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"This ongoing medical crisis is related to access to medical services," the letter said. "Canadians would not, and should not accept the access to health care that those in these remote communities live with on a daily basis."

Robert Salois, Quebec's former health and welfare commissioner, is slamming the province after his position and organization were abolished under last week's provincial budget.

The independent health watchdog — which was created by Quebec Premier Philippe Couillard when he was health minister in 2006 — published annual reports on the performance of the healthcare system. 

The reports were often critical, highlighting flaws within the public system. A March 2015 report, for instance, found that Quebec's drug plan is unsustainable.

Prior to the budget, Salois says he was not giving any indication or warning that his office would close down. A government employee called to tell Salois, but he says he wasn't given any explanation or justification for disbanding the office of 23 staff members.

he Ontario government spent 1.6 per cent less of provincial Gross Domestic Product (GDP) compared to the other provinces in 2010-11. With sharp cutbacks in Ontario, that gap had increased to 2.1 per cent by 2014/15. On this basis, Ontario spent about $15-billion less on programs than the other provinces and territories. On a per capita basis, Ontario is the lowest spending (and lowest revenue) provincial government in Canada. Ontario spent $1,200 less per person in 2010/11 than the other provinces and territories and almost $2,000 less per person in 2014/15. Here the gap is even larger – Ontario spent about $27-billion less on a per capita basis than the other provinces and territories.

Over the last two years, Ontario has lost 19,000 public sector workers, with most of the loss occurring in the last year. The downward trend in Ontario contrasts with the upward trend across the rest of Canada.

On a per-capita basis, Ontario has fallen 60,825 public sector jobs further behind the rest of Canada in just two years. When you need a healthcare worker, this reality will come home to roost.

The current model for paying physicians is “expensive, outdated and doesn’t support the efforts of doctors to provide the best care possible,” said Health Minister Sarah Hoffman at a Feb. 8 policy forum in Edmonton on the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

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

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

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

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

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

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

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

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

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

The government’s contract with t

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

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

were meeting the guideline, while 33 facilities were exceeding it. (Information is missing on another 10 for a variety of reasons. For example, some were new.) The directory's data shows that a quarter of seniors in the homes have a diagnosis of depression and nearly one-third are being given anti-psychotic medication without a diagnosis of psychosis.

Your questions show we have some work to do here," she said. "I will specifically be writing to each Health Authority and the government on this issue. We have a target of care hours and here's how many of your facilities are at that or under that." Mackenzie said her office will also analyze the Residential Care Facilities Quick Fact directory data to determine whether facilities with low staffing levels may also have more seniors who are depressed or who are prescribed antipsychotics medication. She also wants to study whether these homes offer fewer amenities to boost quality of life such as recreational and occupational therapy. Mackenzie said the Quick Facts Directory, available online, provides numbers to back anecdotal evidence that quality of care has declined in many B.C. seniors homes. The directory will be updated annually, but does not include data on private nursing homes that receive no government funding.

"Anecdotally, everyone was saying hours (for staff) were being cut, but now you have quantitive evidence. For policy shifts (in government), they want to know the magnitude of the issue. Let's have a discussion on how we can fix this. Before you can deal with what homes are not providing recreational therapy and OT (occupational therapy), for instance, you have to fix the hours of care first," said Mackenzie. Whiteside said the figures showing the vast majority of government-funded homes are below ministry staffing guidelines prove what HEU members have been saying for years - that they are rushed in trying to care for seniors in nursing homes and concerned that seniors are suffering and workers are placed in dangerous situations when a senior acts out violently.

A recent Vancouver Sun series on violence in nursing homes found more than 1,000 physical assaults by seniors in long-term care facilities last year. And in the past four years in B.C., 16 seniors in care have been killed by other seniors suffering from dementia. "There's simply not enough time for them (care aides) to do their job and provide the care seniors need. When we establish what the level of care needed is, it needs to be mandatory. Clearly, there needs to be more strenuous accountability in this system for seniors - many of whom are frail," said Whiteside. Nor was she surprised to find 74 per cent of the privately owned and operated businesses failed to meet ministry guidelines. "The system is set up so Health Authorities are contracting with private providers and some of those private providers are subcontracting out some of the care to other contractors and at each phase there needs to be a profit made. It's not the kind of system to have for frail seniors. It's quite shocking to think this is the system we have for them," said Whiteside.

