Group items tagged

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.

One of the real opportunities, building up to the accord, are for governments to define the six or ten or twelve questions they want answered, and then ensure that research is done so that when we head into an accord, there is evidence to support potential change, that we actually have some ideas of what will work in moving forward future changes.

We are all trained in silos and then expected to work together after we are done training. We are now starting to train them together too.

The physician does not work for you. The physician does not work for the health system. The physician is a private practitioner who bills directly to the health care system. He does not work for the CEO of the hospital or for the local health region. Therefore, your control and the levers you have with that individual are limited.

the customer is always right, the person who is getting the health care

It is refreshing to hear something other than the usual "we need more money, we absolutely need more money for that". Without denying the fact that, since the population and the demographics are going to require it, we have to continue making significant investments in health, I think we have to be realistic and come up with new ways of doing things.

How do you help patients navigate a system that is so complex? How do you coordinate appointments, ensure the appointments are necessary and make sure that the consultants are communicating with each other so one is not taking care of the renal problem and the other the cardiac problem, but they are not communicating about the patient? That is frankly a frequent issue in the health system.

There may be a patient who requires Test Y, X, and Z, and most patients require that package. It is possible to create a one-stop shop kind of model for patient convenience and to shorten overall wait times for a lot of patients that we do not see. There are some who are very complicated and who have to be navigated through the system. This is where patient navigators can perhaps assist.

There have been some good studies that have looked at CT and MRI utilization in Ontario and have found there are substantial portions where at least the decision to initiate the test was questionable, if not inappropriate, by virtue of the fact that the results are normal, it was a repeat of prior tests that have already been done or the clinical indication was not there.

Designing a system to implement gates, so to speak, so that you only perform tests when appropriate, is a challenge. We know that in some instances those sorts of systems, where you are dealing with limited access to, say, CT, and so someone has to review the requisition and decide on its appropriateness, actually acts as a further obstacle and can delay what are important tests.

Low-income adults who do not have employer-sponsored dental coverage through a publicly funded program - and most don't - must pay for their own dental care. Because the cost is often prohibitive, too many adults avoid seeking treatment at dental offices. Instead, they turn to family doctors and emergency departments for antibiotics and painkillers, which cannot address the true cause of the problem. In 2012, in Ontario alone, there were almost 58,000 visits to Ontario hospital emergency rooms due to oral health problems. Why is access to dental care essential now?

A person's oral health will affect their overall health. Dental disease can cause pain and infection. Gum disease has been linked to respiratory infections, cardiovascular disease, diabetes, poor nutrition, and low birth weight babies. Poor oral health can also impact learning abilities, employability, school and work attendance and performance, self-esteem, and social relationships. It is estimated that 4.15 million working days are lost annually in Canada due to dental visits or dental sick days. Persons with visible dental problems may be less likely to find employment in jobs that require face-to-face contact with the public.

Demand for dental care among adults and seniors will only increase as the population continues to grow in Ontario. From 2013 to 2036, Ontario's population aged 65 and over is projected to increase to more than four million people from 2.1 million. It is time all Canadians had access to dental care. This necessitates federal and provincial leadership in putting a framework together to make this possible. Dental health problems are largely preventable and require a comprehensive approach for all ages that includes treatment, prevention, and oral health promotion.

Pharmaceutical coverage in Canada remains an unco-ordinated and incomplete patchwork of private and public plans - one that leaves many Canadians with no prescription drug coverage at all. This has many negative consequences including: Three million Canadians cannot afford to take their prescriptions as written. This leads to worse health outcomes and increased costs elsewhere in the health-care system.

One in six hospitalizations in Canada could be prevented through improved regulation and better guidelines. Medicines are commonly underused, overused, and misused in Canada. Two million Canadians incur more than $1,000 a year in out-of-pocket expenses for prescription drugs. The uncontrolled cost of medicines is also a growing burden on businesses and unions that finance private drug plans for approximately 60 per cent of Canadian workers. Canada pays more than any comparable health-care system for prescription drugs. We spend an estimated $1 billion on duplicate administration of multiple private drug plans. Depending on estimates, we also spend between $4 billion and $10 billion more on prescription drugs than comparable countries with national prescription drug coverage plans.

Affordable access to safe and appropriate prescription medicines is so critical to health that the World Health Organization has declared governments should be obligated to ensure such access for all. Unfortunately, Canada is the only developed country with a universal health care system that does not include universal coverage of prescription drugs. From its very outset, Canada's universal, public health insurance system - medicare - was supposed to include universal public coverage of prescription drugs. The reasoning was simple. It is essential to deliver on the core principles of "access," "appropriateness," "equity" and "efficiency." Building universal prescription drug coverage into Canada's universal health-care system, based on the above principles, is both achievable and financially sustainable.

