workers who conscientiously objected to immunization. Observing that mandatory programs have been accepted in New Brunswick and the United States, Diebolt also considered that regard should be paid to the precautionary principle in health care settings that "it can be prudent to do a thing even though there may be scientific uncertainty." Moreover, he held that the absence of a reference to accommodation did not make the policy unreasonable, noting that this duty was a free-standing legal obligation that was not required explicitly to be incorporated into the policy and that any such issue should be addressed in an individual grievance if made necessary by the policy's application. He also rejected the union's submission that the policy could potentially harm health care workers' mental and physical health, considering the evidence to fall short of "establishing a significant risk of harm, such that the policy should be considered unreasonable."

Turning first to the KVP test, specifically whether the policy was consistent with the collective agreement and was a reasonable exercise of the employer's management rights, Diebolt noted that the only possible inconsistency with the collective agreement would be with the non-discrimination clause, given his ruling regarding the scope of Article 6.01, and that he would address this issue in his reasons with respect to the Human Rights Code. Diebolt then turned to the reasonableness of the policy and found, after an extensive review of the conflicting medical evidence that: (1) the influenza virus is a serious, even fatal disease; (2) immunization reduces the probability of contracting the disease; and (3) immunization of health care workers reduces the transmission of influenza to patients. Accordingly, Diebolt reasoned that the facts militated "strongly in favour of a conclusion that an immunization program that increases the rate of health care immunization is a reasonable policy."

Diebolt instead regarded the policy as a unilaterally imposed set of rules, making it necessary to establish that they were a legitimate exercise of the employer's residual management rights under the collective agreement and met the test of reasonableness set out in Lumber & Sawmill Workers' Union, Local 2537 v. KVP Co., [1965] O.L.A.A. No. 2 (QL) (Robinson). In addition, given that the policy contained elements that touched on privacy rights, Diebolt held that the policy must also meet the test articulated in CEP, Local 30 v. Irving Pulp & Paper, Ltd., 2013 SCC 34 (CanLII) (reviewed in Lancaster's Disability & Accommodation, August 9, 2013, eAlert No. 182), in which the Supreme Court of Canada held that an employer cannot unilaterally subject employees to a policy of random alcohol testing without evidence of a general problem with alcohol abuse in the workplace, based on an approach of balancing the employer's interest in the safety of its operations against employees' privacy.

In a 115-page decision, Arbitrator Robert Diebolt denied the grievance and upheld the policy as lawful and a reasonable exercise of the employer's management rights.

The Decision:

As noted by the arbitrator, no Canadian decision has addressed a seasonal immunization policy similar to the policy in this case. However, a number of decisions have addressed, and generally upheld, outbreak policies mandating vaccination or exclusion on unpaid leave. B.C. Health Sciences Association President Val Avery expressed his disappointment in the arbitrator's ruling, stating: "Our members believed they had a right to make personal health care decisions, but this policy says that's not the case." Avery said the Association is studying the ruling and could appeal. On the other hand, Dr. Perry Kendall, B.C.'s chief medical officer of health, applauded the decision, calling it a "win for patients and residents of long-term care facilities."

In 2012, Public Health Ontario changed its guidelines to call for mandatory flu shots because not enough health care workers were getting them voluntarily. Other municipal public health units – led by Toronto Public Health – also called for mandatory shots. Ontario's chief medical officer of health, Dr. Arlene King, stated in November 2013 that, while the government wants to see a dramatic increase in the number of health care workers who get a flu shot, it is stopping short of making vaccinations compulsory, but has instead implemented a three-year strategy to "strongly encourage health care workers to be immunized every year." She acknowledged, however, that the number of health care workers getting inoculated remains at 51 percent for those employed in hospitals and 75 percent for those in long-term care homes. For further discussion of the validity of employer rules, see section 14.1 in Mitchnick & Etherington's Leading Cases on Labour Arbitration Online.

We are, overall, quite pleased that the committee recognized that indefinite detention and the lack of alternatives are serious problems with the system in Canada," Mandhane said in an interview. "It hits all the key points we have raised. The fact that the Canadian government is required to report back within a year on its recommendations speaks to the seriousness of the issue."

