Group items tagged

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.

Seniors must find help for house cleaning, shopping or errands elsewhere, either by paying privately, relying on family and friends or turning to a replacement program funded by the United Way called Better at Home, which has received $22 million from the province. Vancouver-Mt. Pleasant NDP MLA Jenny Kwan says Mayer's story is similar to those she's heard from other seniors in her riding during the last month. At least five couples and individuals - most of them Chinese-speaking - contacted her about having their weekly home care hours cut in half. Most have gone from two hours to one, just enough time for a bath. "The government wants seniors to live longer at home, but if you don't provide the supports for them to live successfully and safely, how are they going to manage? That will only mean they are going to need hospitalization, residential care or assisted living," Kwan said. "It's pay now or pay later and pay more," she added, noting that a day in an acute care hospital bed costs taxpayers about $1,500, enough to pay for plenty of routine in-home care. The change in home support hours from Vancouver Coastal Health is part of a move to follow provincial rules more closely, said Bonnie Wilson, director of home and community care for the health authority.

Home support is supposed to help clients with daily needs including bathing, dressing, using the toilet, taking medication or setting up a meal. These are considered medical services. Home support workers are paid only to do those tasks and not a wider range of duties that were covered before policy changes about 10 years ago: visiting, transportation, light yard work, minor home repairs, light housekeeping and grocery shopping. "VCH's home support guidelines are consistent with the Ministry of Health and other health authorities. Historically the mandate for home support services used to be broader, but this was sometime before 2004 (the guidelines that preceded our current ones)," Wilson explained in an email. "This was at a time when there was no distinction between medical and non-medical support services, and when clients went to residential care much sooner than they are now."

The complex medical problems experienced by some of Canada's oldest residents reflect a growing trend: people are living much longer, but not necessarily in good health. They can often stay at home - and avoid the high cost of either private or publicly funded nursing in residential care - but home support workers are being called upon to deliver some services that formerly fell to nurses. Doing laundry or picking up groceries are long gone from their to-do list. Exceptions to that, says Wilson, are allowed if it's unsafe for workers or the client to be in the home because of the mess, or if a client risks eviction or has been refused other government-subsidized services such as HandyDart because of a lack of cleanliness.

In British Columbia, home care is typically provided and subsidized - depending on income - by a local health authority that contracts the duty to a handful of accredited private companies. Clients with higher incomes often hire their own help. In 2013-14, B.C's health authorities spent $1.1 billion on home support for about 39,000 clients. That compares to $1.8 billion spent on residential care for 27,308 seniors. In 2012-13, the province funded 7.37 million hours of home support, according to the Ministry of Health, 23 per cent more than three years earlier. B.C.'s Office of the Seniors Advocate is planning to survey all recipients of publicly funded home support in the province about their experiences for an upcoming report. The Minister of Health was unavailable for comment by press time.

PSWs have a role standard  which says “personal support workers do for a person the things that the person would do for themselves, if they were physically or cognitively able”.

There is a great deal of variation around the kind of care PSW’s provide, with some PSWs providing medical care such as changing wound dressings and administering medication, and others providing  ‘only’ personal care such as bathing, transfers from bed and housework. What PSWs can and cannot do varies based on their training, supervision and employer policies.

An estimated 57,000 PSWs in Ontario work in the long-term care sector, 26,000 work for agencies that provide community and home care, and about 7,000 provide care in hospitals.

Changes to the Long-Term Care Act in 2010 outlined a minimum standard of education for PSWs working in that sector specifically.

PSWs working in long-term care homes are required to work under the supervision of a registered nurse or registered practical nurse

Some have suggested that rather than standardizing education for PSWs, more standards should be put in place around PSW supervision, scope of practice and work environment in long-term care and community agencies.

92% of PSWs are women, and many work at multiple part time jobs, involving a great deal of shift work.  PSWs are often paid minimum wages with few benefits.

Community colleges, continuing education programs and private career colleges offer courses or programs of varying durations, with no standardized core curriculum across the programs. There is no single body in Ontario that monitors the quality of these programs.

a PSW Registry to collect information about the training and employment status of the nearly 100,000 PSWs in Ontario

Long-Term Care Task Force on Resident Care and Safety

“a registry is a mechanism of counting and it doesn’t ensure anything about quality, preparation or standards.”

in the past two months there have been stakeholder consultations around educational standards for PSWs

Catherine Richards, Cause for Concern: Ontario’s Long Term Care Homes (Facebook group)

“PSWs have high expectations put on them but very little support to do their jobs.”

In my opinion, what we need most is a ministry (MOHLTC) that will demonstrate leadership by clarifying the role of the PSW in long-term care, nursing homes, hospitals and yes, home care, and to consistently enforce high standards of care

PSWs should feel able to rely on consistent supervision and clear guidance from registered nursing staff and management, yet from my observation there is a lack of communication between PSWs and RPNs/RNs in a long term care home setting, and rarely in my experience is honest communication encouraged to include patients/residents and families. In home care, PSWs have even less support or supervision which should concern people.

PSWs are rarely afforded the time to properly perform the necessary tasks assigned to them and they often bear the brunt of complaints

it is the leadership that must accept the bulk of responsibility when PSW care standards are low

Ombudsman oversight would provide an immediate and direct incentive to elevate care standards

In Nova Scotia, a registry was put in place for Continuing Care Assistants (the provinces’ equivalent to PSWs) in 2010 which has been used to communicate directly with CCAs as well as keep track of where they work. In addition, the registry provides resources and the development of a personalized learning plan to help care givers who do not have the provincial CCA obtain further training. British Columbia has also recently introduced a registry for Care Aids and Community Support Workers.

CUPE addresses these issues in Our Vision For Better Seniors’ Care: http://cupe.ca/privatization-watch-february-2010/our-vision-research-paper

having someone help you bathe, dress, eat and even wash your hair is as important as the medical care

I have worked in a Long-Term Care Facility for four years and have many concerns

it doesn’t take a rocket scientist to figure out that some point of care is being neglected

need to have more PSW staff on the front line

“it is like an assembly line here in the morning”

I don’t think these people are getting the dignity and respect they deserve.

We want to stop responsive behaviours, we need to know what triggers are. what is the root cause

We can’t do this with having less than 15 mins per resident for care.

I also believe that registering PSW’s will eliminate those who are in the career for just the money.

I have been a PSW for 8 years

Every year they talk more and more about residents rights, dignity ect ect … and yet every year, residents have been given less one on one time, poorer quality of meals, cut backs on activities and more than anything else, a lessened quality of care provided by over worked PSW’s.

Residents have floor mat sensors, wheelchair sensors, wander guard door alarm sensors, bed alarm sensors and add that to the endless stream of call bells and psw’s pagers sounding, it sounding like you are living inside a firestation with non-stop fire

they do not provide the staff to PREVENT the resident from falling

bell fatigue

This registry is just another cash grab

Now, it will be that much easier to put the blame on us.

When we do our 1.5hrs worth of charting every night they tell us to lie and say we have done restorative care and other tasks which had no time to do so they can provide funding which never seems to result in more staff.

for the Cupe reps reading this. You make me sick. Your union doesn’t back us up in the slightest and you have allowed for MANY additional tasks to be put onto psw’s without any increase in pay.

In the past year alone our charting has become computerized and went from 25mins to 1.5hrs. We now provide restorative care like rehab workers and now are officially responsible for applying and charting for medicated creams, not to mention the additional time spent now that prn behavior meds were discontinued and restraints removed created chaos

when your union reps come into meeting with us to “support” us, they side with our managers

about this registry

my sister works for 12 dollars H in Retirenment home

she has over 40 Residents

you should work in Long Term Care then, you will make a few buck more, still have 30-40 residents but at least you have a partner. On the other hand though, unlike retirement homes, for those 30-40 people, you will be dealing with aggressive behaviors, resistive residents, dementia, 75% of your residents will require a mechanical lift, you will have 1-2hrs worth of charting to do on top of your already hectic work load which they will not provide you more time to complete it, so only expect to get one 15min break in an 8 hr shift and often stay late to finish your charting.

As long as retirement homes are privily own they will always be run under the landlord and tenant act. That’s why they can work you like a dog and get away with it.

My 95 year old Dad is in LTC.

PSW’s simply do NOT have time to maintain, let alone enhance seniors’ quality of life.

there are NO rules or regulations about what the ratio of PSW staff to residents “should be”

quality is more than assistance with daily hygene, feeding, dressing, providing meds, getting people up in the morning, putting them to bed in the evening

psw’s are not only caregivers/ nurses we r also sometimes ONLY friend

The solution to our problem begins at the top, and this all seems very backwards to me.

Personal support workers are one of the back bones of the health care system.

Eleven years later, and nothing has changed? Something’s wrong here!

But I will not let this discourage me from taking the course, because no other job I’ve had has even come close to being as rewarding or fulfilling

is to many P.S.W in Ontario,and is not respect for them

Too many PSW’s are working as a Casual Employee

The pay is better in Long Term care as we know but PSW’s work for that extra few dollars more an hour

Most of us enjoy the field but more work has to be done to take care of your PSW’s and a pat on the back is just not going to do it.

administration has to stop being greedy with their big wages and start finding more money to invest in your front line, the PSW

"The goal is to introduce new technologies and inventive management practices, while achieving significant savings throughout the health-care system by standardizing the processes around managing these services, coordinating their planning and improving operational efficiency," Boudreau said. "Close to 1,800 people work to deliver food and cleaning services in New Brunswick hospitals. These employees are a vital part of our delivery of health care and the vast majority of them will continue to be government employees and CUPE members." But union officials said they don't believe it. They see the food service privatization as the tip of a much bigger iceberg that will lead to more cuts to jobs and, eventually, a lower level of service for New Brunswick taxpayers. Norma Robinson, president of CUPE Local 1252, said the union represents over 1,200 hospital support staff, paramedics, licensed practical nurses, patient care attendants and others. She said the Gallant government is trying to pick up on a plan that was started by the Alward Conservatives.

