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he national safety improvement programme, launched in 2008, included a focus on infection prevention, targeted screening of vulnerable elderly patients, and extra checks on administration of high risk drugs.2Although the study was not a randomised controlled trial and so proved no causal relation, the researchers argued that the reductions found in numbers of preventable adverse events in elderly and surgical patients fitted well with progress made in the use of checklists for these groups as part of the national patient safety programme. Though the figures are encouraging, concerns remain that nearly 1000 patients still die every year.

There has been considerable recent interest in bed occupancy in Australia4

80% to 85% is widely, if anecdotally, quoted although the 85% level apparently arises from earlier work on queues.4

There is a great deal of evidence linking "overcrowding" and adverse events

We need to know the true cost of re-work in public hospitals that have become highly "efficient" and this should include costs to patients (who may require extended convalescence on welfare) and society as well as to the hospitals.

it seems unrealistic, at least in the foreseeable future, to be able to run a complex computer program in a busy public hospital at intervals to determine optimum bed occupancy

cutting bed numbers to promote "efficiency" may have unintended and perhaps unforeseen consequences

Now Complexity and Network Science tell us that sustainability and resilience are most important, that some redundancy is essential for resilience, and that as we become increasingly efficient we simultaneously become increasingly vulnerable to failures.

lowering average bed occupancy in busy public hospitals to an average of, say, 85% may still be feasible and very worthwhile.

Stephen Pratt, an anesthesiologist and chief of the division of quality and safety in anesthesia at the Beth Israel Deaconess Medical Center in Boston. From a health care system perspective, supporting second victims may reduce health worker turnover and lead to better patient care.

Canadians appeared to experience higher rates of some hospital errors or adverse events, including trauma during delivery of babies

Canada has higher rates of foreign bodies being left in incisions after surgeries but that may be because Canada does a better job collecting adverse events data than some other countries

wait times to receive care were highest in Canada in an 11-country survey cited in the OECD report

While survival rates for breast cancer and colorectal cancer are among the highest in the OECD, the country has a relatively high rate of cancer compared to other countries, the CIHI report says.

As well, the country's self-reported obesity rate is the second-highest in the G7 countries.

lower smoking rates in Canada today may mean fewer lung cancer cases in the future — but some of this progress could be offset by higher obesity rates

The OECD report says Canada spent 11.4 per cent of its gross domestic product on health in 2009, more than the OECD average of 9.6 per cent. The United States spent the most, at 17.4 per cent of GDP, with the Netherlands, France and Germany spending slightly more than Canada.

Health spending per person in Canada was also higher than the OECD average. Canada spent $4,363 (U.S.) per person on health care in 2009; the OECD average was $3,233 (U.S.).

One year after Dr. Parks’s letter was leaked, the government claims the ER wait times issue is under control.

Should we believe the hype?

In October 2010, local media published a leaked letter from the province’s chief emergency room doctor to Health & Wellness Minister Gene Zwozdesky and other government officials warning of “catastrophic collapse” if immediate action wasn’t taken. The letter was written by Dr. Paul Parks, president of the Alberta Medical Association Section of Emergency Medicine

Dr. Parks started to collect examples of substandard care and “adverse events” caused by overcrowding in the ER

When the letters and reports were eventually leaked to the media in 2010, they launched a firestorm.

It’s common to have five-plus EMS units and their medics tied up for hours while they wait for an ER stretcher to be freed up so that they can download their patient and get back on the streets

The situation has gotten so out of hand that we now have patients calling 9-1-1 from the ER

ER was overcrowded because hospitals were overcrowded

A study in the British Medical Journal found that patients whose ER wait times were six hours or longer were more likely to suffer an “adverse event,” such as the need for hospital admission, or even death.

Dr. Parks estimates that Alberta’s large-volume hospitals are still hovering at around 30 per cent of beds occupied by patients waiting to be admitted—meaning that those hospitals are still operating at well over capacity.

Dr. Parks, ER doctors were clear from the beginning of this crisis that the issue of overcrowding in emergency was due to downstream capacity problems, mostly a lack of long-term-care beds in nursing homes.

despite our vast wealth, Alberta has fewer hospital beds than the Canadian average.