Canada's immigration detention system has been under the spotlight in recent years, after the deaths of detainees in custody, including Mexican migrant Lucia Vega Jimenez in Vancouver in 2013 and Somali native Abdurahman Ibrahim Hassan, a mentally ill man who died in a Peterborough hospital in June. Last year alone, Canada detained 8,519 people - more than half in Ontario - who violated immigration law. While detainees were held an average of 23 days, 58 individuals had been detained for more than a year, including four who had been in jail for five years and more.

thanks to predictable and escalating funding over the first seven years of the plan

however, there are, unfortunately, pockets of inattention and/or mediocrity as well

Six areas, in fact, were identified by CHA

funding matters; health human resources; pharmacare; wellness, identified as health promotion and illness and disease prevention; continuing care; and leadership at the political, governance and executive levels

The focus of this 10-year plan has been on access. CHA would posit that it is at this juncture, the focus must be on quality and accountability.

safety, effectiveness, efficiency, appropriateness

Canada does an excellent job in providing world-class acute care services, and we should; hospitals and physicians have been the core of our systems for decades. Now is the time to ensure sufficient resources are allocated to other elements of the continuum, including wellness and continuing care.

Home care is one readily available yet underused avenue for delivering health promotion and illness prevention initiatives and programs.

four critically important themes: dignity and respect, support for caregivers, funding and health human resources, and quality of care

Nadine Henningsen, Executive Director, Canadian Home Care Association

Today, an estimated 1.8 million Canadians receive publicly funded home care services annually, at an estimated cost of $5.8 billion. This actually only equates to about 4.3 per cent of our total public health care funding.

There are a number of initiatives within the home care sector that need to be addressed. Establishing a set of harmonized principles across Canada, accelerating the adoption of technology, optimizing health human resources, and integrated service delivery models all merit comment.

great good has come from the 10-year plan

Unfortunately, there were two unintended negative consequences

One was a reduction in chronic care services for the elderly and

a shift in the burden of costs for drugs and medical supplies to individual and families. This was due to early discharge and the fact that often a number of provinces do not cover the drugs and supplies under their publicly funded program.

Stakeholders across Canada generally agreed that the end-of-life expectations within the plan were largely met

How do we go from having a terrific acute care system to having maybe a slightly smaller acute care system but obviously look toward a chronic care system?

Across Canada, an estimated 30 to 50 per cent of ALC patients could and should benefit from home care services and be discharged from the hospital.

Second, adopt a Canadian caregiver strategy.

Third, support accountability and evidence-informed decision making.

The return on investment for every dollar for home care is exponentially enhanced by the in-kind contribution of family caregivers.

Sharon Baxter, Executive Director, Canadian Hospice Palliative Care Association

June 2004

a status report on hospice, palliative and end-of-life care in Canada

Dying for Care

inconsistent access to hospice palliative care services generally and also to respite care services; access to non-prescribed therapies, as well as prescription drug coverage

terminated by the federal government in March of 2008

the Canadian Strategy on Palliative and End-of-Life Care

Canadian Hospice Palliative Care Association and the Canadian Home Care Association embarked on what we called the Gold Standards Project

In 2008, the Quality End-of-Life Care Coalition released a progress report

progress was made in 2008, from the 2004 accord

palliative pharmaceutical plan

Canadians should have the right to choose the settings of their choice. We need to look for a more seamless transition between settings.

In 2010, the Quality End-of-Life Care Coalition of Canada released its 10-year plan.

Seventy per cent of Canadians at this point in time do not have access to hospice palliative care

For short-term, acute home care services, there was a marked increase in the volume of services and the individuals served. There was also another benefit, namely, improved integration between home care and the acute care sector.

last summer, The Economist released a document that looked at palliative services across 40 countries

The second area in the blueprint for action is the support for family caregivers.

The increasing need for home-based care requires us to step up and strive for a comprehensive, coordinated and integrated approach to hospice palliative care and health care.