Robinson says union officials were called into a meeting last Thursday and told about the privatization plan. "This is not just about the jobs, it's about the service," Robinson said after her speech to the city hall rally. "We're talking about taking a publicly owned service and putting it in the hands of a private-for-profit corporation. It's not going to cost less, it's going to cost more because they are going to want to make a profit. That's our point, we don't want private companies coming in and taking over any public service in this province," Robinson said. "This is the tip of the iceberg. There are several areas they could look at to privatize. They are not being transparent with their information. They are doing a review of all services in the province, not just in hospitals. It's looking at all levels of government." Robinson called on taxpayers and voters to voice their anger at potential reductions in service as a result of cost-cutting and privatization. "We want answers. We want this stopped. We don't want privatization to come into this province, so we are going to try to stop this before this disease spreads and completely engulfs New Brunswick," Robinson said.

Patrick Colford, president of the New Brunswick Federation of Labour, was another speaker at the rally who said it was time for workers in the province to rise up against the government and fight cost-cutting that results in service reductions. "It's a taxpayer issue and where do taxpayers want their money spent?" he said after his speech. "Whether you are unionized or not, you are still a taxpayer. Is this about protecting jobs? Yes it might be but that's not the whole picture by any means. It's about protecting services that we depend on every day. "Talk to anybody who's ever been on EI and how frustrating it gets trying to talk to a human being to get answers, or somebody who goes to Service New Brunswick and has to take a number and sit there and wait. Or when you go to the emergency room and sit there and wait. All these cuts do is divide the population. Nobody wants to cut services and when the government comes in and says they are going to cut these public services and save X amount of dollars, people don't see the whole picture. The people who do are being vocal about it."

The budget plan involved a large number of stakeholders, including union reps, to vet the issues and evaluate alternative solutions. According to Wren, the April 1 bed reduction was known about since the February 2015 and the physicians have been actively engaged in working towards this eventuality. Outside the hospital, Cindy Schulz, president of CUPE local 1502 representing Registered Practical Nurses, technical staff including x-rays and diagnostics and support staff, begged the question, "What will be next?" Michael Hurly, president of the Ontario Council of Hospital Unions, also addressed the crowd during the rally.

"There are deep cuts to services," Hurly started. "We are here today to say that we are not accepting these cutbacks or the privatization of surgical, clinical and support services." The second issue revolves around the discussion indicating changes to Central Service and Reprocessing department (CSR) at the hospital. CSR provides patient-care areas with clean and sterile supplies and include all reusable patient care equipment such as bowls and basins, anaesthetic supplies and surgical instrument sets. After these supplies are used, they are returned to CSR to be processed before being used by another patient. Processing involves cleaning and may also include disinfecting and sterilizing the item, dependent on its use.

The current discussion evaluates the option of outsourcing a portion of the CSR function to an off-site service provider. "By looking at out sourcing a portion of the work, it allows us to expand our patient services," Wren said. The move will create service capacity that is currently not available internally in the hospital in allowing PRH to expand its patient services through possibilities such as Orthopaedics and other specialized surgical procedures. These additional services will serve to create new jobs in the community. "We're not losing our jobs," said Elizabeth Labron, a CSR department staff member. "We're being repos i tioned within the hospital, but the biggest part of our job is going to be shipped to Southern Ontario."

Labron is concerned that their skills and knowledge will not be utilized by the hospital anymore. A memo from Wren's office confirmed that 'All CSR staff will be retained and will be doing comparable work. There will be no layoffs, and any minor reductions will be facilitated through attrition.' The CUPE campaign will conclude with a public meeting scheduled for 7 p.m. on July 30 at the Knights of Columbus Hall, 170 Ellis Ave., Pembroke.

Ambulance NB has a number of resources already in place to support its paramedics, flight nurses and medical dispatchers. There's a critical incident stress-management program, which is supported by the Department of Health and the College of Psychologists of New Brunswick. It offers peer-to-peer support for paramedics who've responded to difficult calls. The provincial ambulance service also has a free, confidential employee and family assistance program. It's available around the clock and offers employees one-on-one counselling to help them cope with stresses from work or home. Tracy Bell, a spokeswoman for Ambulance NB, told The Daily Gleaner in February that the organization was taking steps to expand its offerings to paramedics.

"We recognize that we need to do more to support our front-line employees and are taking the necessary steps to get there," she said. "In addition to existing resources, Ambulance NB will be introducing an expanded employee support program in the coming weeks. We are also looking seriously at what options are available in terms of facilitating direct access to a mental health professional or network of professionals for our employees. We hope to be able to be able to share news of these new initiatives with staff very soon." When the newspaper asked for an update this week, Bell said Ambulance NB is still working on this project. "Ambulance NB looks forward to being able to share news of new mental health supports with our employees soon," she said. "Our priority is to share information first with our paramedics, dispatchers and flight nurses." Judy Astle, president of paramedics union CUPE Local 4848, said she's still waiting for some more information. "They supposedly have what they're calling an enhanced employee assistance program. But we have not seen the details as a union yet," she said.

"We have a labour management meeting coming up next week. They may present it there. That's what we're hoping." Astle said enhancing the mental health resources for paramedics should help many professionals deal with the difficulties they experience in the line of duty. "Anything that's going to try to prevent high levels of stress in our job is valuable. It's hard to do. But the support is needed out there," she said. "It's a very trying job, to say the least. What affects me may not affect someone else. But what could affect them may not affect someone else. It's often a build up of things." MLA Ross Wetmore, the Progressive Conservative member who represents the Gagetown-Petitcodiac region, recently introduced a private member's bill in the New Brunswick legislature designed to eliminate the need for first responders to prove their post-traumatic stress disorder was caused while on the job. If it passes, that could eliminate the mountains of red tape that many first responders now face as they seek benefits while on leave for treatment.

Specifically, Bill 15 would amend the Workers' Compensation Act to presume post-traumatic stress disorder in first responders has been caused by "a traumatic event or a series of traumatic events to which the worker was exposed" while at work. That would apply to both current and former firefighters, paramedics, police officers and sheriffs who have been diagnosed as having PTSD by a physician or psychologist. A second part of the bill would require workers' compensation to offer, "treatment by culturally competent clinicians who are familiar with the research concerning treatment of first responders for post-traumatic stress disorder." Astle said she supports the bill, and says it could really help first responders as they struggle to get the help they need. "That was fantastic. That's a step in the right direction," she said. "People are talking about it more, are relating to it more. In our job, we're supposed to be the 'tough guy.' We have to share with our co-workers some of the things that are bothering us. Most of us do that. We talk it out." Chris Hood, executive director of the Paramedics Association of New Brunswick, said he's going to be meeting with government soon to ask for their support of this legislation, though he currently doesn't know how they feel about such a program. "We don't know whether or not government is going to support it," he said.

Hood said his organization wants to join the effort to make life easier for paramedics. So it's announced a few goals for the future. "We're working towards increased screening and education prior to entering the profession, improved training during the (early stages of your career), high-quality mental health support through a team of dedicated practitioners during your employment, and then the presumptive diagnosis legislation (introduced by Wetmore)," he said.

? full privatization: where a government enterprise is sold in full to private investors. ? publicly funded with services and management delivered privately, sometimes unknown to the consumer. ? public funding of private services: government provides vouchers to consumers for the purchase of goods and services from private providers.

? public/private partnerships (P3s): full outside contracting, management and service delivery of traditionally delivered public services such as hospitals, roads, schools and prisons. This can include private finance, design, building, operation and possibly temporary ownership of an asset. Can privatization deliver? After decades of experimentation with privatization in different forms across Canada, the data is clear on the failure to deliver on its promises and the high cost society pays - multiple costs, not only in economic terms but also quality and access to services, quality and quantity of jobs, as well as transparency and accountability.

Public/private partnerships (P3s) are the fastest-growing model of privatization in Canada. The P3 models vary but all include the reliance on private sector borrowing to finance the development of public infrastructure projects in a long-term lease arrangement; it is effectively leasing rather than owning and sometimes that lease includes maintenance as well. P3s cost more. Governments have always been able to borrow money more cheaply than private corporations. According to a University of Toronto study of 28 P3 projects in Ontario, P3s cost, on average, 16 per cent more than a traditional public contract. A recent auditor general of Ontario report found that P3 projects cost the province $8 billion more than if they were done under the traditional model.

If they cost more, why do politicians promote them? Political expediency - in P3 lease agreements the debt stays off the books or is postponed for decades. P3s hide debt - which is a dream for politicians looking for easy wins in hard economic times. It is also ideological and it is about private sector lobbying and influence. Public services are a boon to private sector deliverers with guaranteed public payments and profit margins over the long term. Supporters of privatization claim that it leads to better pricing for the public as consumers. A comparison of privately owned Manitoba Telecom Services, privatized in 1997, to SaskTel, Saskatchewan's publicly owned telecommunications crown corporation shows this to not be true. Twenty years after privatization of MTS, the cost of a basic phone with SaskTel is $8 less per month than from MTS.

Private corporations demand a shroud of confidentiality in order to protect their competitive position. This means that privatization reduces both transparency and accountability. An example of this is the Ontario privatization of municipal water testing which has been linked to the May 2000 bacterial contamination of municipal water in Walkerton, Ont., led to the deaths of at least seven people and the serious illness of 2,300 more from water contaminated with E. coli. The absence of criteria governing quality of testing, and the lack of provisions made for notification of results to authorities contributed to the worst public health disaster involving municipal water in Canadian history.

