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.

Device-associated infections (i.e., central-catheter–associated bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia), which have traditionally been the focus of programs to prevent health care–associated infections, accounted for 25.6% of such infections

We estimated that there were 648,000 patients with 721,800 health care–associated infections in U.S. acute care hospitals in 2011.

In the letter to Timmings, lawyer Michael Polvere of Siskinds wrote, "While we encourage all honest and fair debate on the issues, defamatory and untrue statements made of and concerning our client, the LHSC, will not be tolerated and will be met with swift action. The LHSC intends to hold both RNAO and yourself personally responsible for the conduct of this meeting." At the 6:30 p.m. meeting at Wolf Performance Hall in the Central Library, Timmings will lead discussion on a nurses' association report that claims cash-strapped hospitals are cutting registered nurses and replacing them with less qualified and lower-paid staff to the detriment of patients. "These (changes) are detrimental to Ontarians, to nurses, and to the future of health and health care in Ontario," conclude authors of the report Mind the Safety Gap in Health System Transformation: Reclaiming the Role of the RN. No one should be muzzled from discussing key health issues and LHSC's efforts should be addressed by Ontario Health Minister Eric Hoskins, Grinspun said. Hoskins couldn't be reached for comment Thursday. Nor could officials at LHSC. Earlier this year, Glendining refused to comment publicly on Burkoski's firing but defended the hospital in internal memos that insisted that the nurses' association had told a one-sided story and that safety was always a priority.

Prescription drug spending in Canada's private sector has increased nearly fivefold in 20 years, from $3.6 billion in 1993 to $15.9 billion in 2013 [3x[3]Express Script Canada. 2013 Drug trend report. ESI, Mississauga; 2014 (http://www.express-scripts.ca/sites/default/files/uploads/FINAL_executive%20summary_FINAL.pdf [accessed 01.06.14])See all References][3].

Private drug plans in Canada are often considered wasteful because they accept paying for higher priced drugs that do not improve health outcomes for users and use costly sub-optimal dispensing intervals for maintenance medications. As a consequence, it is estimated that private drug plans in Canada wasted $5.1 billion in 2012, which is money spent without receiving therapeutic benefits in return [4x[4]Express Scripts Canada. Poor patient decisions waste up to $5.1 billion annually, according to express script Canada. (June)Press release, ; 2013 (http://www.express-scripts.ca/about/canadian-press/poor-patient-decisions-waste-51-billion-annually-according-express-scripts [accessed 01.06.14])See all References][4]. This amount represented 52% of the total expenditures of $9.8 billion by private insurers on prescription drugs for that year [5x[5]Canadian Institute for Health Information. Drug Expenditure in Canada 1985 to 2012. CIHI, Ottawa; 2013See all References][5].

Respondents from all categories mentioned that, in contrast to employers, the over-riding objective of unions is to maximize their benefits with minimal co-payments for their employees.

The study focused on large unionized workplaces that had Administrative Services Only (ASO) plans, where the employer is responsible for the costs of benefit plans and bears the risks associated with it, while insurers are just hired to manage claims.

This study focused on ASO arrangements because they are the most common insurance option chosen by large private-sector firms [16x[16]Sanofi. Sanofi Canada healthcare survey. Rogers Publishing, Laval; 2012See all References][16]. Those organizations whose activities resided solely in the province of Québec, where the regulation of private drug plans differs [17x[17]Commissaire de la santé et du bien être du, Québec., Les médicaments d’ordonnance: État de la situation au Québec. Gouvernement du Québec, Québec; 2014See all References][17], were excluded.

Respondents from all categories indicated that consistency of benefits with other market players is of significance to employers.

