Group items tagged

It has been known for some time that long-term care facilities use a lot of antibiotics. Earlier studies have suggested there is a significant amount of overuse in this sector of the healthcare system, with potentially between one-third and half of all use being inappropriate or unnecessary. Residents of these facilities are typically frail, elderly people with a variety of health concerns. They are at the point in life where their immune systems cannot fight off invaders easily.

These people often live in close quarters and are cared for by staff who move from resident to resident. It's a situation that makes for efficient spread of bacteria and other pathogens that cause infections. For this study, Daneman and his co-authors looked at antibiotic use in 110,656 residents of 607 nursing homes in Ontario in 2010 and 2011. The nursing homes studied were divided into low, medium and high antibiotic-use categories. The differences were stark: antibiotic prescribing in high-use facilities was 10 times that of low-use homes. If high-use homes had residents who were significantly sicker and more frail, that might explain their heavy reliance on antibiotics. But the authors also did a comparison of the residents of the various facilities and found there were not major health differences among them. That suggests the increased use of antibiotics in the high-use homes likely is a result of the doctors who are prescribing at those facilities, said infectious diseases expert Dr. Andrew Simor, who was not involved in this study. Simor is head of microbiology at Sunnybrook.

He suggested this information could help change prescribing behaviours; facilities where antibiotic use is higher than the norm could be targeted with programs aimed at minimizing misuse of these critical drugs. The article, which Simor praised, also drew a line between high antibiotic use and higher rates of negative consequences of antibiotic use. Those side-effects included allergic reactions to antibiotics, developing antibiotic-related diarrhea, contracting C. difficile infection, or becoming infected with a drug-resistant bacteria. Daneman said the adverse events were generally serious enough to send these people to hospital. "If you live in a high antibiotic-use home versus a low antibiotic-use home, you had 25 per cent increased risk of one of these serious antibiotic-related adverse events," he said. Because of the way the study was designed, the authors could not tell if the antibiotics used were needed in each setting. So they cannot say that the low-use homes had hit the sweet spot for antibiotic use - not too much, but enough.

Still, Simor observed that when hospitals started to develop programs to cut back on unneeded use of antibiotics - it's called antibiotic stewardship - concerns were raised that some people who needed the drugs might not get them. That hasn't proven to be the case, he said. "So if you feel comfortable translating those findings into a nursing home setting, I think you'll find the same situation is true - that stewardship will not place patients at increased risk for not getting an antibiotic when they need it."

Scientists overseeing the studies say the apps could transform medical research by helping them collect information more frequently and from more people, across larger and more diverse regions, than they're able to reach with traditional health studies. A smartphone "is a great platform for research," said Dr. Michael McConnell, a Stanford University cardiologist, who's using an app to study heart disease. "It's one thing that people have with them every day." While the studies are in early stages, researchers also say a smartphone's microphone, motion sensors and touchscreen can take precise readings that, in some cases, may be more reliable than a doctor's observations. These can be correlated with other health or fitness data and even environmental conditions, such as smog levels, based on the phone's GPS locator.

"Participating in clinical studies is often a burden," he explained. "You have to live near where the study's being conducted. You have to be able to take time off work and go in for frequent assessments." Smartphones also offer the ability to collect precise readings, Dorsey added. One test in the Parkinson's study measures the speed at which participants tap their fingers in a particular sequence on the iPhone's touchscreen. Dorsey said that's more objective than a process still used in clinics, where doctors watch patients tap their fingers and assign them a numerical score.

The most important is safeguarding privacy and the data that's collected, according to ethics experts. In addition, researchers say apps must be designed to ask questions that produce useful information, without overloading participants or making them lose interest after a few weeks. Study organizers also acknowledge that iPhone owners tend to be more affluent and not necessarily an accurate mirror of the world's population. Apple had previously created software called HealthKit for apps that track iPhone owners' health statistics and exercise habits. Senior vice-president Jeff Williams said the company wants to help scientists by creating additional software for more specialized apps, using the iPhone's capabilities and vast user base - estimated at 70 million or more in North America alone. "This is advancing research and helping to democratize medicine," Williams said in an interview.