A public body - with federal, provincial and territorial representation - would establish the national formulary for medicines to be covered. This body would negotiate drug pricing and supply contracts for brand-name and generic drugs. Importantly, it would use the combined purchasing power of the program to ensure all Canadians receive the best possible drug prices and thereby coverage of the widest possible range of treatments. To patients, the program would be a natural extension of medicare: when a provider prescribes a covered drug, the patient would have access without financial barriers.

To society, universal access to safe and appropriately prescribed drugs and access to dental care will improve population health and reduce demands elsewhere in the health system. The single-payer system will also result in substantially lower medicine costs for Canada. In short, Canada can no longer afford not to have a national pharmacare program and a national dental care program. Disclaimer: The Guelph and Wellington Task Force for Poverty Elimination is a non-partisan organization. However, the poverty task force does have ties with two Guelph federal party candidates. Andrew Seagram, the NDP candidate, is a current member of the task force and Lloyd Longfield, the Liberal candidate, is a past member.

"You feel isolated and shunned - it hurts your feelings and it just doesn't make sense in this day and age. It just seems like, why wouldn't you help women here?" It is a ritual that plays out routinely for women in the only province in Canada that does not provide surgical abortions within its borders, and one that pro-choice advocates say remains fraught with challenges despite pledges by the provincial government to remove barriers to abortion access.

Liberal Premier Wade MacLaughlan announced soon after his election in May that women from P.E.I. would be able to get surgical abortions in Moncton without the need for a doctor's referral, a measure that received guarded praise from pro-choice advocates. Under the arrangement, women who are less than 14 weeks pregnant can call a toll-free line for an appointment and have everything done in one day, when possible. Previously, women needed a

doctor's approval and had to have blood and diagnostic work done on the Island before travelling almost four hours to Halifax for the operation. Or they could go to a private clinic and pay upwards of $700 for the procedure. Abortion rights advocates say both are costly and stressful options for women, who rely on volunteers to do everything from finding people to accompany them to the hospital to arranging childcare. Becka Viau of the Abortion Rights Network helps women figure out requirements for bloodwork and pinpoint how far along they are in their pregnancy, as well as line up drivers, babysitters and meals while raising funds to cover things like the $45 bridge toll, phone cards and lost wages.

The pressure on the community to carry the safety of Island woman is ridiculous," she said. "You can only look at the facts for so long to see the kind of harm that's being done to women in this province by not having access." Still, for some MacLauchlan's announcement was a significant change for a province that has fought for decades to keep abortions out of its jurisdiction, with some seeing it as the beginning of the end of the restrictive policy. Some say opposition to abortion access is quietly waning on the Island, where it is not uncommon to see pro-choice rallies and political candidates.

Colleen MacQuarrie, a psychology professor at the University of Prince Edward Island who has studied the issue for years, said the Moncton plan had been discussed with former premier Robert Ghiz and was considered a first step toward making abortions available in the province. But a month after those discussions, Ghiz resigned. Reached at his home, he refused to comment on the talks but said everything was on the table. "We've created the evidence and we've gotten community support," said MacQuarrie, who published a report in 2014 that chronicled the experiences of women who got abortions off Island. "It has gotten better, but better is not enough. We need to have local access."

Rev. John Moses, a United Church minister in Charlottetown, published a sermon that condemned abortion opponents for not respecting a woman's right to control her health and called on politicians to "stop ducking the issue." "To tell people that they can't or to make it as difficult as we possibly can for them to gain access to that service strikes me as a kind of patriarchal control of women's bodies," he said in an interview. "It's a cheap form of righteousness."

Holly Pierlot, president of the P.E.I. Right to Life Association, says she's concerned about the easing of restrictions and plans to respond with education campaigns aimed specifically at youth. "Politically, we've certainly got a bit of a problem," she said. "We were disappointed by the new policies brought in by the provincial government and we are concerned by the federal move to increase access to abortion." Horizon Health in New Brunswick says the Moncton clinic saw 61 women from P.E.I. from July through to Nov. 30. P.E.I. Health Minister Doug Currie did not agree to an interview, but a department spokeswoman says that from April to October the province covered 44 abortions in Halifax and 33 in Moncton.

"The government made a commitment to address the barriers to access and they acted very quickly on it," Jean Doherty said. It's not clear whether that will be enough to satisfy the new federal Liberal government under Prime Minister Justin Trudeau, who told the Charlottetown Guardian in September that "it's important that every Canadian across this country has access to a full range of health services, including full reproductive services, in every province." The party also passed a resolution in 2012 to financially penalize provinces that do not ensure access to abortion services. In an interview, Federal Health Minister Jane Philpott would only say the issue is on her radar.