Sean O’BradyxSean O’BradySearch for articles by this authorAffiliationsÉcole de relations industrielles, Université de Montréal, Montreal, Quebec, CanadaInteruniversity Research Centre on Globalization and Work (CRIMT), Montreal, Quebec, Canada, Marc-André GagnonxMarc-André GagnonSearch for articles by this authorAffiliationsSchool of Public Policy and Administration, Carleton University, Ottawa, Ontario, CanadaCorrespondenceCorresponding author at: School of Public Policy and Administration, Carleton University (RB 5224), 1125 Colonel By Drive, Ottawa, Ontario, Canada K1S 5B6. Tel.: +1 613 520 2600.xMarc-André GagnonSearch for articles by this authorAffiliationsSchool of Public Policy and Administration, Carleton University, Ottawa, Ontario, CanadaCorrespondenceCorresponding author at: School of Public Policy and Administration, Carleton University (RB 5224), 1125 Colonel By Drive, Ottawa, Ontario, Canada K1S 5B6. Tel.: +1 613 520 2600., Alan Cassels

The employers indicated that their over-riding strategy is to maintain cost-neutrality in providing drug benefits – in the context of overall compensation – to employees: any increases in the costs of a particular benefits area must be off-set by cost-savings elsewhere. Controlling knowledge was also frequently reported by the union-side respondents (and by one consultant that services employers) as a strategy to achieve greater control over negotiations and plan design by firms. According to one union representative, “

the employer always has the advantage in this stuff because they have all of the information with respect to the reports and the costs from the insurer or the advisor”

According to one consultant, “no one knows the cost of drug benefit plans.” This respondent was arguing that few involved in benefit design, either in private firms, unions, or insurers, are sufficiently competent to undertake proper analyses of claims data so they do not really know how proposed plan changes could affect them. This lack of expertise has ramifications for the education of stakeholders on the outcomes of benefit design.

However, when speaking of for-profit insurers, participants from all groups argued that insurers have no financial incentives to cut costs for employers, as indicated by one employer saying: “from my experience on the committees, I don’t get the impression that the insurers are there to save costs for the employers. I haven’t seen it. It's always been the other direction.” This claim was also corroborated by a benefits consultant, who argued that “there has been a fair bit of inertia, you know, amongst the providers out there in actually doing something too radical, too leading edge” because “there's no direct financial incentive for insurance companies or pharmacy benefit managers to actually help employers save money”.

Expanding on this, another consultant argued that an insurer's commission structure, which is based on volumes of claims expressed in a dollar value, may in fact discourage insurance companies from proposing plan designs that reduce the volumes of claims, as doing so would adversely affect company profits. Furthermore, another benefits consultant indicated that insurers are experts who calculate risk and thereby have no aptitude for the creation of formularies. According to this respondent, the impact is that insurance companies excel at managing risk, yet fare poorly in designing cost-effective plans that rely on the design and implementation of formularies.

An interesting finding from the interview data was that respondents from all interviewed groups declared being in favor of introducing some sort of arrangement for a national drug plan. Some favored having a universal pharmacare program which would apply to all drugs, while others favored programs tailored for catastrophic drug coverage. Two of the insurers that responded to this question explicitly favored some form of universal catastrophic drug coverage while the other favored universal pharmacare.

Each of the union representatives and one employer interviewed for this study expressed their support for universal pharmacare. Three out of five consultants argued in favor of a national pharmacare plan while the other two favored some other form of national risk pooling or formulary management to address costs.

While a majority of interviewees favored some form of universal coverage, a few respondents from the insurer and employer sides expressed concerns that universal pharmacare is not feasible.

Finally, employers were most concerned with the government's role in distributing the costs associated with drug coverage among public and private players in the system. In fact, each employer expressed concern over this. Three of the four employers expressed concern over the government's role as a plan sponsor and how governments shift costs to the private sector. As described by one employer, “the government is a very big consumer of drugs” and if the drug companies “start losing money on the government side, they pass it on to private insurance”. Thus, government regulations that help employers contain costs are desired.

