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"I go help mothers with their sick children while I leave mine at home," Saoud said. "I can't see how I can do more." Saoud has three young children. She devotes 60 per cent of her workweek to a Montreal hospital's emergency department - irregular hours that include evening and weekend shifts - while the rest of her schedule is split between a walk-in clinic and what's known as "dépannage," replacing doctors in Quebec's more remote regions at least once a month. What she wants is more time for her job as a mother - helping with their homework and sharing meals - and not have to meet "an impossible" quota of following 1,500 patients, as the original Bill 20 would have required of each family doctor.

I am already at my maximum," said Saoud. And so, she has applied for a licence to practise outside Quebec. Nearly 24 per cent of Quebecers are on a waiting list or desperately searching for a family doctor. The crisis is rooted in a 1990s provincial government plan to save money by encouraging doctors to retire early. Staffing shortages ensued, and family doctors were obliged to fill the gaps by working outside their clinics in hospitals and far-flung regions. Quebec has attempted, with little success, to improve primary care over the last two decades by expanding community health clinics (CLSCs) and creating pools of doctors known as Groupes de médecine de famille (GMF) but both limped along under budget constraints and heavy bureaucracy. Barrette contends that the province has more than enough physicians to meet its needs, but that a profound structural change is needed.

He presented Bill 20 last fall as his road map to ensure that every Quebecer has a regular doctor. But the bill's punitive measures sparked widespread discontent among doctors against what they called a one-size-fits all, state-controlled, conveyor-belt approach to medicine. Doctors were further incensed at Barrette's assertion that doctors are not productive enough - which they saw as being accused of laziness - and frustrated at being blamed for a broken health system.

Like Saoud, many doctors prepared exit plans - from retiring to leaving the province. Some med students, many of whom were actively recruited to shore up Quebec's supply of family doctors, began reconsidering family medicine - or simply leaving to do their residency out-of-province, according to the Fédération des médecins résidents du Québec. Saoud was heading home to her sick daughter on Monday when Barrette announced he had cut a deal with the provincial federation of family physicians to exempt them from Bill 20 - temporarily. There would be no quotas and no penalties, Barrette said, as long as family physicians were able to collectively ensure that 85 per cent of Quebecers had a family doctor by the end of 2017. But Saoud says the change will not keep her here. And she's not alone.

The buzz among disillusioned physicians is that "everyone has a Plan B." And while the bill's delay has eased tensions a notch, some doctors are saying the two-year delay simply means they now have until 2017 to prepare a better exit. Bill 20 remains a guillotine above the heads of doctors. "Most definitely, there are physicians investing in Ontario licences and poised to leave if Bill 20 passes. I myself may have to leave," family physician Maggie O'Dell, who works at the Wakefield Family Medical Centre near the Ontario border, said before the bill was modified. And after Barrette backtracked, she had this to say: "It's nice to have reprieve, so it's a relief - for now ... a reason for many to hold back on pulling up stakes in the short term."

Montreal family physician Fahimy Saoud hated leaving her sick 5-year-old in someone else's care this week, but it was her turn to staffa walk-in clinic and she didn't want to let those patients down. But as the day wore on, Saoud kept hearing her daughter's plea when she left the house: "Who will take care of me?" So on Monday, after seeing everyone in the waiting room, Saoud left the clinic early; her daughter needed her as much as her patients did.

The group's recent survey - 204 of its members responded - indicated that Bill 20's sanctions would backfire. While the survey was taken three days before Barrette modified Bill 20, Duong said the results reveal that doctors, in particular those whose mother tongue is English, are at risk of leaving the province. Among the 134 francophone doctors polled about their intentions if Bill 20 were applied, 32 per cent said they would resign from hospitals, 12 per cent said they would leave Quebec and another nine per cent would go into private care.

Among the 70 anglophone respondents, seven said they already sent letters of resignations to their hospitals (it's not clear whether they are keeping their office family practice) and among the remaining 63 doctors, 34 - more than half - said they planned to leave Quebec. Another seven said they would retire early, seven would move to the private system and three would stop working as family doctors. It's a small sample, Duong conceded, but the study is nonetheless alarming.

We are worried that doctors will leave," Duong said, noting that every year, more doctors are opting out of the provincial insurance board (RAMQ), meaning they are no longer on the public payroll, though it's not clear whether they went to private practice or left Quebec. RAMQ representative Marc Lortie confirmed this week that 246 family physicians dropped out of RAMQ between May 2014 and May 2015, up from 204 the previous year and 187 in 2012-2013.

In the wake of Monday's announcement to put offBill 20's sanctions, many doctors remain skeptical of Barrette's 85-per-cent target, Duong says, "because it's far too ambitious a goal." Whatever doctors' efforts, Duong says, the reform will fail if the government doesn't help them do their jobs - for example, by abolishing mandatory hospital work. Others suggest the crisis between the province's doctors and Quebec's health minister is over. Bill 20 was heavy-handed, they argue, but if it leads to doctors taking on more patients it will have been a successful negotiating tool. Dr. Yoanna Skrobik, a critical care researcher and adjunct professor at McGill University's department of medicine, is among those who wholeheartedly support the Barrette reform.

It's the most dramatic change in the history of Quebec's health system, and the best thing that's ever happened to patients," said Skrobik, who worked side by side with Barrette at Maisonneuve-Rosemont Hospital in the early 2000s, when Barrette was chief of radiology and she was an intensivecare physician. She said that if 85 per cent of Quebecers have a family doctor, the quality of health care in the province will be much improved. Doctors may be offended by Barrette's manner, and by what they see as an attack on their autonomy, Skrobik said, "but it's also true that he puts patient care in the forefront."

