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Hurley is travelling throughout the province, to explain how over the last decade Ontario's acute hospital funding has been on the slide compared to other provinces. In 2005-06, Ontario was "in the ballpark," with per capita funding of $1,112 compared to $1,159 for the rest of Canada, Hurley said, citing figures from the Canadian Institute for Health Information. Ten years later, Ontario's funding was $1,396 compared to $1,750 for the rest of Canada. He said the numbers extrapolated for Windsor are conservative, taking into account only the City of Windsor's 211,000 population, even though Windsor Regional's patients come from all over the Windsor-Essex region (population 389,000) and beyond.

Hurley said while Ontario did increase its funding for hospitals during the last decade, it did not come close to accounting for inflation, population growth and the aging population. This year, hospitals received a one per cent increase, but their actual costs rose 4.5 per cent, he said. "So their budgets have been cut again." Windsor Regional declined to comment on Hurley's assertions. In a statement, Health Minister Eric Hoskins said his government is doing what citizens want - continuing to invest in a health-care system that "puts patients first," asserting that 94 per cent of Ontarians now have a family doctor, and that wait times for some procedures are among the shortest in the country.

This year, it's increasing health funding by $1 billion, a 2.1 per cent increase, and it's increasing funding to hospitals by $345 million this year. "In Windsor, (since 2003) we've increased funding for local hospitals by more than $126 million - an increase of almost 50 per cent," said Hoskins. He also said Ontario is investing additional millions into home care, community health centres and home-based hospice and palliative care, because people prefer to receive their health care at home instead of a hospital. Hurley said the province argues that while it has been actively downsizing the acute care system, at the same time it's increasing investments in home care and longterm care, to "pick up the slack." But he said Ontario is actually spending less on long-term care and home care than the rest of the provinces. He said Ontario's high readmission rates are a sign the system is suffering. "So we have fewer beds, there's tremendous pressure to get people out of those beds and send them home, and often when they're sent home they haven't been made well actually and they return to hospital for a more lengthy and expensive readmission." Hurley said his council is calling on the government to fund hospitals "at least" at a level that reflects their rising costs, to stop reducing the number of beds and staffing, and to increase access to the people who need it.

The people being hardest hit by this are elderly, he said, who often have lived a long time without serious health problems, until they're hit with a health crisis that lands them at a hospital doorstep. "First they queue up in an ER for hours, and if they're going to be admitted it's likely a stretcher in a hallway," he said. And once admitted, there's likely pressure to get them discharged before they're fully well, he added. "For the elderly in particular they feel the brunt because there's rationing going on, the beds are so scarce." bcross@postmedia.com

Michael Hurley, president of the Ontario Council of Hospital Unions, discussed health-care funding in the province Thursday during a news conference at the Royal Canadian Legion Branch 255.

Under this approach, hospitals begin to admit more patients and discharge them more quickly.More patients are treated for the same number of beds.

New models of funding healthcare that use shared incentives to motivate communication and safe transitions between providers are needed for today's complex patients.

Only a few types of patients are funded with the new 'Quality-Based Procedures' policy, with little cash to spare for buying additional volumes of care.

Traditional hospital-focused patient funding does a good job of buying more surgeries, but it doesn't do much to address the challenge of coordinating care across healthcare providers.

Elsewhere, countries that have used per-patient funding for years, like the U.S. and England, are now wondering if it's time to move on

Instead of pouring money, time and effort into upgrading our 8-track funding models to cassettes, we can learn from what others have done and skip a generation in payment reform.

By introducing per-patient funding approaches that also integrate payments across hospitals, physicians and community care providers, Ontario can begin to tackle the triple challenge of access, cost and quality rather than passing the buck from one healthcare sector to the other.

"Despite the major risk factor working against us, we've been able to increase our funding surplus to 115 per cent, and we remain fully funded," he told reporters Wednesday. "That's a very gratifying outcome, given what went on. A very major risk factor went against us this year, and it could have resulted in a very significant decline in our funded ratio." HOOPP, which invests pension money for 295,000 health-care workers and retirees, has not changed its contribution rates for members since 2004, while some other public sector pension plans have had large contribution increases. The fund also said it is restoring full inflation indexation to pension benefits for retirees because of its funding position. Inflation indexation was reduced to 75 per cent in 2002 when HOOPP had a deficit, but the fund now can afford to fully index-pension benefits to inflation in 2015, Mr. Keohane said.

The improvement will also be applied retroactively to 2002 for retired plan members, who will receive special payments to recoup any additional pension amounts they would have received if indexation had been at 100 per cent since 2002. HOOPP's 2014 investment returns have pushed its five-year compound return to 13.8 per cent, while its 10-year return has hit 10.27 per cent. Mr. Keohane said HOOPP is leading the world with its returns, posting the highest 10-year return of any pension fund monitored by global pension data firm CEM Benchmarking.