Marc-Andre Gagnon has received research funding by the Canadian Federation of Nurses’ Unions for a different research project related to drug coverage in Canada. Alan Cassels is co-director of DECA (Drug Evaluation Consulting and Analysis). The authors would like to acknowledge the financial contribution of the Canadian Health Coalition in order to pay for the transcription of interviews.

Indeed, this nasty internal fight is remarkably similar to what the Republican Party establishment is undergoing in the U.S., with angry OMA dissidents unleashing Donald Trump-style brutishness and Tea Party-style radicalism to scare patients, silence critics and ultimately take over the OMA leadership. Suddenly, the OMA deserves our sympathy because this time it is actually taking on the good fight for Ontario patients.

The conflict centres on a tentative four-year deal reached on July 11 between the OMA and the provincial government on everything from increases in funding for physician services to giving doctors a stronger voice in managing and reforming the health-care system. The tentative agreement came after two years of bitter fighting between the OMA and Ontario Health Minister Eric Hoskins and his senior bureaucrats.

Under the deal, the overall budget for physician services, in other words their pay, would increase by 2.5 per cent a year, rising to $12.8 billion in 2019-20 from the current level of $11.9 billion. But a recently formed group calling itself the Coalition of Ontario Doctors and alleging it speaks for thousands of OMA members wants the tentative deal scrapped, arguing that if approved it would result in fewer doctors, fewer health clinics, less patient care - and even lead to the death of patients.

Like Trump in the U.S. with his anti-Muslim, anti-immigrant rhetoric, such claims by these dissident doctors are meant to scare Ontario patients. At the same time, the coalition, suggesting the deal's approval method was rigged, hired high-priced lawyers and went to court to force the OMA to hold a general meeting, now set for Sunday in Toronto, where doctors will vote in person on the deal rather than cast ballots online.

In addition, some angry doctors have taken to social media to bully, silence and question the motives of physicians who back the agreement. Combined, these tactics are irresponsible, reprehensible and unworthy of doctors who claim their first priority is care of their patients. Leading the charge against the OMA is the Ontario Association of Radiologists, which has about 1,000 members and is bankrolling the court challenges and ad campaigns against the OMA and the tentative deal.

As a group, radiologists are among the highest-paid doctors in Ontario, earning an average of more than $600,000 a year, with some topping $1 million. In recent years they have benefitted from new technologies that allow them to perform medical procedures quicker, thus allowing them to see more patients and send more bills to the government. Despite all their gloom-and-doom rhetoric about pending deaths brought about by the deal, what the dissidents are really upset about is - what else? - their own wallets.

Think of it as a rich man's self-pity. They won't say it openly, but these rich radiologists, along with some ophthalmologists and cardiologists, are most furious because their fees will be cut more than those other physician services. What the deal tries to do is level the pay structure so doctors with similar training receive the same net incomes.

For its part, the OMA concedes that many doctors who support the agreement aren't completely happy with it. But they believe the main benefit is that the deal establishes a period of peace and a better relationship between doctors and the government, one that has been very destructive over the past few years.

Regardless of the outcome of Sunday's vote, the OMA will never be the same, much as the Republican Party will never be the same after Donald Trump's candidacy and the emergence of the Tea Party. Within the OMA, many conservative doctors who hate the Liberal government at Queen's Park, dislike government interference in their profession and want to run the health-care system as they did 30 or 40 years ago are on the move.

The physicians' deal is the first target in their sights. Next up is the leadership of the OMA, its bargaining team and its specialty sections. Yes, it's time to feel some sympathy for the OMA. Bob Hepburn's column appears Thursday. bhepburn@thestar.ca

The Ontario Medical Association deserves public sympathy as it takes on dissident doctors, Bob Hepburn writes.