But Saoud also has priorities. She earned her first medical degree in Haiti, then had to obtain it again after emigrating to Montreal. There's a saying among those who work in the ER, she said: "We know when we go in, but we don't know when we will leave." Saoud, who won the Nadine St-Pierre Award for her research as a resident in family medicine in 2009, still loves being a doctor. "It can be frustrating, but it's really gratifying work. Helping someone is really the cherry on the sundae. But my priority is not that." She would rather not force the children to uproot, but she's skeptical doctors can meet the demands of the health reform. And possible sanctions in two years could force her to to make a tough choice.

"My male colleagues don't have that issue. The bill is discriminatory. I'm just asking for the right to be a mother and not simply a doctor." With her permit application process in motion, Saoud says she will go wherever her licence takes her. cfidelman@montrealgazette.com twitter.com/HealthIssues

Medical students from four major Quebec universities demonstrate against Bill 20 in March near the legislature in Quebec City. • VINCENZO D'ALTO, MONTREAL GAZETTE / Dr. Fanny Hersson-Edery, left, at a diabetes clinic she runs with nurse Jen Reoch. Hersson has a full schedule, from research to teaching and seeing patients.

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

The doctors' campaign has, however, prompted me to wonder how it is that paying doctors more will function to alleviate conditions of overwork?

Also concerning is that the doctors' recent efforts to link declining levels of government investment in health care come in the wake of both long-standing and ongoing efforts to standardize, regulate and privatize care in the sector. More than this, through their organization, the Ontario Medical Association (OMA), physicians have long stood silently by and watched as other front-line workers have been forced to battle against the Dalton McGuinty and Wynne governments' efforts to freeze wages, cut hospital funding and otherwise undermine the working conditions of health-care workers, from cleaners to tradespeople to registered practical nurses and personal support workers.

To put matters into perspective, over the past five years, government spending on doctors has increased - in real terms - by an average of 2.5 per cent a year. Over the same period, government spending on other health-care staff has declined by an annual average of -0.5 per cent. In other words, whereas doctors have seen a 29 per cent increase to their pay over the past seven years, other health-care staff have seen their wages decline in real terms.

Of course, declining wages are not necessarily reflective of working conditions. In that regard, it is notable that Ontario hospitals now receive less funding per capita than hospitals in every other Canadian province. As a result, Ontario hospitals - often with the support of doctors and their representative associations - have worked to find "efficiencies" in ways that have frequently increased the workload of front-line staff, and thereby undermine the conditions these workers face and the quality of care they are able to provide patients.

A visit to any Ontario hospital will make clear that it's not just doctors who have been going above and beyond. Rather, workers throughout the hospital have been stretching, often under increasingly difficult circumstances, to provide excellent care with far fewer resources than are required. And like Ontario's doctors, they are failing; our hospitals are not as clean as they need to be in order to prevent the spread of hospital acquired infections, readmission rates are climbing and too many patients are forced to fend for themselves at home.

Ontario's doctors have nonetheless continued to push for the province to open more private surgery and procedures clinics, even as those clinics leach badly needed resources from our hospitals and undermine care in ways that have been well documented in jurisdictions like the United Kingdom.

Government-sponsored and doctor-supported programs that have aimed to increase the efficiency of the province's health-care system through, for example, jargon-laced policies like "continuous quality improvement" or the "health-based allocation model" have actually worked to undermine patient care. By ignoring the voices of front-line staff, many doctors and administrators have conspired to streamline and standardize care in ways that cut off key lines of communication and create a series of very predictable but nonetheless "unexpected consequences" that undermine patient care and frequently fail to generate the promised level of savings.

Nonetheless the OMA's recent efforts, like those of doctors throughout the province are both laudable and bang-on: there is a crisis in health care in Ontario, and the cuts that the Wynne government has imposed are having a serious and deleterious impact.

Those cuts, however, have hardly been focused on doctors' salaries, but have instead focused on other health-care workers and on hospitals. Ultimately, working conditions, wages and the quality of patient care have long been sacrificed at the altar of efficiency and austerity.

What the OMA should consider is the degree to which Ontario's doctors are now victim to the cold and careless logics of efficiency, standardization and privatization, which they both helped author and supported.

Until Ontario's doctors and the OMA find ways to bridge the divide that they have helped to open between themselves and other health-care workers, any improvement to their wages will not lead to long-term and sustainable improvements in our health system and the quality of care we provide patients together.

Michael Hurley is president of the Ontario Council of Hospital Unions (OCHU), the hospital division of the Canadian Union of Public Employees (CUPE) in Ontario. CUPE represents more than 75,000 health care staff provincewide.

Doctors are campaigning against a pay cut imposed by Kathleen Wynne's government, but Michael Hurley writes that they have supported efficiencies and standardizations in other parts of the health-care system.Sean Kilpatrick, Canadian Press file photo

Much of the rhetoric thrown around today in scuffles between governments and physicians might ring a bell for students of medical history. More than 50 years ago, doctors were also accused of being too stubborn to accept changes to pay structure, and a provincial government was also charged with putting fiscal concerns before patient needs. Of course, if that old saying holds any merit — “Those who cannot remember the past are condemned to repeat it” — perhaps a refresher is in order. There seems, after all, to be a little bit of history repeating itself.

The origin of conflict between provincial governments and physicians can be summed up in one word: medicare. It therefore dates back to midnight of July 1, 1962, when the Saskatchewan Medical Care Insurance Act passed into law, introducing the first universal, government-run, single-payer health system to North America. All of one minute later, most of Saskatchewan’s doctors went on strike.

tually, to be precise, the fighting between the government and doctors in Saskatchewan began a couple of years earlier, during the 1960 provincial election. Premier Tommy Douglas had made universal health care the main peg of his re-election campaign. The College of Physicians and Surgeons of Saskatchewan fiercely opposed the idea, contending that government interference in medicine would do far more harm than good.

A public battle ensued, pitting doctors against politicians. Debates were held, pamphlets were circulated, pledges were signed. Did the whole affair stay civil and free of propaganda? Well, you could say that. But only if you enjoy being wrong.