Apple launched its ResearchKit program in March with five apps to investigate Parkinson's, asthma, heart disease, diabetes and breast cancer. A sixth app was released last month to collect information for a long-term health study of gays and lesbians by the University of California, San Francisco. Williams said more are being developed. For scientists, a smartphone app is a relatively inexpensive way to reach thousands of people living in different settings and geographic areas. Traditional studies may only draw a few hundred participants, said Dr. Ray Dorsey, a University of Rochester neurologist who's leading the Parkinson's app study, called mPower.

Others have had similar ideas. Google Inc. says it's developing a health-tracking wristband specifically designed for medical studies. Researchers also have tried limited studies that gather data from apps on Android phones. But if smartphones hold great promise for medical research, experts say there are issues to consider when turning vast numbers of people into walking test subjects.

Some apps rely on participants to provide data. Elizabeth Ortiz, a 48-year-old New York nurse with asthma, measures her lung power each day by breathing into an inexpensive plastic device. She types the results into the Asthma Health app, which also asks if she's had difficulty breathing or sleeping, or taken medication that day. "I'm a Latina woman and there's a high rate of asthma in my community," said Ortiz, who said she already used her iPhone "constantly" for things such as banking and email. "I figured that participating would help my family and friends, and anyone else who suffers from asthma."

None of the apps test experimental drugs or surgeries. Instead, they're designed to explore such questions as how diseases develop or how sufferers respond to stress, exercise or standard treatment regimens. Stanford's McConnell said he also wants to study the effect of giving participants feedback on their progress, or reminders about exercise and medication. In the future, researchers might be able to incorporate data from participants' hospital records, said McConnell. But first, he added, they must build a track record of safeguarding data they collect. "We need to get to the stage where we've passed the privacy test and made sure that people feel comfortable with this."

Toward that end, the enrolment process for each app requires participants to read an explanation of how their information will be used, before giving formal consent. The studies all promise to meet federal health confidentiality rules and remove identifying information from other data that's collected. Apple says it won't have access to any data or use it for commercial purposes.

Elizabeth Ortiz uses the Asthma Health smartphone app to track her condition. • Richard Drew/the associated press

In the US medical care has become a huge, competitive industry with many private investors, but with relatively little government regulation. Involving more than $2.7 trillion (£1.7 trillion; €2 trillion), the US healthcare industry now constitutes nearly 18% of our entire economy and it continues to expand.

No more than half of the US health economy involves investor owned organisations and institutions, but most of the others (so called not-for-profits) also see themselves as businesses competing for market share, so they act very much like their for-profit, investor owned competitors. Virtually all organisations and many physicians seek to maximise their income.

dependence of the US system on private for-profit insurance plans. Numbering in the hundreds, but increasingly being consolidated within a relatively few giant corporations

about a quarter of those over 65 have opted to have Medicare pay for their care through private plans

private insurance plans comprise a huge and growing industry, with a gross income of more than $800bn. Their profits and business overheads vary considerably but average between 15% and 25% of their premiums.

private insurance plans added over $150bn to the cost of healthcare in 2011.6 (The overhead expenses of Medicare are less than 5% of total expenditures.)

The recent movement of US physicians into large multispecialty groups suggests that this reorganisation of medical care may already be under way. If this trend continues, it could not only facilitate the enactment of legislation, but also help to make our medical care much more affordable and efficient.

bill, the Affordable Care Act (ACA) was passed by the Democratic controlled Congress in March of 2010

many liberals, like me, have reservations.9

The law does contain major advances but, despite its name, it has no provisions that will reliably control rising costs.

group practices can deliver care more efficiently than unorganised physicians in solo or small, single specialty partnership practices who compete for income and depend on fee for service payment.11

substantial savings, as well as improved care, can be anticipated when primary care physicians collaborate with specialists in well organised groups

With so many physicians employed in multispecialty practices it would be much easier to institute new payment methods that replace insurance based reimbursement for itemised services with tax supported prepaid access to comprehensive care.

↵Angell ME. The epidemic of mental illness: Why? The New York Review, June 23, 2011:20-2.

↵Relman AS. In dire health. The American Prospect2012;23:34-7.