Health care is a sector where there is huge pressure on government to control cost, particularly in Newfoundland and Labrador with the aging demographic. Private interests see great profit opportunities. But in health care, for-profit does not deliver. In Manitoba, living in a for-profit long-term care facility increased the odds of dying in hospital or being hospitalized.

In a metadata analysis of hospitals in the U.S., Dr. Philip Devereaux, a cardiologist at McMaster University, concluded that the death rate in for-profit hospitals was two per cent higher than in not-for-profit facilities. In Alberta, the Health Quality Council of Alberta's Long Term Care Family Experience Survey in 2012 found that, on average, private and volunteer operated facilities offered poorer quality in terms of staffing levels, care of residents' belongings, and assistance with daily living activities such as toileting, drinking and eating, than publicly operated ones.

The scathing Ontario auditor general report indicates that there needs to be extensive and comprehensive reviews of provincial privatization projects. Until proper cost-benefit analyses and public reviews and reform of private funding and procurement models occur, governments and public bodies should place moratoria on further public-private infrastructure contracts. The citizens pay either way, but they pay more in a privatized model - either as tax payers or out of pocket.

The government has alternatives. The Newfoundland and Labrador Federation of Labour has published a number of reports and fact sheets on the progressive revenue options open to the provincial government. There are a variety of progressive revenue options open to municipalities as well. There are no silver bullets. It is time to stop stigmatizing government and public services and recognize them for what they are: the way we pool our resources to buy services cheaper, control costs, and maintain accountability for quality.

his should be a debate based on evidence, not ideology. Mary Shortall, president, Unifor Local 597

Imagine if a Canadian diagnosed with cancer were told she could receive chemotherapy paid for by the health-care system, but would have to cough up the cash herself if she needed radiation. Or that she could have a few weeks of treatment, and then be sent home even if she needed more. That would never fly. If doctors, say, find a tumour in a patient's colon, the government kicks in and offers the mainstream treatment that is most effective. But for many Canadians diagnosed with a mental illness, the prescription is very different. The treatment they receive, and how much of it they get, will largely be decided not on evidence-based best practices but on their employment benefits and income level: Those who can afford it pay for it privately. Those who cannot are stuck on long wait lists, or have to fall back on prescription medications. Or get no help at all. But according to a large and growing body of research, psychotherapy is not simply a nice-to-have option; it should be a front-line treatment, particularly for the two most costly mental illnesses in Canada: anxiety and depression - which also constitute more than 80 per cent of all psychiatric diagnoses.

Why aren't we providing evidence-based care?" .. The case for psychotherapy Research has found that psychotherapy is as effective as medication - and in some cases works better. It also often does a better job of preventing or forestalling relapse, reducing doctor's appointments and emergency-room visits, and making it more cost-effective in the long run.

Therapy works, researchers say, because it engages the mind of the patient, requires active participation in treatment, and specifically targets the social and stress-related factors that contribute to poor mental health. There are a variety of therapies, but the evidence is strongest for cognitive behavioural therapy - an approach that focuses on changing negative thinking - in large part because CBT, which is timelimited and very structured, lends itself to clinical trials. (Similar support exists for interpersonal therapy, and it is emerging for mindfulness, with researchers trying to find out what works best for which disorders.) Research into the efficacy of therapy is increasing, but there is less of it overall than for drugs - as therapy doesn't have the advantage of well-heeled Big Pharma benefactors. In 2013, a team of European researchers collated the results of 67 studies comparing drugs to therapy; after adjusting for dropouts, there was no significant difference between the most often-used drugs - selective serotonin reuptake inhibitors (SSRIs) - and psychotherapy.

The issue is not one against the other," says Montreal psychiatrist Alain Lesage, director of research at the Douglas Mental Health University Institute. "I am a physician; whatever works, I am good. We know that when patients prefer one to another, they do better if they have choice." Several studies have backed up that notion. Many patients are reluctant to take medication for fear of side effects and the possibility of difficult withdrawal; research shows that more than half of patients receiving medication stop taking it after six months. A small collection of recent studies has found that therapy can cause changes in the brain similar to those brought about by medication. In people with depression, for instance, the amygdala (located deep within the brain, it processes basic memories and controls our instinctive fight-or-flight reaction) works in overdrive, while the prefrontal cortex (which regulates rational thought) is sluggish. Research shows that antidepressants calm the amygdala; therapy does the same, though to a lesser extent.

But psychotherapy also appears to tune up the prefrontal cortex more than does medication. This is why, researchers believe, therapy works especially well in preventing relapse - an important benefit, since extending the time between acute episodes of illnesses prevents them from becoming chronic and more debilitating. The theory, then, is that psychotherapy does a better job of helping patients consciously cope with their unconscious responses to stress.

According to treatment guidelines by leading international professional and scientific organizations - including Canada's own expert panel, the Canadian Network for Mood and Anxiety Treatments - psychotherapy should be considered as a first option in treatment, alone or in combination with medication. And it is "highly recommended" in maintaining recovery in the long term. Britain's independent, research-guided scientific body, the National Institute for Health and Care Excellence, has concluded that therapy should be tried before drugs in mild to moderate cases of depression and anxiety - a finding that led to the creation of a $760million public system, which now handles therapy referrals for nearly one million people a year.

In 2012, Canada's Mental Health Commission estimated that only about one in three adults and one in four children are receiving support and treatment when they need it. Ironically, anti-stigma campaigns designed to help people understand mental illness may only make those statistics worse. In Toronto, for instance, putting up posters in subway stations in 2010 had the unexpected effect of spiking the volume of walk-ins at nearby emergency rooms by as much as 45 per cent in 12 months. Dr. Kurdyak treated many of them at CAMH. The system, he says, "has been conveniently ignoring this unmet need. It functions as if two-thirds of the people suffering won't get help." What would happen if the healthcare system outright "ignored" two-third of tumour diagnoses?

Essentially, argues Dr. Lesage, adding therapy into the health-care system is like putting a new, highly effective drug on the table for doctors. "Think about it," he says. "We have a new antidepressant. It works as well as many others, and it may even have some advantages - it works better for remission - with fewer side effects. The patients may prefer it. And [in the long run] it doesn't cost more than what we have. How can it not be covered?" ..

A heavy price This isn't just a medical issue; it's an economic one. Mental illness accounts for roughly 50 per cent of family doctors' time, and more hospital-bed days than cancer. Nearly four million Canadians have a mood disorder: more than all cases of diabetes (2.2 million) and heart disease (1.4 million) combined.

Mental illness - and depression, in particular - is the leading cause of disability, accounting for 30 per cent of workplace-insurance claims, and 70 per cent of total compensation costs. In 2012, an Ontario study calculated that the burden of mental illness and addiction was 1.5 times that of all cancers, and more than seven times the cost of all infectious diseases. Mental illness is so debilitating because, unlike physical ailments, it often takes root in adolescence and peaks among Canadians in their 20s and 30s, just as they are heading into higher education, or building careers and families. Untreated, symptoms reverberate through all aspects of life, routinely trapping people in poverty and homelessness. More than one-third of Ontario residents receiving social assistance have a mental illness. The cost to society is clearly immense.

Yet, when family doctors were asked why they didn't refer more patients to therapy in a 2008 Canadian survey, the main reason they gave was cost. For many Canadians, private therapy is a luxury, especially if families are already wrestling with the economic fallout from mental illness. Costs vary across provinces, but psychologists in private practice may charge more than $200 an hour in major centres. And it's not just the uninsured who are affected.

Although about 60 per cent of Canadians have some form of private insurance, the amount available for therapy may cover only a handful of sessions. Those with the best benefits are more likely to be higherincome workers with stable employment. Federal public servants, notably, have one of the best plans in the country - their benefits were doubled in 2014 to $2,000 annually for psychotherapy. Many of those who can pay for therapy are doing so: A 2013 consultant's study commissioned by the Canadian Psychological Association found that $950-million is spent annually on private-practice psychologists by Canadians, insurance companies and workers compensation boards. The CPA estimates t

These are the patients that family doctors juggle, the ones who eat up appointment time, and never seem to get better, the ones caught on waiting lists. Sometimes, they have already been bounced in and out of the system, received little help, and have become wary of trying again. A 40-something mother recovering from breast cancer, suffering from chronic depression post-treatment, debilitated by fear her cancer will return. A university student, struggling with anxiety, who hasn't been to class for three weeks and may soon be kicked out of school. A teenager with bulimia removed from an eatingdisorder program because she couldn't follow the rules. They are the ones dangling on waiting lists in the public system for what often amounts to a handful of talk-therapy sessions, who don't have the money to pay for private therapy, or have too little coverage to get the full course of appointments they need.

Canada's investment does not match that burden. Only about 7 per cent of health-care spending goes to mental health. Even recent increases pale when compared to other countries: According to a study by the Canadian Mental Health Association, Canada increased per-capita funding by $5.22 in 2011. The British government, meanwhile, kicked in an extra 12 times that amount per citizen, and Australia added nearly 20 times as much as we did. Falling off a cliff, again and again

In Winnipeg, Dr. Stanley Szajkowski watched for months as his patient, a woman in her 80s, slowly declined. Her husband had died and she was spiralling into a severe depression. At every appointment, she looked thinner, more dishevelled. She wasn't sleeping, she admitted, often through tears. Sometimes she thought of suicide. She lived alone, with no family nearby, and no resources of her own to pay for therapy. "You do what you can," says Dr. Szajkowksi. "You provide some support and encouragement." He did his best, but he always had other patients waiting.

hat 30 per cent of private patients pay out-ofpocket themselves. When the afflicted don't seek help, the cost isn't restricted to their own pocketbook. People with mental-health problems are significantly more likely to abuse drugs and alcohol, and to become physically sick, further increasing health-care costs. A 2014 study by Oxford University researchers found that having a mental illness reduced life expectancy by 10 to 20 years, roughly the same as did smoking and obesity. A 2008 Statistics Canada study linked depression to new-onset heart disease in the general population. A 2014 U.S. study found that women under the age of 55 are twice as likely to suffer or die from a heart attack, or require heart surgery, if they have moderate to severe depression. The result: clogged-up doctors' offices, ERs, and operating rooms. And an inexorable burden for the patients' families forced to fill the gaps in caregiving - or carry on when they lose a loved one.