Let’s start with some of the literature circulated by opponents of medicare. One pamphlet, Political Medicine is Bad Medicine, was chockablock with scary warnings and seasoned with a liberal sprinkling of words in all-caps for emphasis. Red Tape! Skyrocketing costs! Inferior care! The premier’s plan “proposes a PERMANENT INFLEXIBLE GOVERNMENT SCHEME at a high cost” that would subject medicine “to POLITICAL considerations bearing no relation to your NEEDS.”

Then there was the infamous flyer — later used by Premier Douglas to shame his opponents, according to Saturday Night magazine — that suggested many doctors would flee the province if the medicare bill passed. “They’ll have to fill up the profession with the garbage of Europe,” read one excerpt, a quote from an anonymous doctor taken from the Toronto Telegram. “Some of the European doctors who come out here are so bad we wonder if they ever practised medicine.”

Later, some in the anti-medicare camp acknowledged that mistakes were made, passion had trumped reason, and the medical profession had suffered for engaging in political mudslinging. “Many doctors concede privately that they went too far, that the campaign lost them prestige in their communities,” reported Saturday Night magazine.

Of course, the premier was no stranger to rhetoric himself. In fact, according to some political commenters of the time, he was a master of the form. He accused the province’s physicians of using “abominable” and “despicable” tactics and pedalling “scurrilous trash.”

In the end, Douglas and his party, the Co-operative Commonwealth Federation, won the election and pushed ahead with their health system plan. The doctors and government set aside their differences and all lived happily ever after. Yeah, right.

Medicare was coming to Saskatchewan — that battle was over — but physicians still weren’t cooperating with the government. They focused their efforts on changing sections of the proposed medicare act, specifically those that granted the government almost unlimited power to control the practice of medicine.

There was no provision for negotiation. The doctors would simply have to do what the government told them to do, and be paid what the government said they would be paid,” Dr. Marc Baltzan (1929–2005), a Saskatoon nephrologist and former president of the Canadian Medical Association, wrote in a 1984 article in Canadian Family Physician entitled, “Doctor/Government Fee Negotiations in Canada.”

After the act became law, unchanged, the province’s physicians closed their offices, though they still provided emergency services in hospitals. The standoff lasted 23 days, ending only after both sides compromised and signed the Saskatoon Agreement. The deal amended the act to ensure doctors would maintain their independence and could, if they wanted, opt out of medicare and bill patients directly.

The deal was brokered by Lord Stephen Taylor, a British doctor and politician who helped implement the National Health Service in the United Kingdom. Later, reflecting on his Saskatchewan adventure, Taylor wrote that much of the animosity between the two parties arose because they did not understand each other at all. The government did not anticipate how much their plan would threaten the autonomy of a proud profession. Physicians “could not believe that the government was composed of honest and responsible people.”

Taylor, a man of both medicine and government, chose to take a dispassionate view of the conflict. “I see honest men on both sides, well motivated but mystified by the actions of their opponents.”

Decades later, debate over another act — the Canada Health Act, federal legislation adopted in 1984 — again showed just how differently government and physicians can view a change to how doctors are paid. This time, the government was putting an end to extra billing by physicians. But according to Baltzan, as mentioned in his Canada Family Physician article cited above, this was merely a “political euphemism” for banning a patient’s right to be reimbursed by the government when billed directly by a doctor.

In his lament over the passing of the “deceitful bill,” Baltzan suggested that it was important to revisit the original fight over medicare in Saskatchewan because “it shows that there is nothing new under the sun: it contains all the elements of physician–government confrontation that have been replayed again and again during the Canada Health Act debate.”

Now, more than 30 years later, it might not be a stretch to say there is still nothing new under the sun regarding negotiations between doctors and government. When things go bad, as they have in Ontario, both sides sometimes resort to a little time-tested rhetoric. Then again, though some of the messages sound familiar, other elements of physician–government showdowns have changed since 1962. For one, doctors back then didn’t have Twitter accounts.

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

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

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

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

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

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

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

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

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

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

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

He will succeed Dr. Charles Webb, who takes over as president when Dr. Bill Cavers finishes his one-year term next week. Day's lawsuit is expected to last seven months and is tentatively scheduled in the B.C. Supreme Court at the end of the year. So Day could be leading Doctors of B.C. at the same time he's in court against the government.

Health Minister Terry Lake said that could present challenges. "I obviously want to have a positive relationship with the Doctors of B.C. I've obviously had that with the past presidents. It may pose, I guess potentially, some difficulties if we have an active legal case going forward whether I'm able to meet with the president-elect. "I don't know at this moment in time if this will provide any obstacles, but we'll seek advice on that." "But this is a democratic process, it's an organization of membership, of self advocacy, and we have a working relationship with the Doctors of B.C. and we have to obviously abide by their democratic process." Opposition health critic Judy Darcy said she's flabbergasted by the election.

"Brian Day has led the charge to try to bring more private forprofit health care to B.C. I know those are not values shared with the majority of B.C. doctors that I've spoken with, but it is very disturbing at a time when there's an active court case with government about bringing in more private health care in B.C. that this is the person leading the Doctors of B.C." "That's pretty serious if the minister can't meet with him because there's a legal case, but also Doctors of B.C. is involved in many, many joint committees across the province ... so I think it's very worrisome ... and I'm very concerned about what it means for health care in B.C." Darcy said patients end up in the private system out of frustration and she thinks government should do more to improve access to publicly funded care.

But Day said he expects his trial will be over by the time he's president because lawyers for both sides have been trying to scale it back by reducing the number of witnesses testifying. Day's lawsuit contends patients have a constitutional right to pay for private care if their health is suffering by waiting too long for care in the public health system. Under current laws, private clinics are not supposed to collect money from patients if the treatment is an insured service in the public system.