The member of the scheduling team responsible for that work unit would receive the request along with a list of employees that have the skill-sets and availability to work in that vacationing staffer's place. "They assign that work according to the various union collective agreements," he said. However, if the matter is unfolding in a shorter period of time, such as if someone was calling in sick for a shift scheduled to start later today, there's a different protocol. "Obviously that needs more immediate attention. There's an actual telephone call from a manager or a supervisor at (the unit) to a dedicated line in the scheduling centre," he said. Together, the employee's manager would work with the scheduling team to sort out the appropriate person to be offered the shift. Why is Horizon making this change? The goal is to lighten the administrative load on health-care managers across the province so they can focus on the day-to-day delivery of care.

"We're taking that sort of task or transaction work out of the nursing units. Typically, it's done by ward clerks or, in many cases, the managers themselves. It consumes a lot of their time. But that's only part of their job. They have responsibilities for other operational requirements in their various units," he said. Doull said the health authority also sees value in managing schedules in a consistent way across the province. "What we want to do for all of the areas is standardize the processes and the application of the collective agreement rules. So instead of having (more than) 200 people in Horizon who have as some small part of their job (tried) to get by in doing scheduling work as best they can with no formal software support or training, we're going to bring that into a purpose-built department," he said. "And there are efficiency payoffs for that, both financial and operational, for us as an organization." He did acknowledge that there will still be room for personal interventions by managers, particularly if a quick conversation at the office door can resolve a pressing matter easily and effectively.

If a matter is of an urgent nature, the employee can contact their manager or appointed supervisor directly and have a conversation about the request for time off and the manager can figure out a specific way to handle the situation. "All the manager is going to do is simply call the centre in Saint John, or email the staffing team that they work with, and say, 'An employee has talked to me. This is what we're going to do and here's how I want you to deal with the shift on Saturday,'" he said. "The manager always has that direct-line option to deal with things that are of a more timely nature." Although, too much of that can be a problem, said Doull, explaining that in some units across the province managers can fall into routines where the easiest employee to reach, or the most willing employee to work, receives most of the overtime or sick-time shift offers. "Later on, one of the four or five people (ahead of the preferred employee) may very well come back and say, 'I have a grievance because I should have been offered that shift. What are you going to do for me?' And we may be in a situation of having to, in effect, pay twice for time that needs to be worked," he said.

"I wouldn't characterize it that it happens often, but it certainly happens often enough that we know about it and it's one of the problems that we're specifically trying to solve." Members of the scheduling team are working to determine which site will be the next to adopt this new staffing system. Ultimately, when the scheduling team is fully operational and slotting shifts for units across Horizon, a team of 21 staff members will be working at the Saint John centre between the hours of 5 a.m. and 11 p.m. "That's roughly 70 full-time equivalent (positions for our team)," he said.

Doull said he knows many employees are likely worried about this change, but the move is expected to create significant savings for Horizon. "What we're looking to do is return time to managers and clinical staff," he said. "We know patients have a better experience if they know who the manager is in their area and they're able to interact with them regularly ... We know staff are more satisfied at work if they're able to have access to their manager." There are also savings expected through reductions in payroll errors.

"If someone puts in the wrong code for a specific number of hours and an employee gets paid the wrong thing, we know how often we're going back and correcting these. What this system will do is take a lot of the manual data entry of our pay processes away," he said. "It'll be automated and driven by what the employee is scheduled to work." It should also help to highlight problems in specific units, he said. "If we have an area, for example, that is using a lot of overtime, we'll know who is not there, why they're not there, which positions are not actually filled because there's nobody to work them, and we'll be better able as an organization to identify where our recruiting issues are," he said.

Ralph McBride, CUPE Local 1252's provincial co-ordinator, said he's concerned about the economic impacts the move could have on communities across the province. "We're not overly impressed with centralizing services. We see this as taking away important jobs in rural New Brunswick and moving them to urban centres," he said. "We think there are economic hard times happening currently in the Miramichi. This won't help." There are no plans to integrate this system with scheduling protocols used by the Vitalité Health Network. The Daily Gleaner requested information from the Vitalité Health Network on how the province's other regional health authority schedules its staff and the paper is still waiting for a response.