The same situation exists for long-term care, where Alberta’s number of beds per capita falls below the national average. But don’t think the province makes up for this by supporting those folks in their homes. Alberta also sits close to the bottom of provinces for home-care spending.

the government opened 360 new hospital beds in Edmonton and Calgary in 2011. It announced plans to open 5,300 new long-term care beds by 2015 (1,174 of them were ready by April 2011), to make additional investments in home care (800 new clients in Edmonton and Calgary) and to improve patient discharge planning. It also announced a five-year plan that includes a primary-care focus

But there’s no plan to increase full long-term care, nursing homes and auxiliary hospitals. This is the category of care that is most needed to take pressure off our hospitals

He also says that even if beds are created, they may not match the needs of hospitalized patients, because of the lower levels of nursing support and the high personal cost for the patient and his family. “Indications are that the private, for-profit care model may actually create barriers to moving patients out of hospital beds,” he says.

New research points to a close relationship between our oral and overall health. In Oral Health in America: A Report of the Surgeon General published by the U.S. National Institute of Dental and Craniofacial Research, the authors conclude that "the oral cavity is a portal of entry as well as the site of disease for microbial infections that affect general health status." And: "Animal and population-based studies have demonstrated an association between periodontal diseases and diabetes, cardiovascular disease, stroke and adverse pregnancy outcomes." My own experience getting total knee-replacement surgery offers indisputable proof of that all-important connection between mouth and body. And the inherent risk to my overall health from the lack of dental medicare proved undeniable. An abscess under my crown went untreated because I could not afford to properly replace the tooth once it was extracted.

Due to the infection, my kneereplacement surgery was postponed because the bacteria from the gum and tooth infection could have wreaked havoc on the surgery site, destroying any chance of a new knee now or in the future. So I had the tooth and infection removed and my surgery was rescheduled. I chose a better life and being able to walk again over worrying about an unsightly hole in my mouth. But why should I have to choose?

I am immensely grateful that the medical costs of replacing both my knees are covered. But when an infection in my tooth and gums adversely impacts this lifechanging surgery, it seems unbelievably obtuse and ludicrous that there is no universal medical coverage for my mouth. That is like trying to purify and clean a jug of water while ignoring a small patch of toxic material floating on the top. Brushed Aside: Poverty and Dental Care in Victoria, A Report

from the Vancouver Island Public Interest Research Group by University of Victoria researcher Bruce B. Wallace raises important questions: Are Canadians - regardless of income - entitled to basic health care, including basic oral health care? Why do we disconnect the jaw from the body? A person's dental health affects their whole health status, and yet we refuse to treat it. In Canada, while we pride ourselves on our provision of universal health care, we exclude oral health. As a society we are agreeing to not provide basic health care to a significant part of our population." Let's show the world that we know how to take care of each other. Universal dental care should get top billing in the fall federal election campaign. Doreen Marion Gee is a Victoria writer and activist.

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

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

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

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

Daneman and his team investigated antibiotic use among 66,901 people aged 66 and older living at long-term care facilities in Ontario. They found nearly 78 per cent or 50,061 patients received a course of antibiotics in 2010.

The antibiotics were most commonly prescribed for seven days. But nearly 45 per cent of the treatments, 21,136 courses, exceeded a week, the researchers found.

However, we should avoid diagnosing this problem merely as a failure of law enforcement. Murders represent the tip of an iceberg of problems related to endemic violence in communities. Many Aboriginal women and girls, and indeed men and boys, live each day under the threat of interpersonal violence and its myriad consequences.

Initial statements from the three federal ministers tasked with leading the forthcoming inquiry — the ministers of Indigenous and Northern Affairs, Justice and Status of Women — suggest that its purpose is to achieve justice, to renew trust between indigenous communities and the Canadian government and law enforcement bodies, and to start a process of healing.

The inquiry surely must also endeavour to lay the groundwork for a clear plan to address the broader problem of interpersonal violence, which, in turn, is rooted in several key determinants. Addressing interpersonal violence is not merely an issue of justice; it is also a public health concern.