As to Darcy's concerns, Day said: "Everyone like that is against using the private system until you, or a family member or friend, needs it. When it becomes a personal matter, they may want and need to access care in the private sector." Referring to a front-page story in The Vancouver Sun Tuesday about the projected explosion in cancer cases due to population aging and growth, he said: "That's the sort of thing we need to be spending public health dollars on, not skiers at Whistler who harm their limbs and want quick surgical repairs."

Cavers said, in an interview, he couldn't comment on whether Day's simultaneous lawsuit and presidency could present conflicts or potentially awkward interactions between the government and Doctors of B.C. "I can tell you that when you are president, you are representing the interests of all doctors. It's not about your personal agenda. And if anyone has a reason to recuse themselves from board discussions, then they do that. Because sometimes interests do collide."

Cavers, a Victoria family doctor, said the organization is constantly interacting with the Ministry of Health on a multitude of issues involving the health system. But most often, he said, the meetings are between government staff and Doctors of B.C. staff. Cavers recalled having a halfdozen direct encounters with the health minister in the past year. Ruddiman declined to comment.

Dr. Lloyd Oppel, an emergency medicine physician at the University of B.C. Hospital who was third in the balloting, said he has no idea if Day's presidency will "present lots of hiccups," nor if the trial will be a distraction from Doctors of B.C. work. "Brian (Day) appeals to doctors who like his gutsy style, the fact he's not afraid to fight the good fight. They see him as a beacon of hope for change. So I knew when he entered the race that he'd have a big effect," Oppel said. Sun health issues reporter pfayerman@vancouversun.com Follow me on Twitter: @MedicineMatters Read more about Brian Day on my blog: vancouversun.com/medicinematters © 2015 Postmedia Network Inc. All rights reserved. Illustration: • Steve Bosch, PNG Files / Dr. Brian Day will become president of Doctors of B.C. in 2016-17.

Just now in Ontario this arrangement would appear to have hit a wall. Having negotiated a four-year deal offering average annual fee increases of 2.5 per cent, the Ontario Medical Association executive was dismayed to find it rejected by nearly two-thirds of its members, who complain it does not make up for cuts in fees imposed last year. How things should have broken down to this extent need not detain us here. But it does perhaps point to the need to find another way.

Because doctors' fees, as such, are not the issue. To be sure, they are part of the puzzle: at $11.5 billion annually, they are roughly one-fifth of Ontario's health-care budget. But all the hard bargaining in the world isn't going to rescue Canada's health-care system from the fiscal cliff to which it is headed. Much more important than doctors' fees are doctors' decisions, as the gatekeepers dictating how resources are allocated within the system: how many tests are ordered, what procedures are done, and so on.

The problem is that decisions about treatment are too often divorced from decisions about budgets. Governments set a budget constraint at the macro level, which filters down through the various regional health authorities and local health networks the provinces have seen fit to establish. But doctors typically do not: they make whatever they can bill. And the incentives of feefor-service are to perform as many surgeries and other treatments as they can. Absent changes in those incentives, simply capping fees isn't going to change much.

You can see why doctors felt the need to organize. Governments had set themselves up as sole purchasers of medical services. The idea was supposed to be that they could exploit that monopoly power to drive down costs. But it didn't quite work out that way: politicians in need of re-election, it seems, do not make terribly tough negotiators (who knew?). It was always easier to pass the problem on to the next government, or the next generation - or, as federal governments got in on the act, Ottawa. In consequence, health-care spending skyrocketed through much of the 1970s and 1980s.

Traditionally, doctors have been paid per service, while hospitals have been funded on a block grant basis. The key to reform is to turn this around: giving groups of doctors a fixed amount per patient, with which to purchase services from hospitals, clinics and other providers, that is on a per-treatment basis. Paying doctors a lump sum localizes the budget constraint, forcing doctors to take account of costs in decisions on treatment; paying hospitals per service makes it possible for lower-cost competitors to undercut them.

Even in the more recent wave of cuts following the last recession, these have been largely untouched. As documented in a new study by the C. D. Howe Institute

("Hold the Applause: Why Provincial Restraint on Healthcare Spending Might Not Last"), governments have largely resorted to the familiar public-sector strategy of starving the capital account to feed the operating account: while capital spending has been sharply curtailed, physicians' fees have not.

This is not sustainable in the long run - as new doctors enter the profession, and most of all, as the population ages. As it is, provinces are now spending more than 40 per cent of their budgets on health care; by 2030, a recent Fraser Institute paper projects the number will have risen to nearly 50 per cent. Yet wait times continue to mount: at more than 18 weeks, on average, from GP referral to treatment, they are nearly twice what they were 20 years ago.

Clearly the answer does not lie in more money, least of all more federal money: for every additional dollar in federal transfers the Howe study's authors find that provincial health spending increases by 36 cents. But neither is the answer ever stricter doses of austerity - any more than one would improve a car's mileage by putting less gas in the tank. Rather, what's needed is systemic reform, altering the way that public funds flow through the system, and how the different players within it are remunerated.

Only with the onset of the early 1990s recession, and particularly the sharp cut in federal transfers as Ottawa tried to stabilize its finances, was there the first serious effort at retrenchment. But as the fiscal crisis eased, and particularly after the 2004 health-care accord, with its massive 10-year increase in federal transfers, whatever impetus for reform there might have been dissipated. Rather than "buying change," most of the new money went to increases in provider compensation.

In sum, rather than doctors and governments negotiating with each other at one gigantic bargaining table, what we need are lots of little bargaining tables, at which providers can haggle with each other.

Online balloting has opened and will continue until May 15. While Day and Larsen Soles are both repeat contenders, they are distinctly different candidates who will appeal to different segments of the association's 12,000 members.

As an orthopedic surgeon, Day should draw more votes from specialists who have long felt the organization is too loaded with primary care doctors. Indeed, the current board of five doesn't include a single specialist and such doctors have long felt that has disadvantaged them when it comes to negotiations over fees with government. Family doctors have made impressive gains in the past two contracts while specialists, such as fee-for-service anesthesiologists, have complained bitterly about their fees and work terms. If Larsen Soles wins, she would become the fourth consecutive family doctor to be president and the second consecutive rural doctor; Ruddiman, the presidentelect, is from Oliver. She said in an interview she expects doctors will naturally want to mull those questions over.

