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David Hume, the 18th-century Scottish philosopher. Hume realized that, although people talk about causes as if they are real facts—tangible things that can be discovered—they’re actually not at all factual. Instead, Hume said, every cause is just a slippery story, a catchy conjecture, a “lively conception produced by habit.” When an apple falls from a tree, the cause is obvious: gravity. Hume’s skeptical insight was that we don’t see gravity—we see only an object tugged toward the earth. We look at X and then at Y, and invent a story about what happened in between. We can measure facts, but a cause is not a fact—it’s a fiction that helps us make sense of facts.

our stories about causation are shadowed by all sorts of mental shortcuts

when it comes to reasoning about complex systems—say, the human body—these shortcuts go from being slickly efficient to outright misleading

causal explanations are oversimplifications

the power of statistical correlation, which has allowed researchers to pirouette around the problem of causation

statistical significance, invented by English mathematician Ronald Fisher in the 1920s. This test defines a “significant” result as any data point that would be produced by chance less than 5 percent of the time. While a significant result is no guarantee of truth, it’s widely seen as an important indicator of good data, a clue that the correlation is not a coincidence

require that we understand every interaction before we can reliably understand any of them

we often shrug off this dizzying intricacy, searching instead for the simplest of correlations. It’s the cognitive equivalent of bringing a knife to a gunfight.

Although the scientific process tries to makes sense of problems by isolating every variable—imagining a blood vessel, say, if HDL alone were raised—reality doesn’t work like that. Instead, we live in a world in which everything is knotted together, an impregnable tangle of causes and effects

the R&D to discover a promising new compound now costs about 100 times more (in inflation-adjusted dollars) than it did in 1950. (It also takes nearly three times as long.)

it’s not just MRIs that appear to be counterproductive

an in-depth review of biomarkers in the scientific literature

83 percent of supposed correlations became significantly weaker in subsequent studies

we’ve constructed our $2.5 trillion health care system around the belief that we can find the underlying causes of illness, the invisible triggers of pain and disease

If only we knew more and could see further, the causes of our problems would reveal themselves. But what if they don’t?

We keep trying to fix the back, but perhaps the back isn’t what needs fixing.

more than 40 percent of them were later shown to be either totally wrong or significantly incorrect

two leading drug firms, AstraZeneca and GlaxoSmithKline, announced that they were scaling back research into the brain. The organ is simply too complicated, too full of networks we don’t comprehend.

85 percent of new prescription drugs approved by European regulators provide little to no new benefit

According to the Centers for Disease Control and Prevention, things like clean water and improved sanitation—and not necessarily advances in medical technology—accounted for at least 25 of the more than 30 years added to the lifespan of Americans during the 20th century

the things we can see will always be bracketed by what we cannot

In dollar terms, the size of all of that post-recession debt is staggering. Some fear that when interest rates return to normal, governments will face crippling debt-servicing costs. But the scope of the problem is a matter of significant debate in policy circles. Experts do agree that whether or not government debt is a serious problem depends on where you live. Government books in Western Canada are relatively healthy. East of Manitoba however, debt is already forcing hard choices. Political debate over government finances is typically focused on the annual bottom line, which shows whether there is a annual surplus or a deficit.

Economists say the often overlooked - but far more important figure - is the size of government debt in relation to the size of the economy. As a percentage of gross domestic product, the net debt of all provinces and territories has grown to 28.6 per cent in 201314 from 20.5 per cent in 2007-08. The federal debt grew to a peak of 33.3 per cent in 2012-13 from 29.2 per cent in 2007-08. That's nowhere near the 67.1 per cent debt levels reached by Ottawa in 1995-96, when The Wall Street Journal warned that Canada was at risk of hitting the "debt wall." The size of the federal debt has already started to decline, reaching 32.3 per cent in 2013-14. The 2015 budget forecast that the federal debt-to-GDP ratio will reach prerecession levels by 2017 and decline further to 25 per cent by 2021. The debt picture among the provinces varies dramatically.

Alberta and Saskatchewan are currently facing hard times owing to low oil prices, but they are the darlings of Confederation when it comes to low debt. Alberta had no debt at all as of last year. The real debt troubles can be found in Central and Atlantic Canada. Quebec's net debt is the largest, at 50 per cent of GDP, followed by Ontario, at 38.4 per cent, and Nova Scotia at 37.7 per cent, using figures for 201314. While Quebec announced a balanced budget this year, Ontario's deficit was up slightly to $10.9-billion last year. Ontario insists the deficit will be erased by 2017-18.