Canadian Caregiver Coalition

in Manitoba they have made great strides

In New Brunswick they have done some great things in support of family caregivers. Ontario is looking at it now.

we keep on treating, keep on treating, and we need to balance our systems between a curative system and a system that will actually give comfort to someone moving toward the end of their life

Both the Canadian Institute for Health Information and the Canadian Health Services Research Foundation have produced reports this year saying it is chronic disease management that needs our attention

When we look at the renewal of health care, we have to accept that the days of institutional care being the focus of our health care system have passed, and that there is now a third leg of the stool. That is community and home care.

Over 70 per cent of caregivers in Canada are women. They willingly take on this burden because they are good people; it is what they want to do. The patient wants to be in that setting, and it is better for them.

The Romanow report in 2002 suggested that $89.3 million be committed annually to palliative home care.

that never happened

What happened was a federal strategy on palliative and end-of-life care was announced in 2004, ran for five years and was terminated. At best it was never funded for more than $1.7 million.

Because our publicly funded focus has been on hospitals and one provider — physicians, for the most part — we have not considered how to bring the other pieces into the equation.

Just as one example, in the recent recession where there was special infrastructure funding available to stimulate the economy, the health system was not allowed to avail itself of that.

As part of the 10-year plan, first ministers agreed to provide first dollar coverage for certain home-care services, based on assessed need, by 2006. The specific services included short-term acute home care, short-term community mental health care and end-of-life care. It appears that health ministers were to report to first ministers on the implementation of that by 2006, but they never did.

One of the challenges we find with the integration of mental health services is

A lot of eligibility rules are built on physical assessment.

Very often a mental health diagnosis is overlooked, or when it is identified the home care providers do not have the skills and expertise to be able to manage it, hence it moves then over to the community mental health program.

in Saskatchewan it is a little more integrated

Senator Martin

I think ideally we would love to have the national strategies and programs, but just like with anything in Canada we are limited by the sheer geography, the rural-urban vast differences in need, and the specialized areas which have, in and of themselves, such intricate systems as well. The national picture is the ideal vision, but not always the most practical.

In the last federal budget we got a small amount of money that we have not started working with yet, it is just going to Treasury Board, it is $3 million. It is to actually look at how we integrate hospice palliative care into the health care system across all these domains.

The next 10-year plan is about integration, integration, integration.

the Canadian Patient Safety Institute, the Health Council of Canada, the Canadian Health Leadership Network, the health sciences centres, the Association of Canadian Academic Healthcare Organizations, the Canadian College of Health Leaders, the Canadian Medical Association, the Canadian Nurses Association, the Canadian Public Health Association, the Canadian Agency for Drugs and Technologies in Health and Accreditation Canada

We are all meeting on a regular basis to try to come up with our take on what the system needs to do next.

most people want to be cared for at home

Family Caregiver Tax Credit

compassionate care benefit that goes with Employment Insurance

Have you done any costing or savings? Obviously, more home care means more savings to the system. Have you done anything on that?

In the last federal election, every political party had something for caregivers.

tax credits

the people we are talking about do not have the ability to take advantage of tax credits

We have a pan-Canadian health/human resource strategy in this country, and there is a federal-provincial-territorial committee that oversees this. However, it is insufficient

Until we can better collaborate on a pan-Canadian level on our human resources to efficiently look at the right mix and scope and make sure that we contain costs plus give the best possible provider services and health outcomes right across the country, we will have problems.

We have not as a country invested in hospital infrastructure, since we are talking about acute care settings, since the late 1960s. Admittedly, we are moving away from acute care centres into community and home care, but we still need our hospitals.

One of the challenges is with the early discharge of patients from the hospital. They are more complex. The care is more complex. We need to train our home support workers and our nurses to a higher level. There are many initiatives happening now to try to get some national training standards, particularly in the area of home support workers.

We have one hospital association left in this country in Ontario, OHA. Their CEO will constantly talk about how the best thing hospitals can do for themselves is keep people out of hospitals through prevention promotion or getting them appropriately to the next place they should be. Jack Kitts, who runs the Ottawa Hospital, and any of the CEOs who run hospitals understand one hundred per cent that the best thing they can do for Canadians and for their institutions is keep people out of them. That is a lot of the language.