"The thing is, people who choose rural medicine are those who are attracted to challenges and change and that's who doctors would be getting if they elect me. "Day, a private medicine pioneer, is hardly a stranger to challenge and change himself. Evidence of that is his seven-year-old lawsuit against the provincial government over whether private surgery clinics can bill patients for publicly insured services normally done in hospitals, usually after waiting long periods. Day said the litigation should not be a factor in the campaign, as it was last year. The oft-deferred sixmonth trial was supposed to begin in June but it has now been delayed to the fall. Day said provincial government lawyers recently asked for another deferral because they need yet more time to prepare. Providing the trial does start in September and lasts six months, as expected, if Day won the presidency, he'd be assuming the helm about four months after the trial ends. But regardless of which side in the trial wins, appeals all the way to the Supreme Court of Canada are expected in the landmark case that could reshape the health care system.

Day said only about 60,000 B.C. residents pay out of their own pockets to use 60 or so private surgery clinics. "I'm not saying we should privatize the health care system," he said, but he believes in a hybrid system in which private centres are used far more, as Saskatchewan is doing with its large scale contracting out of cases in which patients are waiting too long for care in hospitals. "Saskatchewan, the birthplace of socialized medicine, has taken a more pragmatic, less ideological approach, and it seems to be working. They are empowering patients to get their treatment in other places (like private surgery and radiology centres)." Larsen Soles said she's interested in the innovations in Saskatchewan but worries that a burgeoning private sector will draw health professionals away from the public sector. Sun health issues reporter pfayerman@postmedia.com twitter: @MedicineMatters

He wants the OMA to return to the negotiating table and discuss lowering some of the 7,300 fees on the physicians’ pay schedule. He said the province has made no less than 80 offers since talks broke down two years ago — close to one a week — to no avail. If they don’t, he said he’s prepared to make another unilateral cut (even though the cuts imposed in 2015 have already sparked the second Charter challenge from the OMA this decade). “If necessary we will be forced to make those changes,” he said. Hoskins doesn’t want to cut back on all doctors’ pay, but create a more equal system that doesn’t go over budget every single years, as has historically been the case.

“The top biller, an ophthalmologist, billed more than $6.6 million last year. The top diagnostic radiologist billed more than $5.1 million and the top anesthesiologist billed more than $3.8 million,” a government fact-sheet states. That’s far above the average doctor’s gross payment of $368,000 a year. And though the OMA argues that often doesn’t account for overhead and staffing costs, the province also subsidizes pay in many indirect and direct ways, including allowing doctors to incorporate, which reduces tax and liability burdens. Ontario, unlike many provinces, covers 80 per cent of doctors’ liability insurance. Hoskins said the ministry even sometimes covers hardware costs like computers.

Hoskins says his goal is to make things more equal and better distribute the money going to certain specialists whose work has gotten easier. MRIs and CT scans used to take an hour, now they take 20 minutes. Same with cataract surgery — that’s why diagnostic radiologists and eye surgeons are so disproportionally represented on the list.

It may pose, I guess, potentially, some difficulties if we have an active legal case going forward whether I'm able to meet with the president-elect of the Doctors of B.C. I'll have to obviously seek [legal] opinion about that." Darcy questioned why the province's doctors would choose a champion of private medicine to represent their concerns to government. "Brian Day has led the charge to try and bring more private, for-profit health care to British Columbia," she said. "I know those are not values shared with the majority of B.C. doctors that I've spoken with."

Darcy said many doctors end up referring people to the private system, not because they believe in it but out of frustration. "We need to hear those voices loud and clear saying we need to be investing in innovation and improving wait lists in the public system. And that's the answer rather than moving to a private system." The current president, Victoria family physician Dr. Bill Cavers, will step down on June 6, to be replaced by Dr. Charles Webb until Day begins his term.

Cavers said the president's job is to represent the interests of all doctors. "It's not about your personal agenda. And if anyone has a reason to recuse themselves from board discussions, then they do that. Because sometimes interests do collide."

While the association does not support two-tier health care, Carvers said there is room for private care clinics to help relieve pressure on the public system, by providing elective day procedures, for example. "We believe the patient should get timely access to care and if they can't, then the government and/or health authority should provide some public funds so they can get access to care as a backstop, as a safety valve," Cavers said.

A total of 2,176 votes were cast Tuesday. Day was elected with 946 votes, while Dr. Alan Ruddiman received 945 votes. Dr. Lloyd Oppel was a third with 285 votes. ceharnett@timescolonist.com

Dr. Brian Day is the 2015-16 president- elect of Doctors of B.C. He will assume the position in June 2016.

OMA President Dr. Mike Toth says the province owes doctors a “fair, reasonable negotiation done in good faith.” This ought to include an impartial, binding process for resolving an impasse between the parties, he adds. “There’s a power imbalance if the government can go through a series of negotiations and still have the right to unilateral action without any recourse.” OMA wants negotiations to go through a form of mediation–arbitration that would give a neutral third party the power to issue a binding decision in cases where the province and doctors can’t agree. Failing that, “we’re also looking at our legal options,” Toth says.

Eight of the provinces and territories currently have a binding dispute resolution mechanism, although they may not often use it, he explains. The Canadian Medical Association also gave its support to OMA’s request for mediation-arbitration at its August General Council meeting in Halifax. Normally, the national doctors’ association doesn’t get involved in provincial pay disputes, but in this case there could be national implications. According to Steven Barrett, a constitutional lawyer with Sack Goldblatt Mitchell in Toronto, if physicians feel there isn’t a fair process for determining their compensation within Medicare, they may be more willing to advocate for their right to practise and bill outside the public system.