A Vancouver Sun request to interview Health Minister Terry Lake was not granted. However, the ministry sent an email stating there are no plans to introduce mandatory staffing levels. The recommended 3.36 direct care hours is a number used "as a starting point for planning decisions," the email said. "The standard that we want care providers to meet is high quality care at whatever level is most appropriate for an individual patient," the ministry email states. "Direct care hours are dependent on the individual's needs and are determined through a comprehensive assessment process involving the client, their family and staff. Experts all agree that having a legislated or policy requirement for staffing ratios and staffing hours is not appropriate, because of the complexity of patient needs." Daniel Fontaine, the CEO of the B.C. Care Providers Association, whose members represent approximately 60 per cent of the government's contracted-out beds, said home operators would be happy to provide 3.36 direct care hours, but the government funding isn't enough to reach this level.

We can only do what we are funded to do," said Fontaine. "While the government and health authorities are trying to bring those on the lower (staffing) levels up, it's been a slow process." One of the solutions could be to take some of the money spent in the acute care system and shift it into continuing care so seniors in long-term care facilities benefit, Fontaine said. Lorri Chmilar, who retired from nursing last year after working mainly for the Interior Health Authority, said the most stressful place she worked during her career was nine months spent in geriatric care. "Anyone who has worked in public care facilities has seen a decrease in staffing, decrease in activities, and decrease in quality of meals. What has increased is the amount of time in recording statistics, and basically CYA (cover your ass)," she said. "Understaffing is also a result of the poor mix of residents. It only takes one or two residents with severe dementia or severe physical impairments to increase the workload significantly to the detriment of the rest. To increase staffat this point, or to transfer a resident to a different care area is a major undertaking that requires much justifying and time. Nurses are derided for asking for extra assistance, if there is any to be had, and roadblocks to transfers are numerous. I fear for my family, and others, and the grey wave of us to come."

THE NUMBERS DRUGS WITHOUT DIAGNOSIS In B.C. facilities, an average of 31 per cent of residents were given antipsychotics without a diagnosis of psychosis. 133 facilities were above this average. 11 were at the average.

136 were below the average, but just one reported zero cases of providing antipsychotics without a diagnosis of psychosis. DAILY PHYSICAL RESTRAINTS In B.C. facilities, an average of 11 per cent of residents have daily physical restraints placed upon them. 116 facilities are above the average.

9 are at the average. 155 are below the average, of which 27 made no use of physical restraints. Source: Office of the Seniors Advocate, Province of B.C. © 2016 Postmedia Network Inc. All rights reserved.

To do so he’s launched a petition and is organizing a rally aimed at bringing attention to the health-care crisis in western Newfoundland.

Closing clinics, doctors leaving and no replacements and long waits in emergency rooms are things he feels need to be addressed.

“The fact that 10 hours has become the expected normal is very concerning to me,” he said of the average emergency room wait.

The petition he launched on March 24 on change.org under the heading “Western Newfoundland Needs Doctors” has just over 800 signatures. He’s also printed off copies — which others can also do — and placed them at his workplace.

He’d like to get a couple thousand signatures before the end of the month, for the rally he’s planning. The rally is set for April 30 at Sir Thomas Roddick Hospital at 1 p.m.

these facilities, ambiguities exist around the private and public entities involved in the management of each home and its employees. "The history is quite patchy. Think about how much government has changed in 40 years, how the health authorities are structured. From what we understand, and this is extremely confusing, we think that the five homes were always owned and operated as non-profit legal entities, with local boards, and the staff within those homes were clearly employees of the homes," said Noonan.

But what we think happened, at least in our area, is that an organization [called Health Services Management Group] wanted to have a presence in these communities. So they co-located themselves, we think, next to these homes. They sometimes shared facilities." Sometimes, the two entities would share space, resources, even people, Noonan says. In the early 1990s, Health Services Management Group was given some of the responsibilities for the management of these nursing homes by the provincial government.