We have an in-depth brief that details a lot of what is happening in Australia

I would suggest that it is a potentially slippery slope to compare to international models, because often the context is very different.

While the findings and recommendations are not binding, Smith said they highlight the challenges faced by African Canadians for the international community and hopefully put more pressure on Ottawa to rectify the inequities. "The situation is only going to get worse," Smith said. "We have families in the community torn apart at an alarming rate. "The future looks pretty bleak for our young people."

The UN delegation was in Toronto, Ottawa, Montreal and Halifax to meet with government officials, community members and rights groups to identify good practices and gaps in protecting the rights of black people. "We had been trying to secure a visit to Canada for a long time. It's a great joy that we were officially invited here," the working group's chair Ricardo Sunga told the Star in a phone interview Tuesday. "We look at Canada as a model in many ways when it comes to human rights protection.

We appreciate Canada's effort in addressing discrimination in various forms, but no country is exempt from racism and racial discrimination." Despite the wealth of information on socio-economic indicators in Canada, the investigators criticized the "serious" lack of race-based data and research that could inform prevention, intervention and treatment strategies. "The working group is concerned that the category 'visible minorities' obscures the realities and specific concerns of African Canadians," its report said. "There is clear evidence that racial profiling is endemic in the strategies and practices used by law enforcement. Arbitrary use of 'carding' or street checks disproportionately affects people of African descent."

The overrepresentation of black people in the criminal justice system was of particular concern for the group, who found African Canadians make up only 3 per cent of the population but account for 10 per cent of the prison population. In the last decade, the number of black detainees in federal correctional facilities has grown by 71.1 per cent, it warned. Among other findings by the UN experts: Across Canada, African Canadian children are being taken into child welfare on "dubious" grounds. Forty-one per cent of children in Children's Aid Society of Toronto's care were black when only 8 per cent of children are of African descent. The unemployment rate for black women is 11 per cent, 4 per cent higher than the general population, and they earn 37 per cent less than white males and 15 per cent less than white women.

A quarter of African Canadian women live below the poverty line compared to 6 per cent for their white counterparts. One-third of Canadian children of Caribbean heritage and almost half of continental African children live in poverty, compared to 18 per cent of white Canadian children. Chris Ramsaroop, an advocate with Justicia for Migrant Workers, hopes the report will raise awareness of the plight of African Canadians. "We need every opportunity to hold the feet of the federal and provincial governments to the fire," he said. The UN experts recommend a national department of African-Canadian affairs to develop policies to address issues facing black people and implement a nationwide mandatory disaggregated data collection policy based on race, colour, ethnic background and national origin.

Odion Fayalo, of Justice is Not Color Blind Campaign, protests racial profiling before a Toronto Police board meeting. • René Johnston/TORONTO STAR file photo

"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.

How timely will the service be? Do wait times threaten the health of those waiting? Wait times are obviously a form of rationing within the system, but at what point does a person's "right to life," a phrase from the Charter of Rights and Freedoms, become threatened by this rationing? These questions were central to the Supreme Court's Chaoulli decision in 2005. If, as is almost certain, the B.C. case winds up back in Ottawa, will the court stand by its earlier decision? The 4-3 Chaoulli judgment found that the ban on private insurance violated the Quebec Charter of Human Rights and Freedoms.

Three judges said it also violated the Canadian Charter; three judges disagreed and one expressed no opinion. In other words, the court was conflicted 10 years ago. Its membership has changed hugely in a decade. Who knows what all the new judges appointed since 2005 might decide? And, as we have just seen in its recent assisted suicide ruling, the court is not above reversing itself by overturning previous decisions.

These B.C. and Quebec healthcare cases illustrate the legalization of politics that has become such a feature of Canadian public life under the Charter of Rights and Freedoms. No issue has been more debated in Canada, and no public program has absorbed more public money (and attention) than health care. Judges might be unhappy with the results of the debates and decisions, but no one can deny that the issue has been central in Canada's politics. And yet in the Chaoulli case, a majority dismissed the decisions of elected officials and barged into the health-care field, despite an obvious lack of expertise.