Patients refer to it as falling repeatedly off a cliff. And they can only manage the climb back up so many times. Family doctors interviewed for this story admitted that they are often "handholding" patients with nowhere else to go. "I am making them feel cared for, I am providing a supportive ear that they may not get anywhere else," says Dr. Batya Grundland, a physician who has been in family practice at Toronto's Women's College Hospital for almost a decade. "But do I think I am moving them forward with regard to their illness, and helping them cope better? I am going to say rarely." More senior doctors have told her that once in a while "a light bulb goes off" for the patients, but often only after many years. That's not an efficient use of health dollars, she points out - not when there are trained therapists who could do the job better. However, she says, "in some cases, I may be the only person they have."

Family doctors aren't the only ones struggling to find therapy for their patients. "I do a hundred consultations a year," says clinical psychiatrist Joel Paris, a professor at McGill University and research associate at the Montreal Jewish General, "and one of the most common situations is that the patient has tried a few anti-depressants, they have not responded very well, and from their story it is obvious they would benefit from psychotherapy. But where do they go? We have community clinics here in Montreal with six-to-12-month waiting lists even for brief therapy." A fractured, inefficient system

"You fall into the role that is handed to you," says Antoine Gagnon, a family doctor in Osgoode, on the outskirts of Ottawa. He tries to set aside 20-minute appointments before lunch or at the end of the day to provide "active listening" to his patients with anxiety and depression. Many of them are farmers or self-employed, without any private coverage for therapy. "Five of those minutes are spent talking about the weather," he says, "and then maybe you get into the meat of the problem, but the reality is we don't have the appropriate amount of time to give to therapy, even to listen, really." Often, he watches his patients' symptoms worsen over several months, until they meet the threshold of a clinical diagnosis. "The whole system could save on productivity and money if people were actually able to get the treatment they needed."

But these issues aren't insurmountable, as other countries have demonstrated. Britain, for instance, has trained thousands of university graduates to become therapists in its new public program, following research showing that, as long they have the proper skills, people don't need PhDs to be effective therapists. Australia, which has created a pay-for-service system, also makes wide use of online support to cost-effectively reach remote communities.

Except for a small fraction of GPs who specialize in psychotherapy, few family doctors have the training - or the time - to provide structured therapy. Saadia Hameed, a GP in a family-health team in London, Ont., has been researching access to psychotherapy for an advanced degree. Many of the doctors she has interviewed had trouble even producing a clear definition of therapy. One told her, "If a patient cries, than it's psychotherapy." Another described it as "listening to their woes." A 2007 survey of 163 family doctors in Ontario found that almost four out of five had not received training in cognitive behavioural therapy, and knew little about it. "Do family doctors really need to do that much psychotherapy," Dr. Hameed asks, "when there are other people trained - and better trained - to do it?"

What further frustrates treatment for physicians and patients is lack of access to specialists within the system. Across the country, family doctors describe the difficulty of reaching a psychiatrist to consult on a diagnosis or followup with their patients. In a telling 2011 study, published in the Canadian Journal of Psychiatry, researchers conducted a real-world experiment to see how easily a GP could locate a psychiatrist willing to see a patient with depression. Researchers called 297 psychiatrists in Vancouver, and reached 230. Of the 70 who said they would consider taking referrals, 64 required extensive written documentation, and could not give a wait-time estimate. Only six were willing to take the patient "immediately," but even then, their wait times ranged from four to 55 days. Psychiatrists are in increasingly short supply in Canada, and there's strong evidence that we're not making the best use of these highly trained specialists. They can - and often do - provide fee-for-service psychotherapy in a private setting, which limits their ability to meet the huge demand to consult with family doctors and treat the most severe cases.

A recent Ontario study by a team at CAMH found that while waiting lists exist in both urban and rural centres, the practices of psychiatrists in those locations tend to look very different. Among full-time psychiatrists in Toronto, 10 per cent saw fewer than 40 patients, and 40 per cent saw fewer than 100 - on average, their practices were half the size of psychiatrists in smaller centres. The patients for those urban psychiatrists with the smallest practices were also more likely to fall in the highest income bracket, and less likely to have been previously hospitalized for a mental illness than those in the smaller centres.

And those therapy sessions are being billed with no monitoring from a health-care system already scrimping on dollars, yet spending a lot on this care: On average, psychiatrists earn $216,000 a year. There is nothing to stop psychiatrists from seeing the same patients for years, and no system to ensure the patients with the greatest need get priority. In Australia, Britain and the United States, by contrast, billing for psychiatrists has been adjusted to encourage them to reduce psychotherapy sessions and serve more as consultants, particularly for the most severe cases, as other specialists do.

As the Canadian system exists now, says Benoit Mulsant, the physician-in-chief at CAMH and also a psychiatrist, the doctors in his specialty "can do whatever they please. If I wanted, I could have a roster of actor patients who tell me entertaining stories, and I would be paid the same as someone who is treating homeless people. ... By treating the rich and famous, there is zero risk of being punched in the face by a patient." Left out in all this, by and large, are other professionals who can provide therapy. It doesn't help that the rules are often murky around who can call themselves psychotherapists. While psychologists and social workers are licensed under their professional associations, in some provinces a person can call himself a marriage counsellor or music therapist with no one demanding they be certified. In 2007, Ontario passed a law to regulate psychotherapists, requiring them to register with a provincial college that would set standards and handle complaints. Currently, however, the law is in limbo, although the government has said it will finally bring it into force by December. The brain keeps many secrets

Science, however, has yet to find depression's equivalent of insulin. Despite being scanned, poked and stimulated over and over and over again, the brain keeps its secrets. The "chemical imbalance" theory is now viewed as simplistic at best. It may not do much for patients, either: A 2014 study published in the journal Behaviour Research and Therapy suggested that, rather than reassuring them, focusing on the biological explanation for depression actually made patients feel more pessimistic and lacking in control. SSRIs work by increasing the amount of serotonin, a chemical that helps deliver messages within the brain and is known to influence mood. But researchers aren't sure why the drugs help some patients and fail with others. "Basically, it's like we have a bucket of water and we pour it over the patient's head," says Dr. Georg Northoff, the University of Ottawa's Michael Smith chair of Neurosciences and Mental Health. "But you want a drug that injects the water in a very specific brain regions or brain system, which we don't have."

Critics of therapy have argued that it's basically "good listening" - comparable to having a sympathetic friend across the kitchen table - and that in the real world of mercurial patients and practitioners of varying abilities, a pill just works better. That's true in many cases, especially when the symptoms are severe and the patients is suicidal: a fast-acting medication is safer, and may even be necessary before starting talk therapy. The staunchest advocates of therapy do not suggest it should be the first course of treatment for psychosis, or debilitating chronic depression, or mania - although, in those cases, there is evidence that psychotherapy and medication work well in tandem. (A 2011 meta-analysis found that patients with severe depression who received a combination approach had higher recovery rates and were less likely to drop out of treatment.) But drugs also don't work as well as the manufacturers would like us to think. Roughly one-third of patients given a drug will see no benefit (although they often respond to a second or third medication). In randomly controlled trials, drugs often perform only marginally better than sugar pills.

Yet it's talk therapy that the public often views most skeptically. "Until you go to a therapist, or a member of your family has a serious psychological problem, people are unsympathetic [about therapy]," says Dr. Paris, the Montreal psychiatrist. "They are very skeptical, and they don't believe the research. It's amazing, because pharmaceutical trials will get approval for a drug on the basis of two clinical trials that they paid for. And we have 100 clinical trials and no one believes us."

Dr. Ajantha Jayabarathan, an assistant professor at Dalhousie University's medical school, spent her early years as a family doctor in Spryfield, N.S., trying to manage an overload of mental-health cases. Most of her patients had little insurance; there was one reduced-cost counselling service in town, but the waiting lists were long. In 2000, her group practice became a test site for a shared-care project, which gave the doctors access to a mental-health team, including weekly in-person consultations with a psychiatrist. "It was transformative," she says. "We looked after everything in-house.

Over time, Dr. Jayabarathan says, she learned how to properly assess mental illness in patients, and how to use medication more effectively. "I just made it my business to teach myself what to do." It's the kind of workaround GPs are increasingly experimenting with, waiting for the system to catch up. Who would pay - and how?

The case for expanding publicly funded access to therapy is gaining traction in Canada. In 2012, the health commissioner of Quebec recommended therapy be covered by the province; it is now being studied by Quebec's science-based health body (INESSS), which is expected to report back next year. A new Quebec-based organization of doctors, researchers and mental-health advocates called the Coalition for Access to Psychotherapy (CAP) is lobbying the government.

In Manitoba, the Liberal Party - albeit well behind in the polls - has made the public funding of psychologists one of its campaign platforms for the province's spring 2016 election. In Saskatchewan, the government commissioned, and has since endorsed, a mental-health action plan that includes providing online therapy - though politicians have given themselves 10 years to accomplish it. Michael Kirby, the former head of the Canadian Mental Health Commission, has been advocating for eight annual sessions of therapy to be covered for children and youth in need.