And Nashwaak Villa isn't the only facility trying to sort this question out. She said similar scenarios exist at the White Rapids Manor in Fredericton Junction, W.G. Bishop Nursing Home in Minto, Wauklehegan Manor in McAdam, and Fundy Nursing Home in Blacks Harbour. However, officials with the unions that represent these employees say the move isn't needed, given that they believe collective bargaining agreements are in place that should be respected. At each of

There are times the situation has created problems for administrators. "It's hard to manage the day-to-day of the nursing home in a way that is efficient and that's not distracting from the resident care when you're constantly navigating through these different channels and there's ambiguity. When I call the payroll department, for example, and ask them to pay a new nurse a certain amount of money, following the collective agreement, they might say to me, 'No, Horizon doesn't pay that way.' I'm not being treated autonomously from the corporate entity of Horizon Health, even though we are a separate entity. It's a lot for the employees. The processes are such that it's unclear to them if they work for Horizon or Nashwaak Villa. And that creates a lot of tension, at times." In recent months, Noonan said her board asked the unions that represent her employees to work with them to sort this out. But those unions believe no changes are needed, taking the position that a collective bargaining agreement is in place and the nursing home facilities can simply work within the terms of those contracts.

Noonan said that her board of directors has decided it needs clarity and has filed an application with the provincial labour and employment board to investigate the matter. What would happen if the labour and employment board rules that Nashwaak Villa is completely autonomous from any other organization, which would mean its employees could no longer be part of a bargaining unit involving colleagues from the Horizon Health Network? It could mean that the facility's employees could retain, or lose, their seniority. Their pay could increase, or decrease, as could their benefits. There are many uncertainties at this point, said Noonan. "We haven't begun any discussions around a transition, if there is one. So that would be done in a negotiation," she said.

"But we think [the impacts would be negotiable] in terms of what the salaries might be. Our funding model would change, as we're funded through the Department of Social Development. But what it would mean for the employees is that they've been part of a bargaining unit, one of the largest units, and the big question mark is: Would I get to keep my seniority? We don't know the answers to that because all the parties haven't gotten together to talk. That's what we're trying to do with this." Obviously, that's concerning for the employees, said Noonan, who added they are in uncertain times. Ralph McBride, provincial co-ordinator for CUPE Local 1252, said the spectre of layoffs, related to a quest for efficiencies within the province's health authorities or to proposed changes to the professional staffing ratio in nursing homes, has created concerns for the employees at Nashwaak Villa.

That's one of the bad things for the employees to be caught up in," he said. "With their employment status with Horizon, if there is a skill-mix change, and there does happen to be layoffs, or a reduction in care-givers, they'd have a bigger pool to bump into. If they become a single employer, as they've indicated, then that limits the ability for people to move around and find a new job." He said his union will do what it can to support its members, explaining that in his view the current situation is manageable. "We're saying they've got a collective agreement. I think what the Villa is trying to say is that they're not recognizing that," he said.

We appreciate any reduction of funding can create a pressure that must be managed. Therefore, staff from the Department of Health and Wellness met with sector representatives to discuss their concerns and possible solutions on how to address funding pressures individually and collectively. If operators decide to lay off employees or reduce hours that is a business decision, not one mandated by our government. Government has to make very difficult choices about where we spend taxpayers' money. We are focused on improving our health care system and finding new and improved ways to deliver the care Nova Scotians need. Thank you very much for your attention and remember my door is always open. David Wilton MLA, Cape Breton Centre

Penner’s argument addressed core questions in the closely watched case: Does the law infringe doctors’ freedom to provide and patients’ right to receive timely medical care and, if it does, are those restrictions reasonable under the Canadian Charter of Rights and Freedoms?

The strains on the public system, such as waiting lists to see specialists and for surgeries, are “indisputable facts,” Penner told Justice John Steeves. But the remedy proposed by the plaintiffs — a hybrid system where doctors can deliver private and medicare services and patients can buy insurance for services already covered by medicare — will not solve the problem. In fact, said Penner, it could make things worse by disrupting the public system and diverting resources from it.

Penner warned that if the Cambie plaintiffs win their challenge, the implications will extend outside British Columbia. Other provinces have similar restrictions on physician practice and private insurance that, like BC, are tied to federal transfer payments under the Canada Health Act. The trial opened Sept. 6 when Peter Gall, acting for Cambie, an affiliated clinic and several patients, argued BC’s Medicare Protection Act handcuffed both doctors and those seeking timely care.

The law prevents physicians from operating both inside and outside of the provincial Medical Services Plan. The restriction on so-called dual or blended practices violates Section 7 of the Charter of Rights and Freedoms guaranteeing “right to life, liberty and security of the person,” Gall said.

Orthopedic surgeon Dr. Brian Day of Cambie Surgery Centre says provincial laws limiting private care have resulted in rationing and long waiting lists.