Health care - its provision, organization and financing - is an essentially political issue in the broadest sense of the term, but in the age of the Charter, judges can make just about anything into a legal issue. So they did in Chaoulli, and might again when confronted with the B.C. case. Madame Justice Marie Deschamps, writing for the majority in Chaoulli, declared about the situation in Quebec: "For many years, the government has failed to act; the situation continues to deteriorate." Much has been done since those words were written. More than $40-billion in extra funds has been spent on health care, courtesy of a federalprovincial agreement. The share of the national economy taken by health care has risen since 2005 (although it has dropped in the last two years).

Wait times in some provinces have come down. But have they come down enough to satisfy the Supreme Court, which set itself up as the arbiter of such answers in the Chaoulli case? Many more hip and knee replacements have been done, but wait times have not come down, owing to increased demand. How long is reasonable? Should a person in distress have the right to spend his or her money to relieve pain, or must they be triaged by the state? It shouldn't be this way, but the courts will decide.

Canada has catching up to do compared to other OECD countries. Canadians have difficulty accessing primary care, particularly after hours and on weekends, and are more likely to use emergency rooms.

only 32 per cent of Canadians had access to more than one primary health care provider

In Peterborough, Ontario, for example, a region-wide shift to team-based care dropped emergency department visits by 15,000 patients annually and gave 17,000 more access to primary health care.

We believe that jurisdictions are now turning the corner on primary health care

Sustained federal funding and strong jurisdictional direction will be critical to ensuring that we can accelerate the update of electronic health records across the country.

The creation of a national pharmaceutical strategy was a critical part of the 10-year plan. In 2011, today, unfortunately, progress is slow.

Your committee has produced landmark reports on the importance of determinants of health and whole-of- government approaches. Likewise, the Health Council of Canada recently issued a report on taking a whole-of- government approach to health promotion.

there have also been improvements on our capacity to collect, interpret and use health information

Leading up to the next review, governments need to focus on health human resources planning, expanding and integrating home care, improved public reporting, and a continued focus on quality across the entire system.

John Wright, President and CEO, Canadian Institute for Health Information

the Canada Health Act

Since 2008, rather than repeat annual reporting on the whole, the Health Council has delved into specific topic areas under the 2003 accord and the 10-year plan to provide a more thorough analysis and reporting.

We have looked at issues around pharmaceuticals, primary health care and wait times. Currently, we are looking at the issues around home care.

John Abbott, Chief Executive Officer, Health Council of Canada

I have been a practicing physician for 23 years and a CEO for 10 years, and I would say, probably since 2005, people have been starting to get their heads around the fact that this is not sustainable and it is not good quality.

Much of the data you hear today is probably 18 months to two years old. It is aggregate data and it is looking at high levels. We need to get down to the health service provider level.

The strength of our ability to report is on the data that CIHI and Stats Canada has available, what the research community has completed and what the provinces, territories and Health Canada can provide to us.

We have a very good working relationship with the jurisdictions, and that has improved over time.

One of the strengths in the country is that at the provincial level we are seeing these quality councils taking on significant roles in their jurisdictions.

As I indicated in my remarks, dispute avoidance activity occurs all the time. That is the daily activity of the Canada Health Act division. We are constantly in communication with provinces and territories on issues that come to our attention. They may be raised by the province or territory, they may be raised in the form of a letter to the minister and they may be raised through the media. There are all kinds of occasions where issues come to our attention. As per our normal practice, that leads to a quite extensive interaction with the province or territory concerned. The dispute avoidance part is basically our daily work. There has never actually been a formal panel convened that has led to a report.

each year in the Canada Health Act annual report, is a report on deductions that have been made from the Canada Health Transfer payments to provinces in respect of the conditions, particularly those conditions related to extra billing and user fees set out in the act. That is an ongoing activity.

there has been progress. In some cases, there has been much more than in others.

How many government programs have been created as a result of the accord?

The other data set is on bypass surgery that is collected differently in Quebec. We have made great strides collectively, including Quebec, in developing the databases, but it takes longer because of the nature and the way in which they administer their systems.

I am a director of the foundation of St. Michael's Hospital in Toronto

Not everyone needs to have a family doctor; they need access to a family health team.