Provincial governments are responsible for programs such as education and health care that can affect people more directly than federal programs. Spending restraint is easier said than done. The 2015 budget season has coincided with student protests in Quebec, New Brunswick and Nova Scotia, while Ontario is dealing with labour unrest from teachers' unions. Many provinces have also been negatively affected by a recent change to the federal health-transfers formula. The move to per-capita funding won out over arguments that the average age of provincial populations should be factored into the equation. Some of the most indebted provinces also face the most challenging demographics, with a shrinking ratio of younger workers to cover the costs of growing numbers of older citizens. The Parliamentary Budget Officer has said that while federal finances are sustainable over the long term, the provinces are facing structural shortfalls that will demand spending cuts, higher taxes or both. University of New Brunswick economics professor David Murrell said the return to surpluses in Ottawa will likely rekindle pressure from the provinces for more generous transfers. Shrinking deficits, growing debt

Provincial finance ministers are quick to pat themselves on the back over shrinking deficits and balanced budgets, but economists urge Canadians to view these claims with a bit of skepticism. Accounting methods vary across the country, making comparisons difficult. Unlike the federal government, provinces generally present two sets of books: an operational budget and a capital budget. Boasts of balanced budgets are in reference to operational spending. A province's overall debt could still be rising on the capital side even though the government is in an operational surplus. Supporters of this accounting method - including Calgary Mayor Naheed Nenshi - argue that it separates good debt from bad debt: Using debt to build public assets such as roads and bridges is better than slipping into the red to pay for public service salaries and other operational costs.

Critics such as tax-policy expert Jack Mintz have warned this approach allows provinces to play "hide the deficit." Charles Lammam, director of fiscal studies with the Fraser Institute, a conservative think tank that regularly warns about the dangers of mounting government debt, agrees that claims of improving budget balances can be misleading. "This is a real problem in places like British Columbia and Ontario," he said. "It doesn't seem like the growth in government debt will let up." Mr. Lammam's research found that Canadian governments - including municipalities - spend more than $60-billion a year servicing debt, which is about the same as the entire cost of providing primary and secondary education across the country. Ontario's recent budget said a one-point increase in interest rates would cost the government $400-million. "There's a real risk that provinces like Ontario, provinces like Quebec, can be subject to this very negative situation where they're paying even more to service their outstanding debt," he said. The new debt debate

Department of Economics, Laurentian University

This paper uses a new (Hartwig-Colombier) method to decompose the growth rate of provincial per capita health-care spending in Canada over the period 1982–2011 into the contributions of the cost disease, traditional observable variables, and technological progress. Based on extensive robustness analysis across a variety of specifications, estimation methods, and two separate data sets, we find that the cost disease (rent extracting) is a relatively minor contributor, while technical progress in health care and growth in per capita incomes are by far the biggest contributors to the secular growth in health-care spending in Canada.

Staffing levels in nursing homes are a concern not only because they are low, but they may not be increasing fast enough to meet the rising medical complexity of patients in nursing homes.

Data from the Canadian Institute for Health Information shows that between 2008 and 2012, the proportion of residents in Canadian nursing homes with disease diagnoses increased for every category of disease.

Dementia is also increasingly common among Canadian nursing home residents, with over three quarters of residents having some level of cognitive impairment. More than one in four residents suffers from severe dementia.

As a result, the care needs of nursing home residents have grown. In Ontario, care needs are assessed using the Method for Assigning Priority Levels (MAPLe) scoring system. The system ranges from a score of 1 (low needs) to 5 (very high needs). In 2012, 85% of new admissions from the community and 78% of admissions from hospital were in the High or Very High (MAPLe 4 and 5) clinical needs categories. Less than 1% of admissions were in the low and mild (MAPLe 1 and 2) clinical needs categories. Projections from the Ontario Long Term Care Association suggest that soon virtually all patients admitted to nursing homes will be from the two highest need categories.

The increasing needs of nursing home residents in Ontario has been driven in large part by the shift from letting individual nursing homes choose their residents, to having Community Care Access Centres determine who is in greatest need of long term care, says Dr Samir Sinha, lead for Ontario’s Senior Strategy

Ontario has begun to increase both the number and skill sets of nursing home staff, while also trying to find efficiencies to free up more staff time for direct patient care.

“One of the most promising initiatives to date has been Behavioral Supports Ontario (BSO),” says Sinha. The BSO initiative is province-wide, and has funded the hiring of 604 new staff (194 nurses, 272 PSWs, and 138 other health care professionals, such as social workers) with specialized skills in caring for and supporting residents with complex and challenging behaviors, such as violence.

Researchers and policy strategists in Alberta believe another key to improving quality in nursing homes is to engage Health Care Aides (HCA in Alberta is the rough equivalent of a PSW) as full members of the care team.