Medical buildings often have standard benchmarks — basing the number of examination rooms, for example, on the expected volume of patients. Ms. Brandenberg and her team instead used C.P.I. to map out common paths that patients, staff members, supplies and information would flow through. They worked in an empty office building, using cardboard mock-ups of surgical sites, recovery rooms, anesthesia areas and waiting rooms. Fifty staff members then play-acted various scenarios to test the design’s effectiveness. The final design reduces walking distances and waiting times for patients by grouping related facilities together and creating rooms that can be used for more than one purpose. The hospital was able to shave 30,000 square feet and $20 million off of the new building

Last year, amid rising health care expenses nationally, C.P.I. helped cut Seattle Children’s costs per patient by 3.7 percent, for a total savings of $23 million, Mr. Hagan says. And as patient demand has grown in the last six years, he estimates that the hospital avoided spending $180 million on capital projects by using its facilities more efficiently. It served 38,000 patients last year, up from 27,000 in 2004, without expansion or adding beds.

checklists, standardization and nonstop brainstorming with front-line staff

The program, called “continuous performance improvement,” or C.P.I., examines every aspect of patients’ stays at the hospital

The system is just one example of how Seattle Children’s Hospital says it has improved patient care, and its bottom line, by using practices made famous by Toyota and others. The main goals of the approach, known as kaizen, are to reduce waste and to increase value for customers through continuous small improvements.

“The health care industry could be on the verge of an efficiency revolution, because it is currently so far behind in applying operations management methodologies,” says Professor Litvak.

All medical centers, especially larger ones, would have significant return on investment by using operations management techniques like C.P.I., says Eugene Litvak, president and chief executive of the Institute for Healthcare Optimization and an adjunct professor of operations management at the Harvard School of Public Health.

Similar methods are now in place at other hospitals and health systems, including Beth Israel Deaconess Medical Center in Boston, Park Nicollet Health Services in Minneapolis and Virginia Mason Medical Center, also in Seattle.

TO be sure, not everyone believes that factory-floor methods belong in a hospital ward. Nellie Munn, a registered nurse at the Minneapolis campus of Children’s Hospitals and Clinics of Minnesota, thinks that many of the changes instituted by her hospital are inappropriate. She says that in an effort to reduce waste, consultants observed her and her colleagues and tried to determine the amount of time each of their tasks should take. But procedure times can’t always be standardized, she says. For example, some children need to be calmed before IV’s are inserted into their arms, or parents may need more information. “The essence of nursing,” she says, “is much more than a sum of the parts you can observe and write down on a wall full of sticky notes.”

one-day strike by the Minnesota Nurses Association against six local health care corporations, including her employer, partly in protest of lower staffing levels her union thinks have resulted from hospitals’ “lean” methods

the Lean Enterprise Institute

George Labovitz, a management professor at Boston University, says there are limits to performance-improvement methods in hospitals. “Human health is much more variable and complex than making a car,” he said, “so even if you do everything ‘right,’ you can still have a bad outcome.”

Joan Wellman & Associates, a process improvement consulting firm in Seattle

examine the “flow” of medicines, patients and information in the same way that plant managers study the flow of parts through a factory

In a typical workshop at Seattle Children’s, a group of doctors, nurses, administrators and representatives of patients’ families set aside a 40-hour week to work through C.P.I. methods. They plot each “event” a patient might encounter — like filling out forms, interacting with certain staff members, having to walk various distances or having to wait for assistance — and brainstorm about how each could be improved, or even eliminated.

it never ends

Standardization is also a C.P.I. cornerstone. Last year, 10 surgeons at Seattle Children’s performed appendectomies, and each doctor wanted the instrument cart set up differently. The surgeons and other medical staff members used C.P.I. to come up with a cart they all could use, reducing instrument preparation errors as well as inventory costs.

The data, which were released Sept. 30 by the Centers for Medicare & Medicaid Services (CMS), a branch of the US Department of Health and Human Services that manages care for more than 100 million Americans, describe 4.4 million payments totalling $3.5 billion. The payments were from commercial sources for “consulting fees, research grants, travel reimbursements, and other gifts” made to 546 000 US physicians and 1360 teaching hospitals during the last five months of 2013.

Early analyses of the data reveal that some drug-makers spend lavishly on doctors, especially doctors from a small subset identified as “thought-leaders” who communicate with their peers most energetically in return for compensation in cash or luxury travel and other in-kind payments.