The family doctors in our hospital feel like second-class citizens, and they should not. Unfortunately, although 25 years ago the family doctor was everything to everybody, today family doctors are being pushed into more of a triage role, and they are losing their ability.

The problem is that the family doctor is doing everything for everybody, and probably most of their work is on the social end as opposed to diagnostics.

At a time when all our emergency departments are facing 15,000 increases annually, Peterborough has gone down 15,000, so people can learn from that experience.

I have to be able to reach my doctor by phone.

They are busy doing all of the other things that, in my mind, can be done well by a team.

That is right.

if we are to move the yardsticks on improvement, sustainability and quality, we need that alignment right from the federal government to the provincial government to the front line providers and to the health service providers to say, "We will do this."

We want to share best practices.

it is not likely to happen without strong direction from above

Excellent Care for All Act

quality plans

with actual strategies, investments, tactics, targets and outcomes around a number of things

Canadian Hospital Reporting Project

by March of next year we hope to make it public

performance, outcomes, quality and financials

With respect to physicians, it is a different story

We do not collect data on outcomes associated with treatments.

which may not always be the most cost effective and have the better outcome.

We are looking at developing quality indicators that are not old data so that we can turn the results around within a month.

Senator Eaton

There are different types of benchmarks. For example, there is an evidence-based benchmark, which is a research of the academic literature where evidence prevails and a benchmark is established.

The provinces and territories reported on that in December 2005. They could not find one for MRIs or CT scans. Another type of benchmark coming from the medical community might be a consensus-based benchmark.

universal screening

A year and a half later, we did an evaluation based on the data. Increased costs were $400 per patient — $1 million in my hospital. There was no reduction in outbreaks and no measurable effect.

A thorough research of the literature simply found that there are no evidence-based benchmarks for CT scans, MRIs or PET scans.

The evidence is pretty clear for the high acuity; however, for the lower acuity, I do not think we know what a reasonable wait time is

If you are told by an orthopaedic surgeon that there is a 99.5 per cent chance that that lump is not cancer, and the only way you will know for sure is through an MRI, how long will you wait for that?

colorectal screening

the next time they do the statistics, there will be a tremendous improvement, because there is a federal-provincial cancer care and front-line provider

adverse drug effects

over-prescribing

There are no drugs without a risk, but the benefits far outweigh the risks in most cases.

catastrophic drug coverage

a patchwork across the country

with respect to wait times

The interesting thing about Saskatchewan is that, on a three-year trending basis, it is showing positive improvement in each of the areas. It would be fair to say that Saskatchewan was a bit behind some of the other jurisdictions around 2004, but the trending data — and this will come out later this month — shows Saskatchewan making strides in all the areas.

In terms of the accord itself, the additional funds that were part of the accord for wait-times reduction were welcomed by all jurisdictions and resulted in improvements in wait times, certainly within the five areas that were identified as well as in other surgical areas.

We are working with the First Nations, Statistics Canada, and others to see what we can do in the future about identifiers.

Have we made progress?

I do not think we have the data to accurately answer the question. We can talk about proxies for data and proxies for outcome: Is it high on the government's agenda? Is it a directive? Is there alignment between the provincial government and the local health service providers? Is it a priority? Is it an act of legislation? The best way to answer, in my opinion, is that because of the accord, a lot of attention and focus has been put on trying to achieve it, or at least understanding that we need to achieve it. A lot of building blocks are being put in place. I cannot tell you exactly, but I can give you snippets of where it is happening. The Excellent Care For All Act in Ontario is the ultimate building block. The notion is that everyone, from the federal, to the provincial government, to the health service providers and to the CMA has rallied around a better health system. We are not far from giving you hard data which will show that we have moved yardsticks and that the quality is improving. For the most part, hundreds of thousands more Canadians have had at least one of the big five procedures since the accord. I cannot tell you if the outcomes were all good. However, volumes are up. Over the last six years, everybody has rallied around a focal point.

The transfer money is a huge sum. The provinces and territories are using the funds to roll out their programs and as they best see fit. To what extent are the provinces and territories accountable to not just the federal government but also Canadians in terms of how effectively they are using that money? In the accord, is there an opportunity to strengthen the accountability piece so that we can ensure that the progress is clear?