This is something I am aware of, that I will be looking into and discussing with my team here and with my provincial and territorial counterparts," she said. Successive provincial governments have argued that the small province cannot provide every medical service on the Island or that there are no doctors willing to perform abortions, something pro-choice activist Josie Baker says is untrue. "We're tired of being given the run around when it comes to a really basic medical service that should have been solved 30 years ago," she said. "The most vulnerable people in our society are the ones that are suffering the most from it. There's no reason for it other than lack of political will."

Patients suffering in pain on wait lists for surgery have once again been denied their Charter right to access health care outside of the government's cruel, inefficient, and unaccountable monopoly. In 2005, the Supreme Court of Canada famously declared in Chaoulli vs. Quebec that "access to a waiting list is not access to health care." But last week, the Alberta Court of Appeal refused to apply and follow the Chaoulli precedent, citing a lack of evidence in the case of Darcy Allen vs. Alberta.

until September 2010 - a date later pushed back to June 2011. No longer able to work to support himself and his family, unable to perform ordinary day-to-day tasks, and experiencing pain so severe that not even the strongest drugs were effective, he spent $77,000 of his own money on surgery in Montana. Dr. Allen's surgery immediately and significantly reduced his pain, and started his slow journey back to better health. Apart from paying out of pocket, Dr. Allen's only other option was to suffer two years of extreme pain, waiting for the Alberta government's monopoly system to provide necessary surgery.

Dr. Allen's experience with medical wait times is, unfortunately, not unique. While patients in France, Germany, Japan and dozens of other developed democracies count their medical wait times in days and weeks, the government health monopolies in Canadian provinces subject patients to wait times that are counted in months and years. The international evidence demonstrates that there is simply no need for government to impose a monopoly over health care in order to ensure that health services are available to all members of the public. In Chaoulli, the Supreme Court held that while government has every right to create health-care programs, it does not have the right to create a monopoly that prevents patients from accessing health care outside of that government monopoly.

Last week's Court of Appeal decision, as well as the trial decision under appeal, declared that Dr. Allen had not brought forward enough evidence to support his claim. Curiously, neither decision refers to the extensive evidence put before the court about Alberta's long wait lists, and how wait times hurt patients, even killing them in some cases. While refusing to consider - or even mention - this abundant evidence, the court declared that Darcy Allen should have introduced expert reports and expert witnesses to testify about the fact that wait lists exist, and the fact that wait lists inflict suffering - and sometimes death - on patients. The Alberta government has not disputed either of these two facts. They are the same facts on which the Supreme Court relied in Chaoulli.

Following the court's logic, Darcy Allen should have spent $77,000 out-of-pocket on his medically necessary surgery, and then an additional $200,000 to $400,000 to assert his Charter rights, by paying a panoply of experts to "prove" basic facts that have already been admitted by the Alberta government. So much for access to justice.

To respect Charter rights, governments have only two options: ensure that a monopoly system provides real access to health care (not just access to a waiting list), or allow Canadians the freedom to access health care outside of the government's system. A law that creates a government monopoly over health care, by banning private health insurance, complies with the Charter only if that monopoly does not inflict pain and suffering - and a real risk of death - on waiting patients.

Ignoring the evidence before them about Alberta's long and painful waiting lists, Alberta's courts have refused to deal with the violation of Darcy Allen's Charter rights. Hopefully the Supreme Court of Canada will not refuse to do so. National Post Calgary lawyer John Carpay is president of the Justice Centre for Constitutional Freedoms (Jccf.ca) and acts for Darcy Allen.

Wait times and coverage vary widely between and even within provinces, with only one in six hospitals offering surgical abortions and access is most difficult for women living in rural communities - including First Nations reserves - who may have to travel long distances to get an abortion. Prince Edward Island does not provide any abortion services at all, although it does cover the cost of the procedure for provincial residents who obtain an abortion at a hospital in Moncton, N.B., where no referral is needed, or in Halifax, where women need to be referred by a P.E.I. doctor.

Philpott was not available for an interview Tuesday to elaborate on what she has in mind, and spokesman Patrick Gaebel was unable to add many details. Prime Minister Justin Trudeau said last year that all Liberal MPs would have to vote along pro-choice party lines, but the campaign platform and his ministerial mandate letter to Philpott did not mention anything about improving access to abortion services.

Calls for a Canadian national seniors’ strategy intensified in 2015 – everyone from the CMA to the IRPP held consultations across the country, identifying key issues and laying impressive groundwork for a future strategy. Lack of political will, however, holds us back – discussion of a national seniors’ strategy during the federal election was very limited, and it is still a political black box. An effective seniors’ strategy would provide a framework for all of the issues I have described – access, affordability and advance planning.

The long-term-care sector will be a critical partner for implementing, supporting and evaluating assisted-dying requests when the proposed legislation becomes law. Home-care workers and health-care providers in long-term-care facilities, alongside family members, are often the last to care for dying patients outside hospital settings. For many Canadians, long waiting lists to access limited long-term-care spaces are a significant barrier. Regional disparities in access, quality and affordability also exist, and multiple advocacy organizations have emphasized the need for national leadership on issues of elder abuse and neglect in long-term-care facilities.