“This is an opportunity for the public to learn about the relationships among health care providers, and pharmaceutical and device companies,” CMS Administrator Marilyn Tavenner said in a statement accompanying the release of the data on CMS’s “Open Payments” website. The release was mandated under the “Sunshine” section of the US government’s 2010 Patient Protection and Affordable Care Act.

Not all financial relationships between clinicians should be viewed as improper, the CMS cautions. In a statement emphasizing “the importance of discouraging inappropriate relationships without harming beneficial ones” the agency underlined that many payments support research and other medically important activities.

But with the pharmaceutical industry alone spending about $30 billion per year promoting products, and with 90% of that money directed to physicians and other prescribers, the scale of inappropriate relationships aimed at distorting evidence-based clinical judgments for commercial gain is potentially significant, says Neil Kirschner, senior associate for Health Policy and Regulatory Affairs, American College of Physicians.

New data from the US describe 4.4 million payments to physicians totalling $3.5 billion.

“Plenty of studies have shown that marketing relationships between physicians and health care companies can introduce conflicts of interest that influence prescribing, research, education, use, and ultimately patient outcomes,” says Kirschner. “And there is substantial evidence that this is often in ways that favor the company’s interests.”

The primary beneficiaries of the CMS disclosure will be patients, Kirschner believes. “The public availability of this data will increase patients’ trust in doctors,” he says. “The evidence suggests even little things like meals can have an effect on prescribing and that there will likely be a reduction now in things you would want reduced, like free trips for doctors paid for by industry.”

These observations, Kirschner notes, are rooted in evidence after the State of Massachusetts began publishing state-wide data in 2004 similar to what CMS has released (Arch Intern Med 2010;170:1820–6).

Dr. Leana Wen, founder of Who’s My Doctor?, an advocacy group calling for full physician disclosure of all commercial relationships, agrees with Kirschner’s view that the CMS data dump will yield salutary results for patients.

These latest data are a “very good start,” but Wen would like to see far more financial data made available, including information about how physicians are paid. “It can make a huge difference to the care they receive if payment is by volume of procedures delivered.” The group is also calling for physician disclosure about their political affiliations and “philosophy of practice” concerning issues such as contraception, abortion, early breast cancer screenings and vaccination.

Kirschner and Wen both mix their praise for the CMS with criticism of the quality and scope of the data released so far. The information is for a partial year only, and about one-third of the records were withheld due to concerns about accuracy voiced by the American Medical Association and other groups. CMS’s decision to exempt payments within continuing medical education programs also attracted heat.

Despite the shortfalls, Canadian lawmakers should follow the US lead, says Dr. Andrew Boozary, cofounder of Open Pharma, a Toronto-based group that advocates for greater medical transparency. “A province like Ontario could take up this charge. There’s no doubt that patients benefit from financial disclosure.”

Boozary notes that conflict-of-interest disclosures are now the norm in medical research and publishing. “Patients clearly deserve the same.”

Emily Nicholas, spokesperson for Patients Canada, another group that advocates for medical transparency, agrees. “It seems contradictory for a health system or government to promote patient engagement, patient-partnership, self-management and shared decision making and yet withhold certain information that they believe patients don’t need, can’t handle, or will over-react to.”

Freedom of Information Act request

more than 17 percent of nursing home residents in 2010 were given daily doses of antipsychotics in excess of recommended levels.

Participation in the program to reduce use of antipsychotics is voluntary

Last week, three US senators filed a proposal that would require federal regulators to issue standardized rules for nursing homes to follow in seeking permission from patients, or their designated health care agents, such as a family member, before administering antipsychotics for so-called off-label use.

Toby Edelman, senior policy attorney at the Center for Medicare Advocacy, said that there are already strong rules against overmedicating nursing home residents but that regulators too often fail to enforce them.

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

Stakeholders throughout the province's health-care system have been lobbying successive provincial governments for at least a decade, urging them to lift restrictions that force the province's roughly 35 advanced-care paramedics to work below their full scope of practice. In February, the provincial government announced it had set aside $580,000 for a new pilot project, which will help New Brunswick figure out how best to make use of these valued health-care providers.