In health care, the good news is that you do not have to incent people to do anything. I do not know of any professionals more competitive than doctors or executives more competitive than executives of hospitals. Give us the data on how we are performing; make sure it is accurate, reliable, and reflective, and we will move mountains to jump over the next guy.

There have been tremendous developments in data collection. The accord played a key role in that, around wait times and other forms of data such as historic, home care, long term care and drug data that are comparable across the country. Without question, there are gaps. It is CIHI's job to fill in those gaps as resources permit.

The Health Council of Canada will give you the data as we get it from the service providers. There are many building blocks right now and not a lot of substance.

send him or her to the States

Are you including in the data the percentage of people who are getting their work done elsewhere and paying for it?

When we started to collect wait time data years back, we looked at the possibility of getting that number. It is difficult to do that in a survey sampling the population. It is, in fact, quite rare that that happens.

Do we have a leader in charge of this health accord? Do we have a business plan that is reviewed quarterly and weekly so that we are sure that the things we want worked on are being worked on? Is somebody in charge of the coordination of it in a proper fashion?

Dr. Kitts: We are without a leader.

Mr. Abbott: Governments came together and laid out a plan. That was good. Then they identified having a pharmaceutical strategy or a series of commitments to move forward. The system was working together. When the ministers and governments are joined, progress is made. When that starts to dissipate for whatever reason, then we are 14 individual organization systems, moving at our own pace.

You need a business plan to get there. I do not know how you do it any other way. You can have ideas, visions and things in place but how do you get there? You need somebody to manage it. Dr. Kitts: I think you have hit the nail on the head.

The Chair: If we had one company, we would not have needed an accord. However, we have 14 companies.

There was an objective of ensuring that 50 per cent of Canadians have 24/7 access to multidisciplinary teams by 2010. Dr. Kitts, in your submission in 2009, you talked about it being at 32 per cent.

there has been a tremendous focus for Ontario on creating family health teams, which are multidisciplinary primary health care teams. I believe that is the case in the other jurisdictions.

The primary health care teams, family health care teams, and inter-professional practice are all essentially talking about the same thing. We are seeing a lot of progress. Canadian Health Services Research Foundation is doing a lot of work in this area to help the various systems to embrace it and move forward.

The question then came up about whether 50 per cent of the population is the appropriate target

If you see, for instance, what the Ontario government promotes in terms of needing access, they give quite a comprehensive list of points of entry for service. Therefore, in terms of actual service, we are seeing that points of service have increased.

The key thing is how to get alignment from this accord in the jurisdictions, the agencies, the frontline health service providers and the docs. If you get that alignment, amazing things will happen. Right now, every one of those key stakeholders can opt out. They should not be allowed to opt out.

the national pharmaceutical strategy

in your presentation to us today, Dr. Kitts, you said it has stalled. I have read that costing was done and a few minor things have been achieved, but really nothing is coming forward.

The pharmacists' role in health care was good. Procurement and tendering are all good. However, I am not sure if it will positively impact the person on the front line who is paying for their drugs.

The national pharmaceutical strategy had identified costing around drugs and generics as an issue they wanted to tackle. Subsequently, Ontario tackled it and then other provinces followed suit. The question to ask is: Knowing that was an issue up front, why would not they, could not they, should not they have acted together sooner? That was the promise of the national pharmaceutical strategy, or NPS. I would say it was an opportunity lost, but I do not think it is lost forever.

Socialist Action participated in the NL Rising! rally on May 5 at the Confederation Building. The event was organized by the Newfoundland and Labrador Federation of Labour and was attended by public and private sector unions, social justice groups, women and youth rights groups, and all those affected by the cuts to services, axed jobs and unfair tax measures. There were about 2,500 in attendance and a Socialist Action member held an SA banner on the main stage with the help of a member of Anonymous.

Socialist Action also has participated in town halls to rally support against the austerity budget. "This is the most miserable budget I've ever seen, except for Greece, and Greece's was forced on them" is how one CUPE economist put it.