Negotiations between doctors and the Ontario government have stalled since January, after the OMA rejected a proposal to cap growth in the physician services budget at 1.25%. Ontario ended up imposing the cap anyway, despite the fact that its own estimates peg the current rate of growth in demand for medical services at 2.7%. This means doctors won’t be reimbursed if patient demand for their services exceeds the limits of the public purse.

The province hasn’t given the OMA current data on health care use, but it’s “probably a safe bet to say it’s running over budget,” says Toth. Stephen Skyvington, a former manager of government relations for the OMA, recently reported that Ontario is withholding the data to prevent doctors from slowing their work in protest of pending claw backs.

David Jensen, a spokesperson for the Ministry of Health and Long-term Care, denies that this is the case. “The ministry continues to share data with the OMA per our data sharing agreement.” Jensen neither confirmed nor denied reports that spending on physician services is running 10%–20% over budget. In theory, doctors can protest pay cuts through work slowdowns and strikes, but it’s often not politically or ethically feasible because of the essential nature of their services. Nevertheless, “we’re obviously looking at all of our options right now,” says Toth.

The OMA successfully brought Ontario back to the bargaining table in 2012 by launching a constitutional challenge to unilateral cuts imposed by the government of the day. Ultimately the parties resolved their differences out of court, producing fee agreements for fiscal years 2012/13 and 2013/14. At the same time, the OMA agreed to the current negotiating framework, in which the government may act unilaterally if an impasse remains after receiving help from a facilitator and advice from a conciliator. “During the latest round of negotiations, this process was followed,” explains Jensen, for the ministry. A binding dispute resolution process “wasn’t on the table” in 2012, says Toth. “We couldn’t get to it at that time but we think we can get to it now.”

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.”

Speaking before his appearance at the Health Select Committee, he conceded that urgent care services were “getting closer to the cliff edge,” with A&E admission increasing by 51 per cent over the past 10 years

The letter from the 20 A&E leaders talks of the “institutional exhaustion” of the nursing, medical and even clerical staff who being pushed ever harder by the growing volume of work with little outside support

. It also describes how doctors and nurses are being forced to work in what are verging on dangerous environments

They further warn that overcrowding is likely to lead to more deaths in hospitals and reveal that standards of care are deteriorating as serious clinical incidents and delays are rising.

The letter states: “The aforementioned issues have led to us routinely substituting quality care with merely safe care; while this is not acceptable to us, what is entirely unacceptable is the delivery of unsafe care; but this is now the prospect we find ourselves facing on too frequent a basis

Recent developments such as the introduction of 111 and financial penalties for holding ambulance crews in ED are touted as solutions to the crisis: however we as ED physicians recognise that these measures will actually make the problem worse instead of better, and evidence is already emerging to support our opinions.

Furthermore, we firmly believe and strongly recommend that ED leads should be intimately involved with and consulted on the commissioning of Emergency services in the region, as well as other related emergency care changes-such as 111.

There is toxic ED overcrowding, the likes of which we have never seen before.

They were angry that victims like them had not been personally informed about the hearings (good point). They were upset that previous patient complaints of sexual assault about Doodnaught had not been investigated years before they were assaulted (also, good point). And they were furious that doctors who sexually assault their patients are treated differently than bakers who sexually assault their customers, or city staff who sexually assault their colleagues, or anyone else for that matter (I hear you sisters!). "Take it out of the hands of a group of doctors and contact the police like you would do for any other profession in the real world. Medical staff are not gods. They are being treated like gods," said Eli Brooks, who was assaulted by Doodnaught while undergoing liposuction in 2009. "What has happened over and over will continue to happen until they are made criminally responsible." Brooks had the publication ban on her lifted, so I can tell you her name. She believes naming herself as a sexual assault victim will help weaken the crime's stigma. I applaud her for that.

I can't tell you the second victim's name. During the preliminary hearings of Doodnaught's trial, she was known simply as D.S. Her case was not, in the end, included among the 21 charges, so has not been proven in court. She tells the story that was the trial's refrain: Doodnaught was the anesthesiologist during her surgery at North York General Hospital in 2009. A screen was raised at her midsection, preventing her from seeing the doctors and nurses working below, but also preventing them from seeing Doodnaught at her head. She was barely conscious when she protested him touching her breasts, she said. She awoke to the sight of his penis, she said.

During the trial, it emerged that no fewer than four of Doonaught's colleagues at North York General Hospital had received complaints from patients who said Doodnaught had sexually assaulted them while they were in semi-conscious states. The complaints started in 2006 - four years before Doodnaught was charged. The four were surgeons and anesthesiologists. Not one had reported the complaints to anybody - the head of the hospital, the police, the college. North York General's then-chief of anesthesiology, Dr. Stephen Brown, testified that when police came calling about Doodnaught in 2008, he didn't tell them about two previous complaints by patients. Once police finally laid charges, he sent out an email to staff, entered as evidence, that stated: "We have to support George in any way we can during the investigation." (He said in court he had not meant for them to interfere with the police probe.)

"He didn't protect us," D.S. said. "Had he come forward, we might have saved many of us." She called on the task force to implement penalties for bystanders - doctors who hear about the sexual assault of patients by other doctors, but do nothing. Brooks went further: "Anyone who covers it up should be legally charged with aiding and abetting a crime." Later, the task force's ever-patient chair, Marilou McPhedran, informed the still-barren room that such a provision already exists. Under the Regulated Health Professions Act of Ontario, health professionals with "reasonable grounds ... to believe that another member of the same or a different college has sexually abused a patient" must file a complaint to their college registrar within 30 days - unless they think the accused will continue sexually abusing patients. Then there is "urgent need for intervention."

The penalty for failing to do this is "not more than" $25,000 the first time. The second, it goes up to "not more than $50,000." So, were those four doctors fined by the College of Physicians and Surgeons of Ontario, you might be wondering - particularly since they testified in criminal court about their failure to alert their college to patients' complaints about Doodnaught sexually assaulting them? No.