There are significant hurdles: Which practitioners would provide therapy, and how would they be paid? What therapies would be covered, and for how long? Complicating every aspect of major mentalhealth change in Canada is the question of who should shoulder the cost: the provinces or Ottawa. In a written statement in response to questions from The Globe and Mail, federal Health Minister Rona Ambrose lobbed the issue back at her provincial counterparts, pointing out that the Canada Health Act does not "preclude provinces and territories from extending public coverage to other services or providers such as psychologists."

One result can be overloaded family doctors minimizing mental-health problems. "If you have nothing to offer someone," asks Dr. Anderson, "how much are you going to dig around to find out what is going on?" Some doctors also admit that the lack of resources can lead to physicians cherry-picking patients who don't have mental illness. And yet family physicians alone bill about $361million a year for counselling or psychotherapy in Canada - 5.6 million visits of roughly 30 minutes each. This is a broad category, and not always specifically related to mental health (some of it includes drug counselling, and a certain amount of coaching is a necessary part of the patient-doctor relationship). When it is psychotherapy, however, doctors admit it's often more supportive listening than actual therapy.

So how would Canada pay for access to such therapy? It wouldn't be cheap, in the short term. The savings would come from what Canadians would not have to spend in the long term: in additional medical and drug costs, emergency-room visits and hospital stays, and in unnecessary disability payments, to say nothing of better long-term health outcomes for patients given good care earlier. Some of the figures being tossed around sound staggering. Rolling out a version of Britain's centre-based program across Canada would cost $950-million. Michael Kirby's plan would amount to $1,000 annually per patient. A 2013 report commissioned by the Canadian Psychological Association calculated that, based on predicted need, and assuming no coverage from private health-care plans, providing an average of six sessions of therapy a year would cost an estimated $2.8-billion annually.

But any of those figures would still be a fraction of the roughly $210-billion that Canada spends annually on health care. Figuring out how to make the system most costeffective is, according to sources, currently delaying the INESSS report to the Quebec government. "You need to facilitate the government," says Helen- Maria Vasiliadis, a professor of community health at the University of Sherbrooke. "You can't be going to policymakers and showing them billions and billions of dollars. People start having heart attacks. With evidence in hand, we have to present possible solutions."

An insurance-based plan is the proposal that has emerged from the Quebec-based CAP group, which sent its proposal to Quebec's health minister last month. In its design, the system would work much like Quebec's public drug plan - Quebeckers not covered through work plans would contribute to a provincial insurance program for therapy. That would be similar to the system that Germany has used for decades. One step forward, one step back

Last year, the Sherbrooke clinic where Marie Hayes works received provincial funding for a part-time psychologist and a full-time social worker. With a roster of 25,000 patients, the clinic team laid out clear guidelines for the psychologist, who would consult on cases and screen patients, and be limited to a mere four sessions of actual counselling with any one patient. "We wanted to be careful she didn't become a waiting list - like everything in the system," says Dr. Hayes. The social worker helps guide patients into services such as housing and addiction counselling. They have also offered group sessions for depression management at the clinic. As stretched as those new professionals are in such a large practice, Dr. Hayes says the addition of that mental-health team is improving the care she can provide patients. Recently, for instance, the 32- year-old mother with anxiety attended sessions with the psychologist. "She is making progress," says Dr. Hayes, "slowly."

At Women's College Hospital in Toronto, Dr. Grundland is not so lucky. Asked to describe a difficult case, the family-practice physician mentions a patient suffering from depression after a lifechanging accident. Every month, doctor and patient would repeat the same conversation they'd already had more than a dozen times - and make little real headway. Her patient, says Dr. Grundland, needs a trained therapist: someone she can see regularly, to help her move past her frustration, counsel her about addiction, and ease the burden on her family.

But there's no extra money in the patient's budget for a psychologist. "I do my best," Dr. Grundland says, "but it's not my area of expertise." Meanwhile, the patient isn't getting better, and in the time that it takes to make it through one appointment with her, Dr. Grundland could see three other people with problems she was actually trained to treat. "But," says Dr. Grundland, "she has nowhere else to go." Erin Anderssen is a feature writer at The Globe and Mail. OPEN MINDS How to build a better mental health care system

The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. While CAMH professionals are quoted in this story, the organization had no involvement in the creation or production of this, or any other story in the series. $20.7-billion The cost, according to a 2012 Conference Board of Canada report, of lost productivity each year due to mental illness. What else does $20-billion represent?

$20B: Canadian spending on national defence, 2012-13 $20B: Market valuation of Airbnb, 2015 $21B: Kitchener-CambridgeWaterloo region's GDP, 2009 $21B: Amount food manufacturing contributed to the economy, 2012

Ms. Carter's efforts are just part of a broad effort of Canadians to welcome refugees from Syria. But her work also highlights the ad hoc preparation that is taking place while the federal government scrambles to meet its commitment to bring 25,000 refugees to Canada in the next three months. The Immigrant Services Society of B.C. expects about 400 refugees, half government assisted and half privately sponsored, to resettle in the province by the end of December. Governmentassisted refugees will be placed in the lower mainland, but privately sponsored refugees will head to the communities where their sponsors are based - Victoria, Kelowna, Duncan and Prince George are preparing to greet refugee families before the end of the year.

No more than 20 refugees will likely arrive in the region where Ms. Carter and her team of volunteer professionals are ready to help. Other communities may not be as well served - there is an element of good fortune that the Victoria region happens to have an experienced volunteer corp of therapists at the ready. Ms. Carter just spent four years with the Centre for Victims of Torture in Jordan, where she worked with hundreds of Syrian refugees. Before that, she specialized in trauma support with Medecins sans frontieres (Doctors Without Borders). From that experience, she knows the counsellors themselves will need ongoing support to deal with the topics they'll be processing. "Many of these refugees have gone through incredible trauma," she said. "The stories are very difficult to hear, even for experienced counsellors."

And, after 25 years working in child and mental-health services in Victoria, she knows the system is already strained and would not be able to cope with the urgent needs of the new arrivals. "Mental-health services for adults and children are very, very sparse. Often Canadian children have to wait for months to get into our mental-health system. I'm very concerned that the refugees, when they come to Canada, most of them of have a lot of PTSD symptoms and they are going to need assistance and there was really nothing set up."

Victoria Mayor Lisa Helps is coordinating efforts among immigration support groups, the region's school districts, postsecondary institutions and other levels of government to welcome an unknown number of refugees in the next three months to southern Vancouver Island. "We are rolling out the welcome wagon, recognizing that it looks different for refugees from a war zone," she said in an interview. The biggest challenge, she said, will be finding a place for the new families to live: Victoria has one of the lowest vacancy rates for rental housing in the province, and low-rent housing is particularly squeezed.

"We want to provide a welcoming new home. It will take a heroic effort." These stories are emerging across the country - Canadians pushing aside security fears and making the near-impossible happen.

Cindy Schulz, president of CUPE Local 1502 which representing Registered Practical Nurses, technical staff including x-rays and diagnostics and support staff at the PRH, said they decided to bring their message to Yakabuski in person because they feel let down by the MPP. "We first met June 19 with Mr. Yakabuski regarding stopping the closure of the CSR department and the bed cuts," she said, "and his response was what can he do about it?" Schulz said the MPP promised he would attend a town hall meeting on the matter which was held July 30, and he never arrived.

Schultz said they were not happy with what they see is a lack of commitment to supporting their concerns, and so decided to stage a rally outside his office. Yakabuski was in Toronto Wednesday, so wasn't in his constituency office to hear or speak to those gathered outside. About 60 health care workers and their supporters took part in the rally, which included those from Kingston, Smiths Falls, Perth and other places within Eastern Ontario. Following the rally, the group marched from 84 Isabella and through the downtown core before looping back.

Federal NDP candidate Dan McCarthy also attended the rally, and said this shows the need for a national approach to health care, where local, provincial and federal levels of government respond and cooperate together to the needs. He said changes to the funding formula from the federal level has led to cutbacks right down the line, which is affecting everyone. "The NDP is the pioneer of public health care," McCarthy said, pledging that an NDP government would step up to see to it this Canadian tradition continues.

The cutbacks at the PRH began April 1, when the medical beds were reduced by five. This reduction was implemented in accordance with the hospital's 2015/2016 budget. Back in July, John Wren, senior vice-president of corporate and support services at PRH, told The Daily Observer the decision to reduce the number of beds in the hospital came after examining hospital services and the needs of the patients that PRH serves. He stated becoming more efficient in patient length of stay has resulted in the beds no longer being needed. According to Wren, the April 1 bed reduction was known about since February 2015 and the physicians have been actively engaged in working towards this eventuality.

Another aspect of the protest is a postcard campaign directed at the Minister of Health Eric Hoskins, asking him to intervene in the hospital's decision to outsource sterilization services. Schulz said this has been going well, with 7,000 of them signed so far, reflecting the public's opposition to the changes. She said they will be hand delivering these to Queen's Park once the fall session starts in September. Stephen Uhler is a Daily Observer multimedia journalist

Members of the Pembroke Regional Hospital staff and their supporters march down Church Street following a rally held Wednesday in front of 84 Isabella Street. They were protesting the contracting out of services and the closure of medical beds.

Although Health Minister Eric Hoskins has vowed that this year's portion of the raise will eventually be doled out retroactively to April 1, the delay has caused "a lot of confusion, uncertainty and frustration," among PSWs in the home and community care field, according to Kelly O'Sullivan, the chair for CUPE Ontario's health-care workers. "It adds to the ongoing precarious nature of this work," she said. "You can't even depend on a wage increase that's been promised to you by the government."