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

Politicians are generally supportive on issues affecting seniors. "Their hearts are in the right place," Simpson said this week. "We want them to start talking about it in the context of an election campaign." Simpson told The Canadian Press that Liberal Leader Justin Trudeau has promised to call a first ministers' meeting on health care and seniors within six months of being elected. The Conservatives have talked of a national dementia strategy, and the New Democrats and Green party have both been "strongly supportive" of a national strategy on seniors. All that is fine, as far as it goes. But whichever party forms the next government will have to respond with more than just talk. Decisive steps are required to deliver an effective strategy. "What we need now is some action," Simpson said.

Pointing in the right direction, the medical association urged federal officials on Monday to make tax incentives and financial supports more available to people caring for elderly family members. Existing tax incentives, for example, are available only to caregivers who are actually living with an aged relative. More than 75 per cent of the care provided to older Canadians is supplied by unpaid, informal caregivers, according to the medical association. "A national seniors strategy," it says, "should take into consideration both the financial needs of individuals who provide this invaluable service and the stress and burnout they often feel." There's no doubt we've fallen behind on care for seniors. A crisis looms. How Canada handles the growing tide of elderly people, and the pressure of their immense medical needs, could well make - or break - this country's health care system. Crafting a bold national strategy to address the problem is a vital first step, not just in helping seniors, but in safeguarding medicare for all Canadians.

The federal government has made a start with the creation of the Employer Panel for Caregivers and the Family Caregiver Tax Credit. However, it must do more to make a meaningful difference in the lives of Canadians caring for family members. For example, making the caregiver tax credit refundable would help mitigate care costs such as paying out of pocket for prescriptions, groceries and personal care items or taking time off work for medical appointments. Until all levels of government come together to form a comprehensive pan-Canadian seniors strategy, piecemeal initiatives will have a limited impact.

In a way, our generation has become a victim of our own success. Progress and innovation in medicine mean Canadians are living longer. At the same time, more people are living with chronic diseases that complicate both their health status and the treatment they need. Treatment of chronic diseases consumes 67 per cent of all direct health-care costs. Chronic disease is the main reason seniors require health care. In 2011, between 74 and 90 per cent of Canada's seniors suffered from at least one chronic condition, while nearly one-quarter had two or more. These conditions jeopardize a person's ability to live independently at home.

On any given day in Canada, "alternative level of care" patients - that is, patients approved for hospital discharge who cannot access appropriate post-hospital care - occupy about 7,500 beds. Hospitals are routinely forced into a state of overcapacity called "code gridlock" in which patient flow grinds to a halt, elective surgeries are cancelled and transfers are put on hold. If you are in a car accident or have a heart attack, our health-care system can effectively mobilize world-class acute health-care services. But the system is woefully inadequate and under-resourced to properly prevent, manage or treat the long-term and chronic health problems facing most of our over 65 population.

Too often, seniors who could and should be getting better are languishing in hospitals when more efficient and effective care could be delivered in their homes or in a long-term care facility. It costs $1,000 to keep a person in a hospital bed for a day. Long-term care costs $130 a day. Home care (excluding the economic costs of caregivers looking after relatives) costs $55. That translates to approximately $2.3 billion a year that could be better spent in the health-care system with some strategic thinking and investing. This country as we know it today was, in fact, built by our seniors - by our own mothers and fathers, aunts and uncles and grandparents. Canada's health-care providers are determined and committed to prioritizing and improving their health. We expect the same of our country's leaders. As the premiers gather just blocks from Parliament Hill, we ask that a comprehensive healthy aging and seniors care strategy be at the top of their agenda.

Christopher Simpson, MD, is president of the Canadian Medical Association. Morel Caissie is president of the Canadian Association of Social Workers. Karima Velji is president of the Canadian Nurses Association.