A national senior’s strategy will be essential to improving seniors’ quality of life, supporting families and caregivers, and planning for Canada’s rapidly aging population. Canada currently has one geriatrician for every 15,000 Canadians, and there are significant gaps across the country in the quality, cost and access to care.

May 24, 2016 

ith Canada’s assisted-dying dying legislation currently before Parliament, it becomes increasingly urgent for the Liberal government to make substantive commitments to policies and programs that will support this sea change in the health-care system.

And one to which many family doctors, struggling to help mentally ill patients, can attest. After months of research, and as detailed in our Open Minds series, The Globe and Mail identified some of the top evidence-based approaches to building a mental health system that will work for Canadians. These are changes that would move the country beyond its patchwork, fragmented mental health system in which the care patients receive is too often determined by what they can afford, or where they live or what they are savvy enough to cobble together on their own. These initiatives abide by the principals of Medicare and good science, and treat the disorders of the mind as diligently as the diseases of the body.

Expanding access to publicly funded therapy One in five Canadians will be affected by mental illness in their lifetimes. The cost to the country's economy is staggering: $50billion a year in health care and social services, lost productivity and decreased quality of life, estimates the Mental Health Commission of Canada. The personal costs are more devastating - unemployment, family breakup, suicide. Canadians who seek help for a mental illness will most often be prescribed medication, even though research shows that psychotherapy works just as well, if not better, for the most common illnesses (depression and anxiety) and does a better job at preventing relapse. According to a 2012 Statistics Canada study, while 91 per cent of Canadians were prescribed the medication they sought, only 65 per cent received the therapy they felt they needed. Access to evidencebased psychotherapy, which experts say should be the front-line medical treatment, is limited and wait-lists are long.

No provinces cover therapy delivered in private practice by a psychologist, social worker or psychotherapist, creating a twotier system, which means families without coverage through work - those more likely to be low-income - often either pay out of pocket or go without or, if they are lucky, rely on a non-profit group working to fill a gaping hole in a flawed health-care system. Even Canadians with coverage rarely have enough for a proper dose that meets treatment guidelines. This kind of inconsistent, unequal and scientifically flawed approach to care would be untenable for diabetes, cancer or heart disease. Yet it persists for some of the most debilitating illnesses suffered by Canadians. "Clearly this is the biggest gap we have, and the one that most needs to be fixed," says psychiatrist Elliot Goldner, director of the Centre for Applied Research in Mental Health and Addiction. Psychotherapy is a medically necessary treatment, he argues, that should be publicly funded. The question is not whether Canadians need it, but how to deliver it.

A system that responds nimbly to patients' needs would have clear treatment guidelines, appropriate screening and good data collection to ensure that therapies are working for patients. There should be a role, for instance, for non-profit groups on the ground to be woven into a comprehensive system to provide additional supports, particularly in areas such as housing, employment and mental health promotion - without expecting them to patch up shortfalls in services the system should provide. That should include, says Dr. Goldner, non-physicians with training in psychotherapy who are integrated into the mental health system, so that access to care is based on sound science and the best treatment plans for individual patients, rather than what happens to be available. Canada doesn't have to start from scratch. As Dr. Goldner points out, Britain and Australia have both made huge investments to expand public access for all citizens to psychotherapy, recognizing both its clinical value and cost-effectiveness over the long run. Britain's system, especially, has been designed to be accountable, to track outcomes with extensive data and to be flexible enough to incorporate changes to the system to improve results.

Using technology to deliver therapy into the homes of Canadians It can be hard enough to get timely treatment if you only have to drive a few blocks to find it. But what if access to care for, say, an anxiety disorder requires traversing a sprawling wilderness, for hours by car, sometimes through a blizzard? These were the stories that Fern Stockdale Winder heard often from Saskatchewan patients, as the psychologist charged with developing the province's new mental health strategy. Even when mental health care was available, reaching treatment was often one more layer of stress. It doesn't have to be this way. Chief among the strategy's recommendations: a provincewide online therapy system. The evidence for tech-delivered therapy, with support over the phone, is strong - for many patients with depression and anxiety, it can be just as effective as face-to-face sessions. It allows patients to manage care around their work and school schedules, to maintain privacy and to take control of their own recovery in a way less likely to happen with medication.

And it's cost-effective, says Dr. Stockdale Winder, potentially reducing appointment no-shows and cutting down on travel time for patients and therapists to and from remote communities. Canadians have ready access to medication for mental illness not because it's the best option, but because it's the easiest - even though psychotherapy works as an effective early intervention, a standalone treatment or in combination with drugs, and to prevent relapse. This front-line treatment can also be delivered in a modern and increasingly convenient way that gives patients more choice in how they receive their care.