Carole Estabrooks, a Professor of Nursing at the University of Alberta has been researching the engagement of HCAs in quality improvement for the last several years. She believes that too often, HCAs are not treated as members of the care team. “Care Aides typically have the least amount of formal training, and as a result doctors, nurses and others too often assume they have nothing to offer,” she says. Frequently, this means they have little input into the care plans they are expected to carry out.

Last week, the Parkland Institute - which is based out of the University of Alberta - released its report Losing Ground: Alberta's Elder Care Crisis. It was an update of another Parkland report from 2013. The report states that as of March 31, 2016, there were 14,768 longterm (LTC) beds in Alberta and 9,936 designated supportive living (DSL) beds, as well as 243 palliative care or hospice beds.

The number of LTC beds in Alberta has been relatively stagnant - Alberta only has 377 more LTC beds than it did in 2010, an increase of only 2.6 per cent. The number of DLS beds, on the other hand, has increased by 4,770 or 92.3 per cent. As well, the number of continuing care beds classified as DLC as opposed to long-term care beds grew from 26 per cent in 2010 to 40 per cent in 2016.

That means nearly half of the continuing care beds available in the province for elderly Albertans do not have a registered nurse on-site and are not subject to minimum staffing requirements. "Losing Ground" also examines who is operating the LTC beds in the province. About 21 per cent are operated by Alberta Health Services (AHS) or a regional health authority. Another 10,808 were run by for-profit corporations and 8,881 were run by non-profits. In the last seven years, Alberta has lost 333 beds in public facilities while private, for-profit facilities have added 3,255 beds.

The issue is that publicly-run LTC facilities generally provide more health care to residents than privately-run or non-profit facilities. On average between 2011 and 2013, registered nurses, licensed practical nurses and health care aids in public facilities provided four hours of direct health care to residents compared to three and 3.1 hours per day in non-profit and private facilities respectively. The report stresses that all facilities are required to provide 4.1 hours of care per day to residents, which means they are all falling short due to a lack of staff.

The report also notes that the NDP government has fallen far short of its election commitment to open 2,000 new long-term care beds by the end of 2019, including 500 new beds in 2015. The growth in the older population, coupled with a stagnant number of new LTC beds and move towards private care, means the availability of beds for Albertans over the age of 85 has nearly been halved since 2001. "This drop has greatly reduced the province's ability to meet the care needs of its most frail seniors," said report author David Campanella, in a release.

Minister's response In an e-mail, Minister of Sarah Hoffman said they know there is a huge demand for longterm care and dementia beds that stems from "years of neglect" on the need for affordable spaces for seniors under the previous government. "As a result, we are building spaces and putting in the beds Albertans need as we committed to do in the election and we are doing it collaboratively with communities and community partners." Hoffman said that last year, the province did a thorough review of all proposed Affordable Supportive Living Initiative (ASLI) projects, and implemented important changes to proposed projects to address the needs of Albertans.

Every new approved ASLI project has since opened with higher numbers of dementia and long-term care beds than originally planned, she said. "With ASLI now ended, we are developing a new capital program for long-term care with criteria to ensure the right level of care and the right methods of delivery are expanded," said Hoffman. She noted they have $365 million earmarked for senior care in the current budget and that will improve access for families across Alberta. Following the report's release, the Canadian Union of Public Employees (CUPE) issued a statement that it is disappointed by the lack of progress being made reforming the province's system of senior care.

CUPE Alberta president Marle Roberts said the union, which represents 2,600 long-term care workers throughout the province, has repeatedly asked the current and previous Alberta governments to shift its focus to publicly-delivered services. "This study confirms what others have indicated before - caregivers in public facilities have more times for patients and deliver better outcomes," said Roberts.

We are disappointed that the number of private beds continue to increase, while the number of public beds has dropped ... We are letting patients down by not offering them the care they need," she added.

A report from the Parkland institute claims there has been a trend away from publicly- run long-term care beds, such as those at the Westlock Continuing Care Centre (seen above). The number of long-term care beds offered by private organizations or non-profit organizations, on the other hand, is on the rise.

It will be the largest scale initiative ever undertaken in Canada. Within five years, it will involve 30 per cent of Canadians from coast to coast, testing new innovative models of care, monitoring success and engaging a national and international network of senior policy-makers to investigate the conditions that will be necessary to scale up successful models of care. We will no longer be a country of pilot projects.

Dr. Armstrong: What we propose in our assessment is to redesign the way the health professions work with each other. As opposed to solo practitioners, we believe they should be integrated, and we believe this requires a substantial cultural change because the historical divisions around scopes of practice have led to a silo mentality, and the future is clearly an integration one.