He said the plan's funding surplus is a regulatory calculation based on a five-year "smoothing" calculation allowed under accounting rules. If the fund's additional $7-billion reserve was applied immediately instead of being smoothed over time, HOOPP would be 130-per-cent funded. HOOPP IN 2014 $60.8-billion Assets at end of 2014, up from $51.6-billion in 2013 17.7 per cent Investment return earned in 2014, compared with 8.6 per cent in 2013 115 per cent Funding surplus at end of 2014, with assets equal to 115 per cent of estimated pension liability.

The main reason for these counter-intuitive reactions to increased demand is the way hospitals are funded. As in most of the rest of Canada, hospitals in Quebec currently receive their funding in the form of global budgets based essentially on the amounts they spent in the past. This kind of lump-sum funding leaves hospitals with a tough choice: Limit admissions or go over budget. There is no incentive for hospital administrators to innovate and become more efficient, since an innovation that reduced expenditures would lead to an equivalent decrease in the hospital's next budget. On the other hand, an innovation allowing wait times to be reduced and more patients to be treated entails increased pressure on the fixed budget.

Almost all other industrialized OECD countries fund their hospitals to a large extent based on services rendered. With such activitybased funding, hospitals receive a fixed payment for each medical procedure, adjusted to take into account a series of factors like geographic location and the severity of cases. The more patients a hospital treats, the more funding it receives. Generally speaking, in countries where activity-based funding is widely used, there is more competition between medical facilities and quicker access to care. Health Minister Gaétan Barrette has said that the Quebec government wants to adopt activity-based funding for medical facilities in the health network. This would make a lot more sense than demanding that MUHC doctors refer oncology and ER patients to other hospitals, as the Health Ministry is currently doing.

But getting rid of Quebec's anachronistic funding of its hospitals through global budgets, while a step in the right direction, should be accompanied by other, complementary measures such as mandatory quality reporting for hospitals. Giving patients and referring doctors access to the information they need in order to determine the best hospital for each case would allow for some healthy competition, leading to quality improvements throughout the system, as has happened in Germany in recent years.

If Brian Day's constitutional challenge now being considered by the British Columbia Supreme Court is successful, two other European measures could also come to Canada: allowing a market for private insurance to develop, and allowing doctors to practise both in the public sector and in the private sector.

International experience confirms that the presence of a mixed health care system is not incompatible with health care services that are accessible to all. Indeed, such measures could improve access to health care by encouraging entrepreneurship without undermining the principles of equality and universality that Canadians hold dear. Jasmin Guénette is vice-president of the Montreal Economic Institute.

But when it comes to pensions, that's not true. Ontario's big public-sector funds are the top of their class. While companies want 110 per cent of our effort, they've largely rewarded workers by abandoning the sort of pension plans that provide security and let people sleep easy in retirement. Some 76 per cent of private-sector employees don't have a pension of any kind. Of those who do have a pension, less than half have defined benefit plans. When you do the math, only about one in 10 people working in the private sector has a defined benefit plan. Such plans pay a monthly amount for life, putting the onus on companies to come up with the money. Corporate Canada doesn't like that idea and has been bailing out, moving to defined contribution (DC) plans where they can throw some money in the pot to match workers' contributions (if they're lucky) and then wash their hands. That leaves workers with all the risks and stress of investing and managing the money on retirement. These are skills most people don't have.

The public sector still believes that collective effort can give a better outcome. So, 86 per cent of workers for provincial and local governments - people such as firefighters and police, those at universities and colleges and workers in health care - are covered by pension plans, mostly the defined benefit kind. Pensions provide a broader social benefit beyond the cash in a pensioner's pocket. According to HOOPP, 7 per cent of all income in Ontario comes from defined benefit pensions, which pay out about $27 billion a year, money that supports the communities where people live. Keohane says 20 per cent of all income in Collingwood, for example, comes from pensions. He says it's a myth that taxpayers are footing the bill. In HOOPP's case, 80 cents of every dollar in the $61-billion fund come from investment returns.

There are several reasons why an individual can't hope to match the performance of a big fund with an RRSP. Big funds bring investing expertise and economies of scale to bear in a way that individuals cannot. It is precisely because they lack a "for-profit" motive that such funds can keep fees low and returns high. Think of how many fees you might pay along the way when investing - for advisers, buying and selling stocks and funds, trailer fees, management expense ratios, fees you can't see. Big funds are also "patient money," which means they can weather market ups and downs and not be forced to sell. The next "quarter" for HOOPP is 25 years, not three months.