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

Comment:

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

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

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

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

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

The Decision:

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

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

"What particularly alarms nurses is the lack of transparency on the part of the Ontario government when it comes to disclosing this ugly trend to the public," stresses Burkoski. Despite letters to both Premier Kathleen Wynne and Health Minister Eric Hoskins calling for a ban on medical tourism, the practice continues. "We hear that the government is investigating but in our view, there is nothing to investigate when there is clear evidence that hospitals are engaging in medical tourism," adding that even one is one too many. The Registered Nurses' Association of Ontario (RNAO) is the professional association representing registered nurses, nurse practitioners and nursing students in Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses' contribution to shaping the health-care system, and influenced decisions that affect nurses and the public they serve. For more information about RNAO, visit our website at www.RNAO.ca( (www.rnao.ca») ).You can also check out our Facebook page at (www.RNAO.org») (www.rnao.org») ) and follow us on Twitter at www.twitter.com/RNAO( (www.twitter.com») ) SOURCE Registered Nurses' Association of Ontario

Unfortunately, that's how many hospitals operate. Inadequate staffing is a nationwide problem, and with the exception of California, not a single state sets a minimum standard for hospital-wide nurse-to-patient ratios. Dozens of studies have found that the more patients assigned to a nurse, the higher the patients' risk of death, infections, complications, falls, failure-to-rescue rates and readmission to the hospital -- and the longer their hospital stay. According to one study, for every 100 surgical patients who die in hospitals where nurses are assigned four patients, 131 would die if they were assigned eight.

In pediatrics, adding even one extra surgical patient to a nurse's ratio increases a child's likelihood of readmission to the hospital by nearly 50 percent. The Center for Health Outcomes and Policy Research found that if every hospital improved its nurses' working conditions to the levels of the top quarter of hospitals, more than 40,000 lives would be saved nationwide every year.

Nurses are well aware of the problem. In a survey of nurses in Massachusetts released this month, 25 percent said that understaffing was directly responsible for patient deaths, 50 percent blamed understaffing for harm or injury to patients and 85 percent said that patient care is suffering because of the high numbers of patients assigned to each nurse. (The Massachusetts Nurses Association, a labor union, sponsored the study; it was conducted by an independent research firm and the majority of respondents were not members of the association.)

And yet too often, nurses are punished for speaking out. According to the New York State Nurses Association, this month Jack D. Weiler Hospital of the Albert Einstein College of Medicine in New York threatened nurses with arrest, and even escorted seven nurses out of the building, because, during a breakfast to celebrate National Nurses Week, the nurses discussed staffing shortages. (A spokesman for the hospital disputed this characterization of the events.)

It's not unusual for hospitals to intimidate nurses who speak up about understaffing, said Deborah Burger, co-president of National Nurses United, a union. "It happens all the time, and nurses are harassed into taking what they know are not safe assignments," she said. "The pressure has gotten even greater to keep your mouth shut. Nurses have gotten blackballed for speaking up."

The landscape hasn't always been so alarming. But as the push for hospital profits has increased, important matters like personnel count, most notably nurses, have suffered. "The biggest change in the last five to 10 years is the unrelenting emphasis on boosting their profit margins at the expense of patient safety," said David Schildmeier, a spokesman for the Massachusetts Nurses Association. "Absolutely every decision is made on the basis of cost savings."

Experts said that many hospital administrators assume the studies don't apply to them and fault individuals, not the system, for negative outcomes. "They mistakenly believe their staffing is adequate," said Judy Smetzer, the vice president of the Institute for Safe Medication Practices, a consumer group. "It's a vicious cycle. When they're understaffed, nurses are required to cut corners to get the work done the best they can. Then when there's a bad outcome, hospitals fire the nurse for cutting corners."

Nursing advocates continue to push for change. In April, National Nurses United filed a grievance against the James A. Haley Veterans' Hospital in Tampa, which it said is 100 registered nurses short of the minimum staffing levels mandated by the Department of Veterans Affairs (the hospital said it intends to hire more nurses, but disputes the union's reading of the mandate).

Nurses are the key to improving American health care; research has proved repeatedly that nurse staffing is directly tied to patient outcomes. Nurses are unsung and underestimated heroes who are needlessly overstretched and overdue for the kind of recognition befitting champions. For their sake and ours, we must insist that hospitals treat them right. ☐