It's very much about how people like to learn. Whether for reasons of stigma or personal preference, many people like to work on life challenges by themselves," says Chris Williams, a psychiatrist at the University of Glasgow, whose self-guided program is used as a first-stage treatment in Britain's publicly funded psychotherapy system. It has also been adapted in British Columbia and is being piloted in other provinces by the Canadian Mental Health Association. Self-guided therapies vary - some use DVDs or booklets, others are delivered online - but the evidence is strongest for ones that also link patients to therapists, either by e-mail or with brief phone calls.

A separate online program at the University of Regina has already had promising results. (Even so, the government is taking a wait-and-see attitude: Health Minister Dustin Duncan said last week that the government is keeping an eye on the project and will consider whether to expand the service after the pilot concludes next year.) What Dr. Stockdale Winder envisions is a system in which family doctors could use depression and anxiety screening to easily steer appropriate patients away from medication and toward accessible, online therapy.

"She clicks a button, and the patient is in," she says. Such a system would also monitor the progress of participants and direct them into more intensive care if their conditions worsened. The need for early intervention is pressing, and the evidence for online therapy is already convincing. In a country of wide open spaces, with remote communities difficult to reach even in the best weather, it's necessary. What are policy-makers waiting for? Teaching the next generation about mental health

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.

Senator Eaton

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.

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

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.

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

Rather than moving toward a countrywide public monopoly, Canada's provinces should follow the lead of Quebec, which in 1997 implemented a reform that made drug insurance coverage in the province universal, but that relies on a range of insurers, public and private. The costs of the Quebec system have risen since its implementation, but this is largely because Quebec has resisted the temptation to ration access to innovative drugs. Indeed, among Canadian provinces, Quebec provides the most generous coverage by far. Whereas on average 23 per cent of all drugs approved by Health Canada between 2004 and 2012 were reimbursable by Canada's provincial public plans as of December 2013, the proportion in Quebec was 38 per cent.

A national plan, it is argued, would provide the public insurer with greater negotiating power, allowing it to obtain price concessions from pharmaceutical companies. But the savings would largely come from increased rationing rather than from greater efficiency. In the United Kingdom, there has been one policy after another since the 1990s aimed at controlling spending. Patients continue to suffer the consequences of a lack of access to many proven drugs. Likely as a result of such restrictions, despite screening rates that are among the highest in the world, English patients have lower survival rates for various cancers than most other industrialized countries. In New Zealand, another country frequently held up as a model, patients' access to innovative drugs is just as restricted, if not more so. Of all the drugs approved in the country from 2009 to 2014, barely 13 per cent were reimbursable by the public insurance plan, the worst result among 20 countries evaluated.

It is also important to note that while Quebec spends more on drugs, this goes hand in hand with lower overall costs in the public health care system compared to other provinces, as more accessible pharmaceutical therapies have likely replaced other kinds of more expensive medical care, like hospital surgeries. Quebec's mixed universal plan is not perfect, but it does provide coverage to all residents. And only 4.4 per cent of Quebecers say they had to forgo taking their medicines or skip a dose for financial reasons - less than the residents of all other Canadian provinces, and less than the residents of many other countries, too. If one is concerned with universal access to the latest drugs, that's a far better model to follow. Yanick Labrie is an economist at the Montreal Economic Institute (www.iedm.org)

e know that the best way to reduce these high drug prices and improve access to treatment is through generic competition. In fact, everyone from ministries of health to medical humanitarian organizations such as Doctors Without Borders and donorsupported global health institutions rely on affordable, quality generic medicines for 85% of their health programming. Yet certain provisions proposed by the U.S. and other countries in the TPP could greatly limit the reach and effectiveness of these programs, thereby diverting badly needed resources away from patient care. Canada supports many important global health programs but the effectiveness of this support is at risk. This year, Canada contributed $500 million to the replenishment of the Gavi Vaccine Alliance's fund. Canada is also one of the leading donors to the Global Fund to Fight AIDS, Tuberculosis and

Malaria, which has provided antiretroviral therapy to more than six-million people living with HIV in developing countries. In addition, Canada provides international assistance to five of the 12 TPP-negotiating countries, amounting to more than $83 million in 2012 and 2013. Two countries involved in the TPP negotiations, Vietnam and Peru, are also on Canada's "Development Countries of Focus" list, due to an even greater need for development assistance. If harmful provisions in the TPP are accepted, driving up the cost of medicines and vaccines, the impact of this use of Canadian taxpayers' money could be seriously diminished. Access to affordable medicines could also become a major concern in Canada. Drug expenditures in this country have been the fastest growing sector of health spending in the last 25 years. Since the mid-1980s, prescription drug spending has more than doubled, costing $27.7 billion in 2012. If Canada does not strongly reject the new protections proposed in the TPP, these expenditures could cost our health-care systems, and all Canadians, billions more per year.