The government's PSW Workforce Stabilization Strategy was designed to make home-care work less precarious, not more. PSWs deliver more than half of all home-care services, helping clients to dress, bathe, prepare meals, tidy up and manage medications, among other tasks. Yet their paycheques are traditionally smaller and their schedules more erratic than those of PSWs who work in hospitals and nursing homes, making it difficult to retain quality workers in home and community care. Persuading PSWs to choose the home-care field is essential to the Ontario government's efforts to keep people out of hospitals and nursing homes for as long as possible - a way to stretch increasingly scarce health-care dollars and respond to the public's desire to heal and age at home.

People interviewed for this story were quick to praise the Liberals for trying to improve the lot of home-care PSWs and their clients by raising their minimum wage to $16.50 an hour from $12.50 over three years. The intention was laudable, they said. The execution of the plan was not. "This should be the best news story ever," said Deborah Simon, the chief executive officer of the Ontario Community Support Association, which represents hundreds of non-profit agencies that help people at home. Instead, Ms. Simon said, the Byzantine rules around the pay hike have created an "administrative burden" for organizations.

At the heart of the problem is which workers - and which kinds of work - qualify for the government-funded pay bump. While the government set a wage floor of $16.50 an hour as of 2016-17, it delivered the public funds through a "wage enhancement" that only applies when PSWs are providing "personal support services" funded by Local Health Integrated Networks (LHINs), the province's regional health authorities.

That means time spent in training, travelling to clients' homes or performing tasks such as food preparation do not qualify for the higher rate. Initially, even statutory holidays were paid out without the increase, although that has been reversed. Jason Lye, national head of independent living services at March of Dimes, says his agency spent months clarifying provincial rules, only passing on the first phase of the raise retroactively to workers in February in the form of a "blended rate" that takes into account how they historically have divided their time.

"The way I like to interpret it is when you see the whites of the clients' eyes, you are paying the $1.50," Mr. Lye said. There were other complications. The raise goes to all PSWs doing work that qualifies, meaning the $4 increase goes to everyone, whether they are making a base wage of $12.50 or $22 an hour. That has put pressure on employers to give raises to others, such as registered practical nurses and supervisors.

The rules also exclude some PSWs because of where they work or because the provincial funds that pay for their services do not flow through the province's 14 LHINs. The result is that PSWs within the same organization can be treated differently. Kingsway Lodge Fairhill Residence in the southwestern Ontario town of St. Marys chose to reject the increase because it would create an untenable disparity in its already well-compensated PSW work force. Hourly wages there range from $17.73 to $20.44. The organization operates a nursing home with round-theclock care, a retirement home and six supportive-housing suites where residents receive a few hours of personal support per day. The wage enhancement would have applied only in the supportive apartments. "There would be no way to do it because our staff flow between the three levels of care," said Theresa Wakem, the facility's administrator. At Traverse Independence, an agency in Kitchener that serves adults with physical disabilities and acquired brain injuries, management had to find $27,000 in a $6-million budget to give eight PSWs working in a day program the same raise as their colleagues. "It was a hardship," said CEO Toby Harris. The agency eliminated half a supervisor's job to cover the increase.

The wage enhancement helped a little bit, but we're still on the losing side," said the PSW, who asked not to be named. The company's London employees are not unionized. The PSW said some workers in London are refusing to serve clients outside the city because they are paid so little to travel there. "If I drove six hours in the county, I'd be lucky to get paid for three hours," the PSW said. Dr. Hoskins said before the Liberals committed to the pay increase, "we didn't have a tremendous amount of information about our PSWs - who they're working for, how much they're being remunerated."

The ministry is gathering data so it can "fine-tune" the second year of the program, including whether future increases should apply to all PSWs, even those already earning much more than $16.50 an hour, he said. He added that nearly 500 health-service providers have passed the increase on to their PSWs and the government expects the 27 holdouts to follow suit. As for Revera's changes, "I find that unacceptable," Dr. Hoskins said. "The ministry would be looking into those circumstances if they were brought to our attention." Ms. O'Sullivan, the CUPE representative, called the program's rollout "a reflection of a broader problem" with home and community care in Ontario.

If we can't figure out - we as in the government, the agencies and the unions - how everyone should be getting something as simple as a wage increase in an equitable way, can you imagine if you are a family member or a patient needing care, what the system must be like?" This is the first article of a Globe investigation into the challenges of moving health care out of hospitals and into the home. If you have a personal story to tell, contact Elizabeth Church at echurch@globeandmail.com and Kelly Grant at kgrant@globeandmail.com.

The auditor's findings come after a report to the government from a blue-ribbon panel in the spring that called on the province to make home-care services easier to navigate and more accountable. An investigation by The Globe and Mail also found a system plagued by uneven access to care, byzantine processes and a troubling lack of transparency for both patients and family caregivers.

"The time has come for the government to take a hard look at how CCACs deliver services to patients," Auditor-General Bonnie Lysyk said. "The solution is not simply to add new programs and make adjustments to existing services," she added. "This will only leave core problems and inconsistencies entrenched."

Catherine Brown, executive director of the group that represents the province's 14 CCACs, took issue with the audit's definition of direct-care spending, noting that time spent in consultations, case management and travelling to homes is a necessary part of delivering care and should not be considered part of overhead costs. "I don't think people understand the complexity of getting service to people in their homes," she said. Kevin Smith, the chief executive officer of St. Joseph's Health System in Hamilton and a member of the expert panel, said the audit provides valuable numbers on which to base future discussions.

Ontario's Minister for Health and Long-Term Care, Eric Hoskins, has vowed to repair the home-care system, laying out a 10-point plan in response to the expert panel report and setting up working groups with a threeyear time frame to make changes. He accepted all of the auditor's findings on Wednesday, saying he intends to "deepen" reform efforts and singling out the recommendation for a review of the way home care is delivered.

"This gives us the opportunity to be bold and be transformational," he said, but stopped short of saying what form such change would take. Dr. Hoskins said it is "premature" to say if the current system of access centres should be scrapped, as critics of the system have long suggested.

Getting it right is crucial for the Ontario government as it, like other provinces, looks to shift an ever-increasing share of health care out of expensive beds in hospitals and long-term care and into the home. The increasing emphasis on home care for the sick and the elderly is also what patients are demanding, and comes as many, including the Canadian Medical Association, say it's a change that is needed as the country's population ages.

The experience in the province of cutting wait times, he said, showed that "data, money and embarrassment" are a powerful combination to lead to change. NDP health critic France Gelinas, a member of the committee that asked for the report in the spring of 2014, said the audit confirms the system is broken.

"The structure has failed us and it is costing us a pile of money," she said. Among the audit's findings:

The province's 14 CCACs manage 264 separate contracts with 160 different agencies, and there is no standard rate for the same services among those contracts. The cost of an hour of care varies even among contracts involving the same CCAC and service provider.

In a sample of three CCACs, the nursing costs ranged from $49 to $73 an hour and personal support costs from $26 to $49 an hour. Pay for top executives jumped by 27 per cent between 2009 and 2013, to an average of $249,000.

Compensation for other senior executives increased 16 per cent during that time. Rapid-response nursing teams, created in 2011 and employed directly by the CCACs, failed to see patients within 24 hours about half the time, with some teams not available on weekends.

CCACs report 92 per cent of expenses are for direct patient care. That drops to 81 per cent when overhead and profit for service providers are taken out, the auditor finds, and to 72 per cent when documentation, travel time and training are not included. When case co-ordination is removed, it falls to 61 per cent.

The report is the first of two on home care by the AuditorGeneral. The second part, to be included in her annual report later this year, will focus on personal support workers. An examination of Ontario's 14 Local Health Integration Networks is also expected at that time.

The current model for paying physicians is “expensive, outdated and doesn’t support the efforts of doctors to provide the best care possible,” said Health Minister Sarah Hoffman at a Feb. 8 policy forum in Edmonton on the health system’s fiscal sustainability.

In 2014, Alberta spent $1060 per capita on physician services — the third highest in the country. More than 80% of payments are through fee-for-service, where doctors bill the government for each medical service provided. Proponents of fee-for-service say it gives doctors the incentive to see as many patients and provide as many services as possible. Hoffman wants some of the doctors on fee-for-service to adopt Alternative Relationship Plans (ARP), which she said are not only less expensive, but also reward doctors for the quality of care they provide.

Under clinical ARPs, doctors are paid for providing a set of services at a facility to a target population. There are several types. The annualized ARP, the most common in Alberta, provides compensation based on a formula that determines the number of full-time equivalents (hours per year or days per year) required to deliver services.

In Ontario, the most common ARP is the capitation model, under which physicians are paid a fixed fee per month for each patient registered with their practices, regardless of services received.

The Alberta Medical Association (AMA), which represents the province’s 8921 licensed physicians, supports the change. President Dr. Carl Nohr told CMAJ that ARPs are part of the move toward modernizing the health care system, which now deals with more chronic illness. They give doctors more flexibility, he said.

“They’ll be able to vary the amount of time they spend with individual patients, define how frequently they see patients — all in the context of what’s good for the patients and not necessarily from the business perspective.”

Neither the AMA nor Hoffman could specify the number of doctors they want to adopt this model. Nohr said compensation under an ARP will remain optional, but “our goal is to make it as attractive as possible and make changes to the model as we go, and hopefully over time see a substantial uptake.”

Alberta’s total health budget is $19.7 billion for 2015–16 — the second highest per capita ($4800) among the provinces. But, Hoffman said, “Given how much money is spent on health care in Alberta, the health outcomes in our province can and should be better.”

Hoffman said health care accounts for 45% of the government’s overall budget, and continues to grow faster than both inflation and the population, which grew 2.17% in 2015. If health care spending continues to rise by an average of 6% annually, it will account for 60% of the province’s budget in 20 years. Hoffman wants to decrease growth in health care spending to 2% annually in the next few years, but stressed this does not mean cutting funding; it means curbing spending growth.