Health Minister Victor Boudreau said two committees have been formed to complete the behind-the-scenes work that is needed to introduce them to the existing ambulance service. So far, he said, things are going well, though he's not sure when advanced-care paramedics will be ready to use their skills on the streets. "We're still trying to put a pilot project together, making sure that we're respecting all the different moving parts to this," he said. "The money is still in the budget for this year. It's just sometimes these things prove to be a little more difficult than you'd like to put together. But it's certainly still on the table."

Chris Hood, executive director of the Paramedic Association of New Brunswick and a participating member of the committee tasked with sorting out the clinical issues around such a change, said that work is progressing nicely and he expects to see advanced-care paramedics in use within the provincial ambulance service soon. "I know the meetings have been happening and, by all indications, we're getting close," he said.

"The committees are still meeting. I've missed the last two meetings, but we had a representative there. They're getting into discussions about the protocols for practitioners, what they'll be following. From what we hear, it sounds like full-steam ahead. They accelerated the meeting times and it seems like everything is on the right track ... All of the prep-work that is necessary is, I would say, probably 80 per cent done, 85 per cent done." Ambulance New Brunswick is also completing some preparatory work, said Hood.

"They're looking at curriculum - refresher programs and things like that. From the clinical side of the business, which is what we're concerned with, that stuff is almost complete," he said. "If form follows function, we should be moving forward rather quickly."

When asked if the province's advanced-care paramedics are excited they'll finally be able to put all of their training to use in this province, Hood said many are still frustrated from the long struggle to lift these restrictions on their scope of practice. "I think many ACPs are still a bit, 'I'll believe it when I see it.' But some are very excited about it. We've had a couple of people enquire about attending ACP school and I know that the requests for enrolments in ACP classes both in New Brunswick and in the state of Maine are increasing," he said.

People are starting to feel more comfortable in spending the money to upgrade their skills, to take the education they need. But with the existing practitioners, I think, it's a wait-and-see mentality." Judy Astle, president of paramedics' union CUPE Local 4848, said she's anxious to learn what the pilot project may look like and how advanced-care paramedics will be used alongside primary-care paramedics across the province.

It's going to be a positive," she said. "But we're still waiting to find out the details."

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

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

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

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

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

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

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

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

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

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

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

the Canada Health Act

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

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

John Abbott, Chief Executive Officer, Health Council of Canada

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

That is right.

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

We want to share best practices.

it is not likely to happen without strong direction from above

Excellent Care for All Act

quality plans

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

Canadian Hospital Reporting Project

by March of next year we hope to make it public

performance, outcomes, quality and financials

With respect to physicians, it is a different story

We do not collect data on outcomes associated with treatments.

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

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

Senator Eaton

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

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

universal screening

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

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

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

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

colorectal screening

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

adverse drug effects

over-prescribing

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

catastrophic drug coverage

a patchwork across the country

with respect to wait times

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

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

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

Have we made progress?

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

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

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

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

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

send him or her to the States

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

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

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

Dr. Kitts: We are without a leader.

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

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

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

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

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

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

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

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

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

the national pharmaceutical strategy

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

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

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

While the access agenda has been the central focal point of the 2004 health accord, it is time to have the 2014 health accord focus on quality, of which access is one important dimension, with the others being effectiveness, safety, efficiency, appropriateness, provider competence and acceptability.

we also propose three specific funds that are strategically focused in areas that can contribute to improved access and wait time

Can the 2014 health accord act as a catalyst to ensure appropriate post-hospital supportive and preventive care strategies, facilitate integration of primary health care with the rest of the health care system and enable innovative approaches to health care delivery? Is there an opportunity to move forward with new models of primary health care that focus on personal accountability for health, encouraging citizens to work in partnership with their primary care providers and thereby alleviating some of the stress on emergency departments?

one in five hospital beds are being occupied by those who do not require hospital care — these are known as alternative level of care patients, or ALC patients

the creation of an issue-specific strategically targeted fund designed to move beyond pilot projects and accelerate the creation of primary health care teams — for example, team-based primary health care funds could be established — and the creation of an infrastructure fund, which we call a community-based health infrastructure fund to assist in the development of post-hospital care capacity, coupled with tax policies designed to defray expenses associated with home care

consider establishing a national health innovation fund, of which one of its stated objectives would be to promote the sharing of applied health system innovations across the country with the goal of improving the delivery of quality health services. This concept would be closely aligned with the work of the Canadian Institutes of Health Research in developing a strategy on patient oriented research.

focus the discussion on what is needed to ensure that Canada is a high performing system with an unshakable focus on quality

of the Wait Time Alliance

Dr. Simpson

the commitment of governments to improve timely access to care is far from being fulfilled. Canadians are still waiting too long to access necessary medical care.