"The College has not commenced prosecutions ... in relation to a physician failing to make a mandatory report in this matter," CPSO spokesperson Prithi Yelaja wrote me in an email. In fact, in the history of the college, it has never prosecuted any physician for failing to make a mandatory report, she confirmed. Not once. See what I mean? The rules don't need to be changed, they simply have to be enforced by people who can be better trusted: the police. The task force hearings continue on May 8. Catherine Porter can be reached at cporter@thestar.ca.

Ontario's doctors are dedicated to protecting high-quality, patient-focused care. A large number of patients in Kitchener are joining Ontario's doctors in expressing concern with the provincial government's cuts to health care. The number of patients adding their voice is growing daily as more people learn about the almost seven per cent in cuts to the funding for all of the necessary care that physicians provide and the government's decision to arbitrarily cap that funding in a way that doesn't account for growth in the system.

Doctors and patients in both the community and hospitals are seeing the negative impact of the Ontario government's unilateral cuts to medical care, which include difficulties accessing a family doctor, growing waiting lists for specialists and surgical treatment, community clinics on the brink of closure and new medical graduates who are looking at leaving the province.

Ontario's population is growing and, with a greater number of people living longer, medical care will be needed more than ever. That is why doctors want to work with government to find solutions that make our health-care system sustainable and able to meet the needs of all patients in Ontario. In fact, Ontario's doctors have a history of helping government find the savings they need, while protecting access to patient care.

Michael Hurley's concerns about the health-care system should be directed squarely at the Ministry of Health and Long-Term Care, which has the responsibility of fully funding all aspects of the health-care system. The most recent figures show that the Ontario government spends less on health per person than 10 other provinces and territories in Canada.

Ontario's doctors are committed to advocating for patients and our focus will always be on ensuring that everyone in the province has access to high-quality care. Dr. Mike Toth President, Ontario Medical Association Toronto

Hoskins said he wants to follow through on Winkler's recommendation to create a task force to make recommendations for improving and funding physician services. "One of the things Winkler spoke to was putting together a team from the OMA and from the ministry and other stakeholders, to really, in a serious way for quite frankly the first time, look at the issue of physician compensation and the delivery of health services by physicians," Hoskins said. "(It would address) how they can and should be best compensated, how to create a sustainable way of doing that, how to frame it within the reforms that are taking place in the health-care system. There's a lot we can do together," he added.

The OMA has so far issued no public response. The organization's board of directors is gathering on Wednesday and plans to discuss the Hoskins' meeting. In an email update sent to doctors on Monday, OMA president Dr. Mike Toth said board members plan to discuss next steps, including possible legal action. The update hints that doctors may be preparing to take some sort of job action. Toth wrote that 200 physician leaders met on Sunday and held a "brainstorming exercise designed to test and confirm innovative and impactful actions that members might undertake in various clinical settings and geographic areas across the province."

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.

Ruddiman, who was recruited to Oliver from South Africa 18 years ago, said the issue comes down to educating young doctors about rural areas while they are still in school, as well as marketing communities to get the right fit. When he was thinking of coming to B.C. in 1991, for instance, Ruddiman said he was warned not to go anywhere with a "prince, a fort, a port or a saint" in its name. "Your towns were generally considered more remote and isolated and less desirable to work in," he said.

Yet many health care specialists are keen to work in communities with a population of 7,000 or more, especially if they are close to a ski hill, he added. Others touted their small communities as being safe and friendly for young families. "Our rural communities have great attributes to offer. You should work with health authorities to spread the word," Ruddiman said. "Port McNeill should be fully stocked with health practitioners, and it's not." Lake acknowledged the problem is rife across B.C., even in mid-sized cities like his riding of Kamloops, which could use another 30 family doctors. He said the province is working on boosting medical residencies to keep B.C. graduates in the province or lure them back from overseas. ksinoski@vancouversun.com Twitter:@ksinoski

The gestures stem not only from the country's growing diversity, but a generally more patient-focused system - and a recognition treating solely physical ailments is not always enough. "If we don't engage in the (cultural) discussion, we won't fully understand their health needs and they won't get met," says Marie Serdynska, who heads a pioneering project in the field, the Montreal Children's Hospital's socio-cultural consultation and interpretation services.

So ultimately they will get sicker and be a greater cost to the health-care system." But with the topic being featured at national pediatric and bioethics conferences recently, medical professionals are debating a difficult question: is there is a point at which catering to cultural preferences crosses a moral - or even legal - line? While a physician in the neonatal intensive care unit at Toronto's SickKids hospital, Dr. Jonathan Hellman was sometimes asked by fathers from "patriarchal" cultures not to discuss a child's condition with the mother unless the husband was also present.

Agreeing to such a request not only raises ethical and practical questions, he says, but might even violate Ontario's Health-Care Consent Act - unless the mother explicitly agreed to the arrangement. "It's challenging to the caregivers in that situation, when the mother is at the bedside and the father is able to visit only in the evenings," says Hellman. "And we believe that both equally have decision-making power, both should have information." Even hospitals that try to be sensitive to specific cultural groups, like Ontario's Hamilton Health Sciences Centre, with its aboriginal patient "navigator," can face vexing dilemmas. When two First Nations girls with leukemia decided to withdraw from chemotherapy at the facility and try native remedies, an emotional courtroom battle followed.

And it recently emerged that a Vancouver-area intensive-care unit was asked to keep a braindead patient on life support for days until he could be flown to his country of origin, the family's culture rejecting the concept of neurological death. Still, for every demanding request, there are dozens of positive incidents - even if they involve once-unheard-of accommodation, say ethicists, doctors and patient advocates.