Hoffman doesn’t know how much will be saved by changing the physician compensation system, but said “changing the way we pay doctors will have a ripple effect on the entire health system.”

The government’s contract with t

e AMA expires in 2018, and both parties are discussing redirecting funds and developing alternative compensation models. Nohr said they’re looking into a blend of ARP and fee-for-service among primary-care physicians.

One of the very good things that gives me hope for the future is that the profession and the government have a very good relationship,” Nohr said. “So there’s a collaborative, positive relationship between the Alberta Medical Association and the Ministry of Health and that creates the possibility for productive, useful change.”

The ralliers walked along a section of Hospital Dr. carrying signs and handed out information to vehicles entering and exiting the hospital parking lot. CUPE Ontario division president Fred Hahn and Ontario Council of Hospital Unions president Michael Hurley were on hand to rally the crowd of about three dozen with short, but loud, enthusiastic messages. The message was two-fold, Hurley said.

First, to remind the hospital that it has an "obligation" to ensure those who work there are "treated with dignity and respect" and make enough salary to support their families. Second, to speak out about hospital dietary staff earning $20 an hour or more -twice that of food service workers who do not have benefits. "We want Compass to engage us meaningfully at the bargaining table ... until we receive a collective agreement with dignity," he said. The hospital has to be account-a ble to the community as it spends tax dollars, Hahn said, calling the food service employees' vocations' "precarious work." Half of workers in the province are in that position, he said.

They have no guarantee ... it's absolutely a shame," he said, telling the workers that they have the support of more than 250,000 union members. "This employer needs to understand that they are not dealing with a small group." Hahn asked those on hand to be on "standby" for another rally, something Hurley said earlier there would be more of, if progress is not made. A conciliation meeting is scheduled for early next month.

Canadian Union of Public Employees Ontario president Fred Hahn speaks as CUPE workers and supporters protested outside Peterborough Regional Health Care Centre on Thursday. They called on the hospital's board of directors and food service provider Compass Group Canada to ensure a fair deal with employees of PRHC's cafeteria and Tim Hortons.

“In a more integrated system of care delivery, it is possible to both save money and increase the quality of care at the same time.”

Eleven commentaries were written by leading health policy experts across Canada to respond to the lead paper by Chappell and Hollander, who also wrote a response to the commentaries.

One system including community services such as meals on wheels, non-professional supportive services, professional home care services, supportive housing, long-term care facilities and specialized geriatric assessment and treatment units in hospitals would also have one overall budget. Professional case managers would coordinate care and assess needs, develop customized care plans, and authorize access to any of the services in the integrated system. They would also coordinate care with other parts of the health system, such as hospitals

budgets for long-term supportive care that allow people to remain in their homes have been frozen or reduced

While some seniors do need some professional care, say the authors, often their needs can be addressed primarily by non-professional supportive care such as feeding, bathing, and maintaining a clean living environment.

We need to stabilize the situation in Attawapiskat in terms of making sure they have the health support they need,” Mr. Angus (Timmins-James-Bay, Ont.) told The Hill Times last week. “We need a plan to get people who are needing help in any of the communities to get that help.”

A rash of attempted suicides prompted Mr. Angus, who’s also the NDP critic for indigenous and northern affairs, to call for an emergency debate on the ongoing suicide crisis in the James Bay community of about 2,000. As a result, the House of Commons convened until midnight last Tuesday for an emotionally charged discussion on mental health services following a string of incidents in northern reserves in recent months. Several MPs choked up during their statements, recounting suicide incidents in their ridings and personal lives.

Sometimes partisan politics need to be put aside and members need to come together to find solutions to prevent another unnecessary loss of life,” Conservative MP Todd Doherty (Cariboo-Prince George, B.C.) said during the debate. NDP MP Georgina Jolibois (Desnethé-Missinippi-Churchill River, Sask.) said the suicide rate went up in her home community of La Loche in northern Saskatchewan after a shooting spree that killed four people last January.

Liberal MP Robert-Falcon Ouellette (Winnipeg Centre, Man.) recalled visiting the northern Manitoba Pimicikamak Cree Nation, which declared a state of emergency over a series of suicide attempts last month.

Mr. Angus made an emotional appeal to action in his opening remarks during the emergency debate. “We have to end the culture of deniability whereby children and young people are denied mental health services on a routine basis, as a matter of course, by the federal government,” he said. Eleven people attempted to take their lives in Attawapiskat two Saturdays ago, prompting the First Nation to declare a state of emergency—the fourth one since 2006. There has been more than 100 suicide attempts in the reserve since the month of September, many of which involved children. The community has been plagued by flooding and several housing crises in recent years.

Eighteen mental health workers were dispatched to Attawapiskat on Tuesday, including two counsellors, one crisis worker, two youth support workers, and one psychologist. While there is no set timeline, they’re not expected to leave for at least two weeks, said Health Canada assistant deputy minister Keith Conn during a teleconference last week.

Some of the people treated for mental health problems last week had previously been airlifted out of the community for assessment before being sent back after their examination, according to Mr. Conn. This past Tuesday, at least 13 people, including a nine-year-old child, had made plans to overdose on prescription pills as part of a suicide pact. The Nishnawbe-Aski Police Service apprehended them before sending them to the local hospital for a mental health assessment.

Mr. Conn said he’s heard criticism of the mental health assessment process from Attawapiskat First Nation Chief Bruce Shisheesh. Individuals who are identified as likely to commit suicide are typically sent to a hospital in Moose Factory, Ont., to be psychologically evaluated by a psychologist or psychiatrist. They are then discharged and sent back to the community, where some try to take their life again. Mr. Conn said Health Canada does not “control the process,” but he personally committed to review the mental health assessment effectiveness.

No federally funded psychiatrists were present in the region prior to the crisis, despite reserve health-care falling under the purview of the federal government. Mr. Conn said the Weeneebayko Area Health Authority (WAHA), a provincial health unit servicing communities on the James Bay coastline, is usually responsible for the Attawapiskat First Nation following an agreement struck with the federal government about 10 years ago.

A mental health worker position for the reserve has been vacant since last summer, in part because there’s a lack of housing for such staff. The community has been left without permanent, on-site mental health care services. Since then, the position has been filled by someone already living on reserve. During the emergency debate in the House last week, Health Minister Jane Philpott (Markham-Stouffville, Ont.) emphasized the need for short- and long-term responses to the crisis.

We need to address the socio-economic conditions that will improve indigenous people’s wellness in addition to ensuring that First Nations and Inuit have the health care they need and deserve,” she said. Ms. Philpott pointed to the Liberal government’s budget, which includes $8.4-billion for “better schools and housing, cleaner water, and improvements for nursing stations.”

“Our department and our government are ensuring that all the necessary services and programs are in place,” she said during the debate. “We are currently investing over $300-million per year in mental wellness programs in these communities.” Yet, Mr. Angus said the budget includes “no new mental health dollars” for First Nations communities. In addition to allocating more funds for mental health services to indigenous communities, Mr. Angus said there needs to be a concerted effort to bring in the aboriginal youth in the conversation.

We need to bring a special youth council together,” he told The Hill Times on Wednesday. “We need to have them be able to come and talk to Parliament about their concerns, so we’re looking at those options now.” Emotion was audible in Mr. Angus’ voice when he read letters he received from Aboriginal youth during the emergency debate, which expressed a desire to work with the federal government to solve the crisis.

The greatest resource we have in this country is not the gold and it is not the oil; it is the children,” he said. “The day we recognize that is the day that we will be the nation we were meant to be.” Mr. Angus met with Indigenous and Northern Affairs Minister Carolyn Bennett (Toronto—St. Paul’s, Ont.) earlier in the week to discuss potential long-term solutions to the suicide crisis. “I’ve always had an excellent relationship with Carolyn Bennett, and as minister we’re trying to find ways to work together on this, to take the tension down, to start finding solutions,” Mr. Angus said. Mr. Angus criticized “Band-Aid” solutions that have been thrown at First Nations issues over the years and said there needs to be a “transformative change” this time.

That’s where we have to move beyond the positive language to actually the brass tacks,” he said. During the emergency debate, Mr. Angus supported the idea of giving more resources to frontline workers such as on-reserve police, and health and treatment centres. 0eMr. Angus’ riding sprawls from shores of the Hudson Bay to the Timiskaming district on the border with Quebec, an area roughly equivalent in land size to that of Guinea. He holds two constituency offices in Timmins and Kirkland Lake.

Our report shows that while demand for seniors' housing in B.C. is outpacing supply as more seniors opt for homes in independent living communities , not enough is being done to understand their longer-term health and housing needs. In the next 25 years, seniors will make up 25 per cent of B.C.'s population. We think it's time for the provincial and municipal governments to sit down with us and come up with a new plan to support the development of more independent housing and assisted living as a cost-effective alternative to residential care.

We also need improved planning and implementation of home health services provided by the Ministry of Health and the health authorities to residents of independent living communities to allow them to remain in the communities for as long as possible. There are approximately 355,700 people in B.C. over the age of 75, of which 8.2 per cent live in seniors' residences. Improved utilization and expansion of B.C.'s independent living and assisted living sectors to accommodate residents with a broader range of health and social needs could reduce reliance on residential care.

In the past, residential care was the primary option for people who needed additional care and support, but increasing costs and a shortage of publicly subsidized residential care facilities led to the development of publicly subsidized assisted living facilities. Since 2004, there has been a dramatic increase in the number of both independent living and assisted living units, which are often located in the same development and provide many benefits for their residents. But the time has come to take a fresh look at the services available to seniors and how we provide them. For example, the Ministry of Health could explore options to allow registered assisted living facilities to offer a more flexible approach to what and how services are provided to residents. Expanding the range of services could allow residents to return from hospital sooner and free up beds for other patients, or delay their admission to residential care facilities .