Table 1 of our 2011 report card shows how provinces have performed in addressing wait times in the 10-year plan's five priority areas. Of note is the fact that we found no overall change in letter grades this year over last.

The WTA has developed benchmarks and targets for an additional seven specialties and uses them to grade progress.

the lack of attention given to timely access to care beyond the initial five priority areas

all indications are that wait times for most specialty areas beyond the five priority areas are well beyond the WTA benchmarks

we are somewhat encouraged by the progress towards standardized measuring and public reporting on wait times

how the wait times agenda could be supported by a new health accord

governments must improve timely access to care beyond the initial five priority areas, as a start, by adopting benchmarks for all areas of specialty care

look at the total wait time experience

The measurements we use now do not include the time it takes to see a family physician

a patient charter with access commitments

Efficiency strategies, such as the use of referral guidelines and computerized clinical support systems, can contribute significantly to improving access

In Ontario, for example, ALC patients occupy one in six hospital beds

Our biggest fear is government complacency in the mistaken belief that wait times in Canada largely have been addressed. It is time for our country to catch up to the other OECD countries with universal, publicly funded health care systems that have much timelier access to medical care than we do.

The progress that has been made varies by province and by region within provinces.

Dr. Michael Schull, Senior Scientist, Institute for Clinical Evaluative Sciences

Many provinces in Canada, and Ontario in particular, have made progress since the 2004 health accord following large investments in health system performance that targeted the following: linking more people with family doctors; organizational changes in primary care, such as the creation of inter-professional teams and important changes to remuneration models for physicians, for example, having a roster of patients; access to select key procedures like total hip replacement and better access to diagnostic tests like computer tomography. As well, we have seen progress in reducing waiting times in emergency departments in some jurisdictions in Canada and improving access to community-based alternatives like home care for seniors in place of long-term care. These have been achieved through new investments such as pay for performance incentives and policy change. They have had some important successes, but the work is incomplete.

Examples of the ongoing challenges that we face include substantial proportions of the population who do not have easy access to a family doctor when needed, even if they have a family doctor; little progress on improving rates of eligible patients receiving important preventive care measures such as pap smears and mammograms; continued high utilization of emergency departments and walk-in clinics compared to other countries; long waits, which remain a problem for many types of care. For example, in emergency departments, long waits have been shown to result in poor patient experience and increased risk of adverse outcomes, including deaths.

Another example is unclear accountability and antiquated mechanisms to ensure smooth transitions in care between providers and provider organizations. An example of a care transition problem is the frequent lack of adequate follow-up with a family doctor or a specialist after an emergency department visit because of exacerbation of a chronic disease.

A similar problem exists following discharge from hospital.

Poorly integrated and coordinated care leads to readmission to hospital

This happens despite having tools to predict which patients are at higher risk and could benefit from more intensive follow-up.

Perverse incentives and disincentives exist, such as no adjustment in primary care remuneration to care for the sickest patients, thereby disincenting doctors to roster patients with chronic illnesses.

Critical reforms needed to achieve health system integration include governance, information enablers and incentives.

we need an engaged federal government investing in the development and implementation of a national health system integration agenda

complete absence of any mention of Canada as a place where innovative health system reform was happening

Dr. Brian Postl, Dean of Medicine, University of Manitoba, as an individual

the five key areas of interest were hips and knees, radiology, cancer care, cataracts and cardiac

no one is quite sure where those five areas came from

There was no scientific base or evidence to support any of the benchmarks that were put in place.

I think there is much less than meets the eye when we talk about what appropriate benchmarks are.