Assuming we have an accord in 2014 to succeed this one, and assuming similar funding methods are used, what are the main proposals or incentives you think should be put to the provinces?

Dr. Armstrong: I believe we need to establish national standards and make our system accountable. We need to measure those standards. We need to get return on our investment that is more meaningful than we have in the past, and we need to emphasize innovative transformative change, then publish the results on an annual basis.

one of the gaps you are referring to is the lack of a robust, country wide technology assessment system

We take it for granted that we practice evidence-based medicine, but in fact we do that only in part.

We talk about 5 million Canadians not having access to a family doctor, but they should have access to an integrated health care team where the first point of care would not necessarily be a physician.

Public health interventions aimed at improving quality of lifestyle, food security and tax reforms with respect to sales tax on foods will be a way forward.

Not all physicians should be trained the same way and, indeed, for many the training is too long.

Dr. Tamblyn: I think you need to focus on the outcomes you are wanting to achieve in accordance with basic principles that we have been known for internationally, which is equitable access, appropriate care and so on, but you need to focus on preventing disease, reducing disparities and improving outcomes, and then you need to put something in an innovation fund to actually make that happen.

VIHA says the new contract with Crothall raises cleaning standards, increases staffing levels, creates a specialist outbreak cleaning team, enhances monitoring processes and introduces more patient and staff satisfaction surveys.

Mike Old, spokesman for the Hospital Employees' Union, said the union supports the decision of the health authority to retain the experienced workers who currently clean the facilities."Our concerns about crushing workloads for cleaning staff have been recognized through a commitment to higher staffing levels in this contract," Old said.

Improper cleaning methods and insufficient cleaner strength had a significant effect in an 11-month C-Difficile outbreak at Nanaimo Regional General Hospital that infected 94 people and killed five which started in 2008.

Compass employees lacked proper training to use toxic chemicals that caused hair loss, nose inflammation, respiratory problems and skin irritation, according to two failed WorkSafe B.C. inspections issued in 2008 and 2009.

Workers used ineffective cleaners. Staff over-diluted bleach cleaner and later needed to switch to a soil-lifting detergent that would remove the virus from surfaces.

If the housekeeping fails on any of the new measures during monitoring, financial penalties will be applied.

In April last year, VIHA said it was getting rid of Compass and signing a new contract with Marquise to provide housekeeping and food services at residential care facilities on the south Island - Glengarry, Mount Tolmie, Aberdeen, Gorge Road and Priory Hospital - as well as Queen Alexandra Centre for Children's Health and Saanich Peninsula Hospital. But before the ink on the contract was dry, Marquise was bought by Compass.

Compass has three of its divisions working in VIHA's contracted sites: Crothall Services, providing housekeeping services; Morrison, providing food services; and Marquise Group, providing both food and housekeeping services in residential care facilities.

Failing to link the supply of health care to the needs of the population means the cost of our health care system is determined by the number of providers. Because the number of suppliers has been increasing at a rate far faster than the size of the population, even after allowing for an aging population, we now face a crisis in meeting the costs of keeping the increasing supply of health care providers fully employed.

Fraser Institute

Both reports are about wait times in health care.

response rate is only 21%.

Though the report does not say this, many of these waits are due to a severe shortage of hospital beds. (Ontario has cut more beds than anywhere in Canada.)

public hospital system including better wait list management and pooled referrals, additional operating room nurses and health professionals have improved wait times in Saskatchewan.

Ontario has one of the most robust reporting systems in the country,

On the negative side, most provinces do not report their wait times on most procedures, so the report is based on limited information and only from those provinces that do report.

So, focusing on the report that is worth looking at – The Wait Times Alliance report is a thought-provoking addition to the body of research on access to care and timeliness of care.

Long waits in hospital emergency departments were cited in Ontario. Waits are up to 26 hours for Ontario patients with complex conditions that require additional diagnostic tests or admission into a hospital bed.

These are good recommendations that we should support.

There is only really one item with which we would take issue in the report: there is considerable confusion about Alternate Level of Care (ALC) patients.T

one type of hospital bed waiting for another type of hospital bed (not waiting for discharge to long-term care or home care).

Unfortunately, this misinformation is driving dangerous levels of hospital cuts.

There is also a gratuitous positive mention of the LEAN methods in the report, without any real analysis. We receive endless complaints about this Toyota management system that is now being used in public hospitals.

askatchewan Premier Brad Wahl,

Instead the evidence is that patients in those provinces are being charged fees ranging from hundreds to tens of thousands of dollars for medically-needed care.

On top of these user fees, private clinics are billing the public system — for the same procedures. I