Not everyone has the resources to look after their own care and housing needs in their senior years, but the public resources to help are not unlimited. That means we have to be smart how we develop and implement policies for our seniors. Carole Holmes is president of the B.C. Seniors Living Association. Elder care in B.C.

Private-pay and publicly subsidized housing and care options for seniors in B.C. include: Independent living: A combination of housing and hospitality services for functionally independent seniors. Assisted living: A semiindependent type of housing regulated under the Community Care and Assisted Living Act and includes housing, hospitality services and at least one, but not more than two prescribed services for people who require regular help with daily activities. Residential care: 24-hour professional supervision and care in a protective, supportive environment for people who have complex care needs and can no longer be cared for in their own homes or in an assisted living residence.

Silas was one of a number of speakers who called on the government of Premier Kathleen Wynne to increase spending on health care in the province. North Bay, they said, is particularly hard hit because it is a P3 (public-private partnership) hospital - and because it brought three hospitals - two general and one psychiatric - under one roof. "It is time to raise the alarm," said Natalie Mehra, executive director of the Ontario Health Coalition.

"This is devastating to the community, so let's raise the alarm." Mehra said people should not make the mistake of "believing that these hospital services are being replaced in so-called community care. You do not replace medical and surgical beds in community care. It's just not community care. It is acute hospital care services that are being cut. "You do not replace emergency room nurses. You do not replace cleaners in community care. Let's not buy into the nonsense that is just window dressing to cuts, cuts and more cuts to local services that are needed by the community." Michael Taylor, one of the organizers of the rally, said the cuts in North Bay are "the worst and deepest". .. that affect departments throughout the whole hospital.

Jamie Nyman was part of a large contingent from Sudbury to travel to North Bay Monday. "This is a very important issue," he said. "The government is cutting services and patient care is declining." Sudbury, he pointed out, has also seen many cuts.

"It's leaving us with too much workload," he said. "We are seeing a lot of workload issues because of cuts." Debbie McCrank from Kirkland Lake, the local co-ordinator for the Ontario Nurses Association, said the cuts are "going to impact all the North." She is responsible for the area from Kirkland Lake to North Bay, including Mattawa and West Nipissing.

"It's obvious the cuts in Northern Ontario have become excessive, and especially in North Bay," he said. "We are taking big hits in this. Hospital cuts hurt everybody. "Wynne has got to get the message. Northern Ontario is suffering more than any other area." Nipissing MPP Vic Fedeli, speaking at Queen's Park, called on the provincial government to address the funding crisis at the North Bay Regional Health Centre.

"It comes down to cheaper care versus quality care," she said. "The province is driven by the budget, not by the concern for quality health care." Another supporter was Mike Labelle, a locked-out employee at Ontario Northland. "I'm here to support all the nurses and everyone on down," he said. "Health care has really deteriorated here, and it's time the government wakes up."

Labelle said the mass of protesters "is the heart of the hospital." About 100 Ontario Northland employees, he said, turned up for the rally. Canadian Union of Public Employees president Mark Hancock said the province's health care cuts amount to an attack on the local hospital and the community.

The funding freeze means hundreds of staffand beds across Northern Ontario," he said, pointing to placards waved by hospital workers from Timmins, New Liskeard and Sudbury pointing out the effects of cuts at those facilities. Hancock said health care needs a 5.8 per cent annual increase just to meet rising costs, but the freeze means hospitals are getting zero per cent. In real terms, he said, that works out to a 20 per cent cut over the life of the spending freeze.

Also speaking was North Bay Mayor Al McDonald, who said the situation at the hospital is a major concern in the city. In addition to proper health care for all members of the community, he said, the jobs being cut at the hospital are good-paying jobs, and "if you want to build the city, you need your hospital to provide the same level of care as they have in southern Ontario." Nearby, Stan Zima was waving a large Canadian flag on a 10-foot flagpole.

The North Bay Regional Health Centre, she said, is "a major treatment centre," but the province's cuts are putting that designation at risk, and putting extra pressure on all hospitals in the North. "It's just having a huge impact," McCrank said of the health funding cuts.

Health-care professionals and patients alike in my riding are concerned that the quality of care we're getting in Nipissing is in jeopardy. And it's creating turmoil in the community," Fedeli said, asking the government to restore "proper ongoing funding" to the facility.

Pj Wilson, The Nugget / Natalie Mehra, executive director of the Ontario Health Coalition, addresses a crowd of close to 1,000 people at Lee Park, Monday. Supporters from across the province were in North Bay to pressure the Kathleen Wynne government into providing more funding for hospitals across the province. • Pj Wilson, The Nugget / Close to 1,000 people called for the provincial government to increase funding to Northern Ontario hospitals and, in particular North Bay Regional Health Centre, at a rally at Lee Park, Monday. Busloads of supporters came from as far as Toronto, Hamilton and Stratford to support North Bay.

Under this program, paramedics will provide basic health-care services, within their scope of practice, in partnership with local health-care providers. The enhanced role is not intended to replace care provided by health professionals such as nurses, but rather to complement and support the work these important professionals do each day, delivered in non-urgent settings, in patients' homes or in the community. "As a former BC Ambulance paramedic, I understand the potential benefits of community paramedicine," said Jordan Sturdy, MLA for West Vancouver-Sea to Sky. "Expanding the role of paramedics to help care for the health and well-being of British Columbians just makes sense." Community paramedicine broadens the traditional focus of paramedics on pre-hospital emergency care to include disease prevention, health promotion and basic health-care services. This means a paramedic will visit rural patients in their home or community, perform assessments requested by the referring health care professional, and record their findings to be included in the patient's file. They will also be able to teach skills such as CPR at community clinics.

"Community paramedics will focus on helping people stay healthy and the specific primary care needs of the people in these communities," said Linda Lupini, executive vice president, BC Emergency Health Services. "This program also allows us to enhance our ability to respond to medical emergencies by offering permanent employment to paramedics in rural and remote areas of the province." "Community paramedicine brings improved patient care and more career opportunities to rural and remote areas," said Bronwyn Barter, president, Ambulance Paramedics of BC (CUPE 873). "Paramedics are well-suited to take on this important role in health-care provision." Community paramedicine was initially introduced in the province in 2015 in nine prototype communities. The initiative is now expanding provincewide, and will be in place in 31 communities in the Interior, 18 communities in northern B.C., 19 communities on Vancouver Island, and five communities in the Vancouver coastal area this year.

At least 80 new full-time equivalent positions will support the implementation of community paramedicine, as well as augment emergency response capabilities. Positions will be posted across the regional health authorities. The selection, orientation and placement process is expected to take about four months. Community paramedics are expected to be delivering community health services in northern B.C. this fall, in the Interior in early 2017, on Vancouver Island and the Vancouver coastal area in the spring of 2017. BC Emergency Health Services has been co-ordinating the implementation of community paramedicine in B.C. with the Ministry of Health, regional health authorities, the Ambulance Paramedics of BC (CUPE 873), the First Nations Health Authority and others. Copyright 2016 Williams Lake Tribune

That's because home care needs a leader who cares deeply about a system that for too long has seen patients struggle to receive basic services they deserve, suffer when their therapy sessions or personal support visits are cut off or reduced, or who are sent home from hospitals with false promises of services to come to their door. "We know from the feedback that we have received from literally thousands of individuals and families that the care that they are currently receiving is patchy, uneven and fragmented," Hoskins admitted last week. It was just six months ago that Hoskins was refusing even to acknowledge that any patients had their services terminated or reduced because of cutbacks by Community Care Access Centres, which oversee home- and community-care services. In fact, those cuts affected thousand of sick and elderly patients across the province.

The most important step was taken by Hoskins when he adopted a new attitude toward home care, a key part of the overall health-care system that has suffered for years from severe underfunding, political neglect and too much bureaucracy. Indeed, Hoskins could actually become the new home-care champion.

First, Hoskins should radically reform the overall bureaucratic structure of home and community care. Gail Donner, former dean of nursing at the University of Toronto who headed a recent government-appointed panel on home care, has called the issue of structure "the elephant in the room" when it comes to poor delivery and co-ordination of services to patients. The most obvious starting point is the 14 CCACs across Ontario. These government agencies, which are filled with many hard-working and dedicated staffers, have been rightly criticized as being too bureaucratic, inefficient and top heavy with high-paid executives. Hoskins said last week he will wait until Auditor General Bonnie Lysyk releases two reports on CCACs before making any moves. The first report looking into CCACs' financial operations, which was requested by an Ontario all-party legislative committee in March 2014, was to have been ready this spring. It now won't be ready until late fall. The second report, which will look into other aspects of home care, will be included in the auditor general's annual report, tentatively set for early December.

Second, Hoskins should demand more money for rehab services, such as physiotherapy and speech-language pathology. This growing area of need has been effectively gutted over the years in the name of cost-saving, with patients getting as few as two visits from front-line health professionals after being sent home from hospitals. At the same time, hospitals have closed in-patient and outpatient rehab clinics, forcing patients to fight for limited home-care services or pay privately. Third, Hoskins should reverse a unilateral decision by CCACs that forbids charitable non-profit home-care organizations to fundraise among former clients.

Such a move would open the door for not-for-profit organizations to provide vital home-care services that are not now being met or are being under-delivered by CCACs. Low-income and aboriginal groups would be among those most likely to benefit from such a move. If non-profit hospitals can fundraise among former patients, it seems logical that not-for-profit home-care organizations should be allowed to do the same thing. Home-care patients can draw some encouragement from Hoskins' small steps forward. But now is the time for bolder steps that will make a real difference in the lives of patients and caregivers around the province. Bob Hepburn's column appears Thursday. bhepburn@thestar.ca.