Thankfully, a version of the TPP text leaked in 2013 shows that Canada and other countries are opposing some of the most harmful provisions in the agreement. As the negotiations are nearing an end, countries will be under immense pressure to reach a deal. Canada has a humanitarian duty to resist that pressure and to stand up to the U.S. and others who would seek to benefit their pharmaceutical industries through the TPP negotiations, at the expense of poor countries and of Canadians. More than 32,000 Canadians have already signed a petition at www.msf. ca/tpp calling on Canada to stand up for public health. Together we must ensure the TPP does not undermine access to affordable drugs, whether here in Canada or around the world. When it comes to access to medicines, it is imperative that Canada does not give in and trade away our health. Stephen Cornish is executive director of Doctors Without Borders Canada.

Your proposed Bill 20 is meant to improve health-care access and cut costs in Quebec. But by banning access to IVF for women over 42, it is overstepping its objectives and violating the rights of citizens. Choosing to limit public funding for a service, when trying to save money, is one thing; but banning it completely, even when people choose to pay out of their own pockets, is an entirely different matter. When you were recently challenged on this point, you said that this is not a matter of cost but rather of "protecting mothers and children." My son and I are doing very well, thank you for your concern. And like other mothers who conceived in their 40s, I would appreciate some respect for my autonomy. This justification of 42 as an age limit for IVF is good old-fashioned paternalism that has no place in today's society. Under the guise of protection, this Bill represents an attack on Quebec women and mothers.

To make things worse, Bill 20 is threatening physicians with heavy fines if they direct me to another province or jurisdiction where I can privately access IVF after 42. This is an alarming violation of the professional autonomy of a doctor to refer patients, not to mention a violation of a woman's freedom to have access to health information she needs. In 2010, the Quebec government introduced a program that funded every aspect of IVF for everyone, an unprecedented level of coverage in North America. The program was in such high demand that it cost much more than expected, $261 million to date. Looking back, there is wide agreement in Quebec that the hasty introduction of the program in the absence of reflection and public consultation led to very problematic consequences. You, Minister Barrette, famously criticized this program for being an "open bar" and allowing access to IVF without appropriate restrictions.

But the fix for bad policy is not another bad policy. Proposing ethically and socially appropriate conditions of eligibility for publicly funded IVF is a laudable objective. The thoughtful and well-argued report published in June 2014 by the Quebec Commissioner for Health and Well-being, based on an extensive public consultation, proposes many such conditions that would allow cutting costs while respecting considerations of justice and equity. Conditions on access to public funding may be justified.

But there is no way to justify draconian measures that have nothing to do with cost control, but are rather an affront to women's rights. Rather than protecting us from IVF, you should protect us from unwarranted government intrusion. Vardit Ravitsky is an associate professor in the Bioethics Program at the School of Public Health, University of Montreal.

In Sweden, the pharmacy sector was a government monopoly from 1971 to 2009. Consequently, it was among the countries with the lowest number of pharmacies by population, with barely one outlet per 10,000 inhabitants, about a third as many as in most Canadian provinces. State pharmacies offered very limited opening hours: from 10 a.m. to 6 p.m. Monday through Friday, and from 10 a.m. to 2 p.m. on Saturday. Not a single pharmacy was open on Sunday, and many closed down completely for the summer. Sweden has since profoundly liberalized this sector and the number of pharmacies has skyrocketed as a result, increasing more in the following four years than in the previous 30. In addition to the hundreds that were privatized, 374 new private pharmacies entered the market, thereby improving access for the inhabitants of all regions. The effectiveness and accessibility of the health services provided by the private sector result primarily from the market mechanisms that govern them, namely entrepreneurship, competition and patients' freedom of choice. We should not be surprised to find that these mechanisms are largely absent in the public healthcare system. Yet it is these mechanisms that ensure that patients remain at the centre of care-providers' concerns. We should keep that in mind when thinking of how to reform our ailing public system. Yanick Labrie is an economist at the Montreal Economic Institute (Iedm.org) and author of The Other Health Care System: Four Areas Where the Private Sector Answers Patients' Needs.

As well, a report this fall from Ontario Auditor-General Bonnie Lysyk found that as little as 61 cents out of every dollar spent by the agencies goes to face-to-face client services, and discovered gaps in the level of care offered across the province. A second report on home care will be included in the Auditor-General's annual report in early December.

Suggested changes to the way primary care is delivered by family doctors and other health-care providers are also expected to gain wide attention, especially from doctors, who are in a battle with government over fees. Ontario Health Minister Eric Hoskins has been hinting for some time that change was in the works, but the existence of a policy paper and its contents have been kept under wraps.