The law also keeps residents from using private insurance to pay for treatment for things covered by the public system, despite the fact that some groups, such as those covered under WorkSafe BC injury claims, get expedited private care. That violates the Charter’s equality provisions under Section 15, argued Gall. The arguments echoed long-held positions of orthopedic surgeon Dr. Brian Day, Cambie’s co-founder and the visible face of the case. He contends provincial laws limiting private care have resulted in rationing and long waiting lists.

The alleged Charter violations are far from clear cut, said Penner, as he reviewed previous Charter decisions. A key test, for instance, is whether legislation violates the principles of fundamental justice under Section 7. Past rulings have specifically warned against applying it to social policies, he pointed out. Gall noted that the Supreme Court of Canada’s 2005 decision in the Dr. Jacques Chaoulli challenge affirmed Quebecers’ right to use private medical insurance to pay for publicly insured services when the public system was inadequate.

But Penner said the wording of the Canadian and Quebec charters differ on fundamental freedoms and only three of nine Supreme Court justices found the Quebec law violated the Canadian Charter in Chaoulli. The evidence in the Cambie case is not the same, he added. “It will tell a very different story.” Even if evidence points to Charter violations, he said, such violations are legal under Section 1 of the Charter, which allows “reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society.”

The justification here is government’s ability to ensure universal access based on need, not ability to pay, said Penner, adding courts have deferred to legislatures on social policies such as those covering housing. Granting the plaintiffs’ application would reverse that by putting patients with money or insurance ahead of those without, said Penner.

Penner was expected to take two days to present the government’s defence, with intervenors on both sides of the case presenting separate arguments later in the week. The trial is scheduled to last six months and hear from dozens of witnesses, including experts, historians and patients. Steeves’ decision is expected to end up being reviewed by the Supreme Court.

"That included Mount Sinai Hospital, the Hospital For Sick Children, Sunnybrook Hospital and McMaster University Centre," said MacDonald.

"All of which were either closed or restricted."

According to the Mount Sinai Hospital website 1,100 babies are admitted to that hospital's Newton Glassman NICU each year.

He pointed out that so far no babies have needed to be sent outside of the province.

Ontario Ministry of Health and Long Term Care officials confirmed that some NICUs are facing an unusual "surge," in critically ill babies, but emphasized the situation is temporary and that they are working with the Local Health Integration Networks and affected hospitals to take immediate action.

"This is a fluctuating situation and hospitals are working closely and in coordination to manage these pressures," said Mark Nesbitt, ministry spokesperson.

"The NICU situation continues to show improvement since last week, this is consistent with the fluctuating nature of patient flow."

Nesbitt says there is no single cause for the sudden increase in babies requiring highly specialized care.

"On Tuesday night of last week (Aug. 22) the possibilities were that the child would have to go to Ottawa or possibly out of province."

"The situation is stabilizing," said Nesbitt on Sept. 1.

"While we know there is always more work to do, investing in health care is a top priority of our government. That's why as part of the 2017 Budget, we are investing an additional $518 million in all public hospitals, a 3.1 per cent overall increase to the hospital sector, to improve patient access to care, reduce wait times, and improve the patient experience for all Ontarians at their local hospital."

He said the ministry is monitoring the situation and will increase NICU capacities as necessary.

While MacDonald said he is optimistic the right people are now listening he pointed out that on Aug. 28 there were still issues at McMaster University Centre because their transport team, which picks up the sick babies from other hospitals did not have enough nurses.

He argues that ultimately this is a government funding issue, which needs to be resolved to expand the capacity of the NICUs at these children's hospitals.

"They have pared down things so much and have gotten away with it in the past and have been able to send babies to other units within the metro area, but for this cycle this wasn't a possibility," said MacDonald.

"There is a need for government funding, not just for beds, but for nurses. Nurses are critical to the running of a NICU. They look after the patients. We of course have to make decisions about how to manage the patients, but the nurses are the ones that deal with the kids from minute to minute. They are with them all the time and if they don't have enough nurses to staff the units then the units will close or the transfer team will close down, like what happened on Monday."

MacDonald also pointed out that while the province is attributing this problem to a "surge" in critically ill babies, the NICU bed shortage has really been happening on a smaller scale for years.

"It is only getting worse with the government cutbacks."

He attributes this reaction to the reality that NICU bed shortages is not a local issue, but a national one with similar problems recently reported in the Maritimes, Alberta, Manitoba and British Columbia.