Factors associated with both the experience and perpetration of interpersonal violence are manifold. They include but are not limited to mental health issues, drug and alcohol misuse, unemployment, social isolation, low income and a history of experiencing disrupted parenting and physical discipline as a child. The Truth and Reconciliation Commission’s report has highlighted that many of these factors are widespread in the Aboriginal populations of Canada.4 Many of the same factors contribute to disparities between Aboriginal and non-Aboriginal peoples in areas such as education, socioeconomic circumstances and justice. T

here is also substantial overlap with identified determinants of poor health in Aboriginal communities both in Canada and elsewhere.5,6 These are the factors associated with higher rates of youth suicide, adverse birth outcomes and tuberculosis, and poorer child health. It’s clear that a common web — woven of a legacy of colonization and cultural genocide, and a cumulative history of societal neglect, discrimination and injustice — underlies both endemic interpersonal violence and health disparities in Canada’s indigenous populations. There is no conversation to be had about one without a conversation about the other — if the aim is healing — because the root causes are the same.

The World Health Organization (WHO) is currently engaged in developing a global plan of action to strengthen the role of health systems in addressing interpersonal violence, particularly that involving women and girls.7 A draft report by the WHO acknowledges interpersonal violence as a strongly health-related issue that nevertheless requires a multisectoral response tailored to the specific context. Evidence from Aboriginal community models in Canada gives hope for healing.

A recent report from the Canadian Council on Social Determinants of Health highlighted important strides that some Aboriginal communities have made to address the root causes of, and to mitigate, inequities through efforts to restore the people’s connection with indigenous culture.8 Increasing community control over social, political and physical environments has been linked to improvements in health and health determinants.

The public health sector in many parts of Canada has embraced the need for strong community involvement in restoring Aboriginal people to the health that is their right. In many community-led projects over the past few decades, the health care sector has worked with others to address common proximal and distal determinants of disparities.

We are presented with not just an opportunity for renewing trust between indigenous communities and the Government of Canada but also for extending the roles of public health and the health care sector in the facilitation of trust and healing. There is much that the health sector can contribute to the forthcoming inquiry. Health Canada should be involved from the start to ensure that public health is properly represented

Governments should band together to bargain for the lowest reasonable wholesale drug prices.

Every effort should be made to reduce over prescribing, particularly in the elderly population, where 20 per cent of hospital admissions are due to adverse drug reactions.

Other countries spend far more on home care and have stricter standards for residential long-term care. Being stingy with either puts frail elderly people at risk.

Successful primary health care prevents health breakdown and helps people to manage their chronic conditions.

If governments really want to bend the hospital cost curve, they must invest in communities.

Not all innovations are useful - 80 per cent of new drugs are no better than older, cheaper drugs. For-profit surgical clinics typically cost more for the same procedure and do not produce better outcomes.

The bill will usher in a new era of commercialisation but still does not make clear the public duties of the economic regulator, Monitor.

And while the proposed duties of clinical commissioning groups remain weak, they will be given the freedom to compete for or select their registered populations, as well as “flexibilities” in defining which services to provide. Allowing clinical commissioning groups to also enter into joint ventures with private companies will create inequalities in entitlement to care and introduce commercial conflicts of interest.

New commercial actors will be driven to compete and maximise income, overshadowing the need to cooperate and collaborate in ways that place the patient and population at the heart of the health system. The absence of clear responsibilities for geographically defined populations will make it difficult, if not impossible, to link clinical NHS commissioning with social care services or with plans and interventions to act on the social determinants of health.

the bill hands over greater control over public budgets to the dictates of the market

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

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

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

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

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

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

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

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

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

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

the Canada Health Act

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

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

John Abbott, Chief Executive Officer, Health Council of Canada

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

That is right.

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

We want to share best practices.

it is not likely to happen without strong direction from above

Excellent Care for All Act

quality plans

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

Canadian Hospital Reporting Project

by March of next year we hope to make it public

performance, outcomes, quality and financials

With respect to physicians, it is a different story

We do not collect data on outcomes associated with treatments.

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

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

Senator Eaton

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

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

universal screening

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

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

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

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

colorectal screening

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

adverse drug effects

over-prescribing

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

catastrophic drug coverage

a patchwork across the country

with respect to wait times

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

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

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

Have we made progress?

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

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

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

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

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

send him or her to the States

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

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

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

Dr. Kitts: We are without a leader.

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

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

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

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

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

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

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

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

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

the national pharmaceutical strategy

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

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

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