Individuals familiar with different aspects of the document, who spoke to The Globe on the condition that they not be identified, describe it as "transformational" - a term that has become a favourite of the Health Minister. Earlier this month, Dr. Hoskins delivered a speech at a hospital conference in Toronto in which he repeatedly spoke of "system transformation" and the need for stronger "local governance."

The minister responded to questions from The Globe in a statement Monday night, saying that the ministry is "putting together a document which we hope will serve as a starting point for discussions and consultation about how we can better integrate various parts of the system and improve the patient experience." "We plan to share that discussion document in the coming weeks and will be engaging with our partners, including care providers and the public, to solicit feedback on those ideas to achieve deeper integration," the statement said.

The plans for change come at a critical time for Ontario's Liberal government as it looks to cut costs and tame the provincial deficit. To do that, keeping health-care spending in check is imperative, but the minister has also pledged to make improvements such as ensuring more people have access to primary care, and are not reliant on walk-in clinics and emergency rooms for after-hours nonurgent care. Any efforts to change how primary care is paid for or organized are likely to meet resistance from doctors, who are already at odds with the province after it imposed a contract and two rounds of fee cuts this year.

An expert panel report on primary-care reform - released quietly this fall and widely criticized by doctors - recommends dividing the province into "patient care groups," similar to school boards, with each group responsible for ensuring every resident in the area has access to primary care. As a prelude to the coming reform, at least one merger plan among two hospitals and a CCAC was paused this fall after the ministry advised the boards involved of the coming changes.

John Davies, chair of the board of William Osler Health System in Brampton, Ont., said merger talks with the Central West CCAC and Headwaters Health Care Centre in Orangeville, Ont., were suspended after deputy Health Minister Bob Bell wrote to them a few weeks ago advising them to suspend talks because of the coming reforms. Those familiar with the proposed reforms say the beefed-up local health networks will be given responsibility for overseeing home care, with front-line workers and case managers retaining their jobs.

"For the client, there will be no change," one source said. Some aspects of home care involving patients who have been hospitalized will continue to move over to a new model called "bundled care," which has been piloted by St. Joseph's Health System in Hamilton and was recently expanded to six other sites, one source said. The province will also look at tailoring care delivery to the needs of local communities, with different models possible for urban and rural settings, another source said.

When the Canada Health Act passed in the House of Commons in 1984 with unanimous support from all political parties, its primary purpose was to put an end to extra billing like this. Charging patients at the point of care for medically necessary services strikes at the heart of the principle that access to health care should be based on need rather than ability to pay. It undermines equity, increases system costs and reduces commitment to the public health care system. It's also illegal.

Why are we not hearing resounding denunciations of Barrette's plan from our federal politicians? Research has consistently demonstrated that forcing people with less money to pay a fee to access care means they might not seek out medical attention until later in the course of their illness. This means patient outcomes are likely to be worse and treatment more complicated and costly. Given higher levels of illness among people in poverty, these fees also shift costs to those who use the system most but can least afford to pay.

Doctors in Quebec and across the country have expressed alarm at Barrette's amendment to Bill 20, which regulates extra billing rather than prohibiting it. The Canadian Medical Association, Quebec Medical Association, Canadian Doctors for Medicare, Médecins Québécois pour le Régime Publique, and the Quebec College of Family Physicians have all come out against this decision, joining patient groups, all of Quebec's opposition parties, and Raymonde Saint-Germain, the independent Quebec Ombudsman. The measure was passed on Oct. 7, with no public debate. Bill 20 is currently before the National Assembly and is expected to become law this fall.

Barrette is effectively bringing user fees in through the back door. Rather than introducing user fees charged by government, he would let clinics do so. This further fragments care and makes access even more inequitable.

In this federal election campaign, the talk has been around reducing barriers to access by improving coverage of prescription medicines, home care and mental health care. Yet at the same time that our federal parties are committing to such muchneeded expansion, they are silent on protecting the core of medicare: publicly funded doctor and hospital services.

Any party that claims to be committed to the Canada Health Act should immediately state its position on the amendments to Bill 20 in Quebec. To do less is to skirt the core federal responsibility for medicare in Canada. Ryan Meili is a family physician in Saskatoon and an expert adviser with the Evidence Network. Danielle Martin is a family physician and vice-president Medical Affairs and Health System Solutions at Women's College Hospital in Toronto. Both are members of the board of Canadian Doctors for Medicare.

JACQUES BOISSINOT, THE CANADIAN PRESS / Health Minister Gaétan Barrette has put forward a measure that would regulate extra billing rather than prohibit it. It will become law when Bill 20 is adopted.