Some Halifax hospitals have convinced the fire marshal to allow smudging, aboriginal purification rituals in which sweetgrass is burned. Sometimes, this means adjusting the smoke detector in a patient's room temporarily so it doesn't set off an alarm, says Christy Simpson, a bioethicist at Dalhousie University in Halifax. Randi Zlotnik Shaul, director of bioethics at SickKids, said she's aware of a request for a drumming circle in a neonatal intensive care unit, a normally very quiet environment. Steps were taken to comply with the proposal - and not interfere with other tiny patients - but the need for an open fire eventually made it impossible, she said.

Yet fulfilling such appeals, often made for dying patients, can be a question simply of innovation and compromise, like when someone asks that a patient's bed face Mecca, she says. "Some might respond very categorically, 'Nope, in this place all beds face the same way,' "she says. "Someone oriented another way might say, 'Yeah, they are all faced that way, but maybe if we got an extension cord, there is actually something we can do.' " Serdynska says she knows of hospitals providing "mementos" of births to new mothers whose cultures traditionally require them to bury their placenta. Dr. Tara Kiran, a Toronto family physician, was taken aback when she first encountered patients from Bangladesh and Pakistan at an inner-city clinic who insisted on fasting between sunrise and sunset during Ramadan, despite health issues like diabetes that normally require strict regulation of diet and medication.

Her patients, however, happily embraced what they saw as the experience's beneficial, spiritual benefits. "It was an interesting challenge to my assumptions," says Kiran. "My gut reaction was that fasting has negative impacts on health." In London, Ont., St. Joseph's Health Centre runs a special clinic during Ramadan to help the city's estimated 3,000 diabetic Muslims. Muslim needs, including heightened privacy for female hospital patients instead of the usual, unannounced arrival of staff at the bedside, were once given short shrift, says Khadija Haffajee, spokeswoman for the National Council of Canadian Muslims. But the system has generally made great strides, adds Haffajee, who has addressed classes of nursing students on her faith's practices. "It's about reasonable accommodation and understanding," she says. "When people are ill, you're dealing with very vulnerable people, so empathy goes a long way."

Accommodation can sometimes simply be a case of bridging the cultural divide, says Montreal's Serdynska. Medical teams at her hospital once saw Vietnamese patients with unexplained bruising and immediately suspected child abuse. Further inquiry revealed the marks were the result of "capping," or "coining," a traditional southeast Asian treatment that involves scraping a smooth edge across the body in the belief it releases unhealthy elements. Her service now has cultural interpreters who will talk to immigrant parents when, for instance, drug treatment is not working. Sometimes, it relates to the side effects and contraindications spelled out on unfamiliar packaging, she says. "For some cultures who do not generally take pharmaceutical medication, this is very frightening." The institutional, impersonal nature of a hospital alone makes it a daunting place for aboriginal people, especially if they attended residential schools, says Margo Greenwood, academic leader at the National Collaborating Centre for Aboriginal Health in Prince George, B.C. Hanging indigenous art, providing culturally appropriate prayer space and consulting local native communities all help alleviate that anxiety, as does being open to other forms of treatment.

You're dealing with two different systems of knowledge: one is what I learned when I went to university and one is what I learned in my community," she says. "People (are) saying ... 'I want the two to work together.' "But what are health-care providers to do when the request stemming from an ethnic or religious practice appears to breach their own ethical boundaries? Reports in 2013 of doctors in Quebec issuing virginity certificates earned a swift response from the province's medical regulatory body. Physicians must refuse to comply, insisted the College des Médecins, and explain such a service has nothing to do with health care. Less black-and-white, perhaps, is the patient asking for a doctor of a particular sex or, less commonly, of a specific race. On the surface, at least, the idea is a repudiation of fundamental human-rights principles, yet for some patients it could be a religious imperative or a fallout from past abuse.

Some hospitals say they will try as much as possible to provide a female doctor for Muslim women, for instance, when asked. In Montreal, about half the obstetrician-gynecologists are women, so supplying a female one is usually quite feasible, said Togas Tulandi, interim head of the McGill University medical school's obstetrics and gynecology department. More troublesome, say ethicists and physicians, are patients who insist they not be treated by a doctor or nurse of a certain race - typically Caucasians rejecting non-white workers in today's multi-hued medical workforce - or want one of their own colour. Ethicists at Toronto's University Health Network (UHN) published a nine-page paper on how to tackle "discriminatory" requests of this sort, suggesting the affected health-care worker should often have the final say.

"It's ugly, it's unfair," says Linda Wright, a bioethicist at UHN, of the potential impact on medical staff. "To ... have someone say you're not good enough because of the colour of your skin is offensive." How often Canadian hospitals have to deal with the dilemma is unclear. A 2010 U.S. study of emergency doctors, though, concluded the scenario is common, with hospitals frequently accommodating requests for race-specific practitioners. And that is not such a bad thing, argued U.S. law professor Kimani Paul-Emile in a provocative 2012 article. He cited evidence that having a "race-concordant" doctor can bring health benefits, especially for blacks and others who have historically faced prejudice. In the meantime, hospitals here are still more likely to encounter less-contentious culturally based issues, such as whether to loosen age-old restrictions on the number of well-wishers in a patient's room.

"In some cultures ... you have everybody there. You have all the aunts and all the uncles, and all the family members and friends," says Dalhousie's Simpson. "For me, that's been one of the really interesting changes. Why did we say it only had to be two? Why did we limit it so much? Because clearly there's value to having your loved ones around you."

Every March 1, starting in 2016, doctors will be closing their practices until the first of April — when the new fiscal year begins — in order to avoid the inevitable clawbacks that government will impose for exceeding their health-care allotment.

Surgeries will be cancelled or delayed, tests will not be run, and appointments with both family doctors and specialists will be harder to get in a timely fashion.

Even worse, can the day be far off when those over a certain age — say 70 or 75 — are denied expensive medical care, and/or other interventions and investigations, simply because there isn't enough money to go around?

Stephen Skyvington is the director of the Meighen Institute’s Centre for Healthcare Reform and Innovation, and former manager of government relations for the Ontario Medical Association. Follow him on Twitter