The one issue that was added was hip fractures in the process, not just hip and knee replacement.

in some areas, when wait-lists were centralized and grasped systematically, the list was reduced by 30 per cent by the act of going through it with any rigour

When we started, wait-lists were used by most physicians as evidence that they were best of breed

That continues, not in all areas, but in many areas, to be a key issue.

The capacity of physicians to give up waiting lists into more of a pool was difficult because they saw it very much, understandably, as their future income.

There were almost no efforts in the country at the time to use basic queuing theory

We made a series of recommendations, including much more work on the research about benchmarks. Can we actually define a legitimate benchmark where, if missed, the evidence would be that morbidity or mortality is increasing? There remains very little work done in that area, and that becomes a major problem in moving forward into other benchmarks.

the whole process needed to be much more multidisciplinary in its focus and nature, much more team-based

the issue of appropriateness

Some research suggests the number of cataracts being performed in some jurisdictions is way beyond what would be expected to be needed

the accord did a very good job with what we do, but a much poorer job around how we do it

the accord has bought a large amount of volume and a little bit of change. I think any future accords need to lever any purchase of volume or anything else with some capacity to purchase change.

We have seen volumes increase substantially across all provinces, without major detriment to other surgical or health care areas. I think it is a mediocre performance. Volume has increased, but we have not changed how we do business very much. I think that has to be the focus of any future change.

It is at these transition points, between the emergency room and being admitted to hospital or back to the family physician, where the efficiencies are lost and where the expectations are not met. That is where medical errors are generated. The target for improvement is at these transitions of care.

I am not saying to turn off the tap.

the government has announced, for example, a 6 per cent increase over the next two or three years. Is that a sufficient financial framework to deal with?

Canada currently spends about the same amount as OECD countries

Many of our physicians are saying these five are not the most important anymore.

they are not our top five priority areas anymore and frankly never were

this group of surgeons became wealthy in a short period of time because of the $5.5 billion being spent, and the envy that caused in every other surgical group escalated the costs of paying physicians because they all went back to the market saying, "You have left us out," and that became the focus of negotiation and the next fee settlements across the country. It was an unintended consequence but a very real one.

if the focus were to shift more towards system integration and accountability, I believe we are not going to lose the focus on wait times. We have seen in some jurisdictions, like Ontario, that the attention to wait times has gone beyond those top five.

people in hospital beds who do not need to be there, because a hospital bed is so expensive compared to the alternatives

There has been a huge infusion of funds and nursing home beds in Ontario, Nova Scotia and many places.

Ontario is leading the way here with their home first program

There is a need for some nursing home beds, but I think our attention needs to switch to the community resources

they wind up coming to the emergency room for lack of anywhere else to go. We then admit them to hospital to get the test faster. The weekend goes by, and they are in bed. No one is getting them up because the physiotherapists are not working on the weekend. Before you know it, this person who is just functioning on the edge is now institutionalized. We have done this to them. Then they get C. difficile and, before you know, it is a one-way trip and they become ALC.

I was on the Kirby committee when we studied the health care system, and Canadians were not nearly as open to changes at that time as I think they are in 2011.

One thing I heard on the Aging Committee was that we should really have in place something like the Veterans Independence Program

some people just need someone to make a meal or, as someone mentioned earlier, shovel the driveway or mow the lawn, housekeeping types of things

I think the risks of trying to tie every change into innovation, if we know the change needs to happen — and there is lots of evidence to support it — it stops being an innovation at that point and it really is a change. The more we pretend everything is an innovation, the more we start pilot projects we test in one or two places and they stay as pilot projects.

the PATH program. It is meant to be palliative and therapeutic harmonization

has been wildly successful and has cut down incredibly on lengths of stay and inappropriate care

Where you see patient safety issues come to bear is often in transition points

When you are not patient focused, you are moving patients as entities, not as patients, between units, between activities or between functions. If we focus on the patient in that movement, in that journey they have through the health system, patient safety starts improving very dramatically.

If you require a lot of home care that is where the gap is

in terms of emergency room wait times, Quebec is certainly among the worst

Ontario has been quite successful over the past few years in terms of emergency wait times. Ontario’s target is that, on average, 90 per cent of patients with serious problems spend a maximum of eight hours in the emergency room.