Despite this increased attachment, the chance of being seen in a timely way did not improve. Ontario's primary care models require evening and weekend clinics and on-call duties, and penalize practices for out-of-group primary care visits; therefore, these findings are unexpected. While many factors are likely involved, Ontario's auditor general noted two major faults: not establishing mechanisms for ongoing monitoring and evaluation, and not enforcing practices' contractual obligations, especially for after-hours care

The access bonus is reduced by outside primary care use but not by emergency department visits. Physicians responding rationally to such a financial incentive would logically direct their patients away from walk-in clinics and toward emergency departments. The access bonus also strongly discourages healthcare groups from working together to provide late evening and night coverage because all parties would lose financially. An incentive that costs more than $50 million annually should be structured to align better with health system needs.

A recent systematic review found insufficient evidence to support or not support the use of financial incentives to improve the quality of care (Scott et al. 2011).

Ontario's reforms occurred in the absence of routine measurement of primary care within practices, groups or communities and with limited accountability for how funds were spent.

Ontario adjusts capitation for only age and sex, whereas most other jurisdictions further adjust for expected healthcare needs, patient complexity and/or socioeconomic disparities (e.g., the Johns Hopkins Adjusted Clinical Groups http://www.acg.jhsph.org/). That may be why Ontario's primary care capitation models have attracted healthier and wealthier practices (Glazier et al. 2012).

Community health centres care for disadvantaged populations with superior outcomes (Glazier et al. 2012; Russell et al. 2009) and could play a larger role in Ontario's health system.

Unlike some other jurisdictions (National Health Service Information Centre for Health and Social Care 2012), Ontario has no routine measurement of primary care at the practice, group or community levels. It has no organized structures, such as the Divisions of General Practice in Australia (Australian Department of Health and Ageing 2012) or the Divisions of Family Practice in British Columbia (2010), that can help practices come together to improve care. It has also failed to hold practices accountable for their contractual obligations, including after-hours clinics.

In Ontario, there was little relationship between incentive payments and changes in diabetes care (Kiran et al. 2012), nor were there substantial improvements in most aspects of preventive care despite substantial incentives (Hurley et al. 2011). Similar cautionary tales about pay-for-performance can be found elsewhere in the health system (Jha et al. 2012).

Access to primary care has proven to be challenging in Canada, leaving it behind many developed countries in timely access and after-hours care, and more dependent than most on the use of emergency departments (Schoen et al. 2007).

A strong primary care system is consistently associated with better and more equitable health outcomes, higher patient satisfaction and lower costs (Starfield et al. 2005).

Also a nursing teacher, Cleveland has brought her compassion and care to clients in hospitals, hospices and private homes. "Home is always best for palliative care, but these days, that's not always possible," said Cleveland. "The two vital pieces of this picture are accessibility and how well the care is being provided. Ontario has large areas where palliative care is not accessible." Statistics from the Canadian Hospice Palliative Care Association (CHPCA) estimate less than 30 per cent of Canadians receive any palliative or end-of-life care - and even that depends on where you live.

"There's definitely not enough money, not enough staff and there's not enough time," said Cleveland. "The staff has to fly in and fly out of homes, instead of having the time to sit and talk. "Often, the care that a person needs is just somebody listening to them." Ontario's nursing leaders know accessibility is the big tipping point for palliative care. But they also believe the Supreme Court of Canada's decision to lift the ban on physician-assisted suicide will focus more attention on all end-of-life services.

We hope the public dialogue over the Supreme Court decision will push up funding for palliative care, if we want top notch, universally accessible palliative care in every corner of this province and country. And that's not the case at present," said Dr. Doris Grinspun, executive director of the Registered Nurses' Association of Ontario. Certainly, the demand for end-of-life care in Ontario is growing fast. Within 20 years, people over 65 will double to four million, making up almost a quarter of this province's population. Many can expect to live longer, even with advanced illnesses. "There is a risk in the focus of palliative care that we will forget that the elderly, dying of natural causes, still need all of the comfort and attention of palliative care as anyone dying of life-altering illness such as cancer," cautions Dianne Martin, executive director of the Registered Practical Nurses' Association of Ontario (RPNAO).

Today, Ontario provides palliative care through a maze of sources: hospitals; 14 Local Health Integration Networks (LHINs); community care access centres; 32 hospices; and 60 other agencies providing companionship visits. Among the fortunate ones served by palliative care is 74-year-old retired firefighter Stuart Ross, who is trying to cope with the death of his wife of 46 years. Ross is a patient of the Trent Hills Family Health Team in Campbellford, southeast of Peterborough, Ont., and is able to draw on the services of Cleveland.

Cleveland provided palliative care to his wife, Barbara Ross, in the final weeks of her life at home. Now she gives followup care and support to the widower over a cup of tea at the kitchen table. "I talk to Gwen about the loneliness," says Ross. "She explains to me it can be a normal part of the recovery period. "Sometimes I just need her words of encouragement over something I'm having difficult in handling."