Socialist Action is also involved in starting a local NDP socialist caucus within the ranks of the provincial NDP modelled after the socialist caucus in the federal NDP. The finance minister has made some of her money thanks to temporary foreign workers working at her fast-food restaurants. She was previously the biggest cheerleader for the Muskrat Falls project when sitting on the board of directors for Nalcor, the provincial utility and energy company. Now she says she has to implement this budget because of the cost overruns on the dam project. It is a project lacking transparency and accountability, and making a lot of people from outside Newfoundland and Labrador wealthier, including foreign construction companies that have never done jobs like this in Canada, a Canadian engineering company that was involved in a bribery scandal with Libya when Moammar Gadhafi was still in power, and foreign banks, bond holders and credit rating agencies. Her goal seems to be to obey the credit rating agencies and please them.

Newfoundland and Labrador is in a more precarious position now than in 1933, when Newfoundland was bankrupt and Canada and Britain were worried about their own credit ratings. The British and Canadian governments appointed a Commission of Government which was controlled by two private bankers. This was the start of a 15-year political breach which eventually led to the Crown selling off Newfoundland and Labrador to the Canadian bourgeois wolves to pay off their war debt in 1949.

Socialist Action NL has unanswered questions about Don Dunphy, an injured worker who was seemingly killed for a tweet when an RNC officer on the then premier's security detail showed up at his home on an Easter Sunday. What is happening to the pensions of iron ore miners from Labrador who have provided raw material to Hamilton Steel Mills for years? We still have foreign multinational corporations willing to exploit our fishery resources. Those corporations and the provincial government are stomping on indigenous peoples' rights in Labrador.

Socialist Action is on the ground in Newfoundland and Labrador, active in the labour movement, social justice, international solidarity, feminist and environmental campaigns. We will continue to make the socialist caucus visible in the NDP provincial party, to be at the table at the N.L. independence debate, to actively support indigenous peoples' struggles, as well as in anti-war, anti-poverty and the human rights movements. Socialist Action NL is in solidarity with the Fourth International worldwide. Chris Gosse St. John's

The way our system is funded - predominantly with block transfers to hospitals and fee-for-service payments to physicians - encourages volume of procedures and the status quo. It does not reward quality of care, or responsible stewardship. In fact, when an individual or a program goes out on a limb and makes changes to improve efficiency or costeffectiveness, the benefits often accrue to others; perverse disincentives are commonplace and counterproductive. These problems and frustrations are not new. The Naylor report cites an example from 1974, when Canadian researchers published a landmark paper showing that nurse practitioners could do 70 per cent of doctors' work with no difference in outcomes or patient satisfaction.

Using NPs also saved money, but hiring more nurse practitioners was hampered by the fact that, generally speaking, doctors are paid on a fee-for-service basis and nurses are salaried. Four decades later, that same bureaucratic hurdle remains. Most other Western countries acted on the research: NPs are an integral part of healthcare delivery and most physicians are salaried. But in Canada, NPs are still grossly underused - except in pilot projects, of course.

We still negotiate physician and nurse contracts separately and our management of health-care human resources is a mess. Until you get workers with the right skills in the right place at the right time, you will never deliver seamless, patient-centered care and you will never control costs, because labour accounts for twothirds of all spending. As the NP story and countless not-actedupon research findings since illustrate, innovation is hampered by policy gridlock. The managers of the system, who are largely powerless and beholden to the whims of politicians, are with few exceptions profoundly mistrusting of entrepreneurship and pathologically risk-averse. For decades, we have produced reports about the need to transform health-care delivery and funding while, simultaneously, clinging to the same old way of doing things. It's a fundamental disconnect between evidence and action. If you don't take risks, you will never innovate. So how do we break the logjam?

According to the Naylor report, it has to begin with leadership, and it should come from Ottawa. One of the panel's central recommendations is the creation of an independent health innovation agency to not just fund pilot projects, but promote scaling-up, using searchable repositories of successful programs, financial incentives, regulatory change, all with the aim of spurring innovation. More resources alone will not ensure the scaling-up of good ideas. There needs to be partnership, commitment and monitoring to ensure implementation. In short, it's not more money the system needs, it's culture change - a shift from perpetual pilot projects to embracing best practices.