OMERS, Ontario's largest pension plan, also reported strong results last week. OMERS manages the assets of 450,000 municipal employees and earned a 10-per-cent investment return in 2014. The fund stumbled during the financial collapse of 2008 and has been working its way out of a hole. In 2014, OMERS made more progress, increasing its funding level to 91 cents per dollar needed, up from 88 cents a year ago. There's still a long way to go to catch HOOPP, but it's going the right way. Our frayed faith and anger with our public institutions is well-deserved, and that general discontent spills over to public pension envy. But a better target would be private-sector employers who have been abandoning their workers because it's expedient, leaving them to make financial decisions in retirement they are often ill-equipped to make.

Adam Mayers writes about investing and personal finance. Reach him at amayers@thestar.ca. What is HOOPP? Healthcare of Ontario Pension Plan is the eighth-largest pension fund in Canada. It cover 295,000 people who work at hospitals, community care facilities, labs, clinics and addiction centres. Nurses are its largest membership group. Fifty of its pensioners are over 100 years old. HOOPP earned a 17.71-per-cent return in 2014, adding $9.1 billion to its assets, which now stand at $60.8 billion. Its average annual return over the past 10 years is 10.27 per cent. Source: HOOPP

Federal Health Minister Jane Philpott, who co-chaired Tuesday's talks, tried to steer the conversation away from money and toward system improvement, innovation and accountability. She repeatedly pointed out that Canada spends more on health care than many other developed countries that have superior health systems. She expressed disappointment that planned system improvements that Ottawa funded in the 2004 health accord did not materialize. Philpott indicated that she wants new funds to be targeted to such areas as mental health and system innovation. She also reiterated an earlier commitment to provide $3 billion for home care, including palliative care.

I have made it clear to them that we would love, for instance, to invest in innovation," she said. "I want to know how they want to use those investments in innovation. I have told them that I am very interested in mental-health care." Hoskins said his provincial and federal counterparts are on board with that, but that they need a boost in the annual increase in health funding as well just to maintain the status quo. "You can transform and we have to transform, but you have to do that in a way which respects and understands that you need to sustain the existing system," he said. Hoskins cited a Conference Board of Canada report that found that a spending increase of 4.4 per cent is needed "just to keep the lights on, just to keep the existing services working" because of pressures from a growing and aging population. Quebec Health Minister Gaétan Barrette said Ottawa's current plans for health spending will amount to $60 billion less over the next decade for the provinces and territories.

"It says to Canadians, 'We will not provide up to the level of $60 billion.' That's what's at stake," he said. The 2004 health accord - which includes annual funding hikes of 6 per cent - expires next spring. The former Conservative government decided unilaterally that annual health spending will increase at a lower rate of 3 per cent after that. The provincial and territorial ministers are hoping Prime Minister Justin Trudeau will reconsider that when the first ministers meet later this year. Hoskins said a 50-per-cent cut in the annual funding increase will translate to $1 billion less for the provinces and territories next year. Ontario alone stands to lose $400 million. Philpott apologized about confusion over comments she made earlier on accountability for funds. Some provincial and territorial ministers expressed anger over an insinuation that health transfers were not being spent on health. Philpott said that was not what she meant.

I apologize if people misunderstood," she said. "There is certainly no intention to make accusations." Philpott said the Canada Health Transfer, which stands at $36 billion, will increase by about $19 billion over the next five years. "It's really important for Canadians to know that we are going to continue to contribute to the Canada Heath Transfer," the federal minister said. Philpott said that over the last five years, $9 of every new $10 spent on health in Canada came from the Canada Health Transfer. "We are contributing he largest part to spending." In addition to the Canada Health Transfer, extra funds will be provided for targeted priorities with strings attached to ensure transformation goals are met, she said.

This is Canadians' money ... We want to find a way that we can work together so that as we agree to make new investments, that we have already got a sense of plan," Philpott said. In elaborating on why Ottawa should fund new, more efficient ways of providing health care while at the same time provide sufficient funding for the current health system, Hoskins offered the example of dialysis for kidney failure. The ministers discussed how it would make more sense to monitor blood pressure to prevent kidney failure and thereby lessen the need for dialysis, he noted. "That's great and we are all working toward that end, but you still have to provide dialysis today because that individual who needs it will be dead in three weeks without it," Hoskins said.

thanks to predictable and escalating funding over the first seven years of the plan

however, there are, unfortunately, pockets of inattention and/or mediocrity as well

Six areas, in fact, were identified by CHA

funding matters; health human resources; pharmacare; wellness, identified as health promotion and illness and disease prevention; continuing care; and leadership at the political, governance and executive levels

The focus of this 10-year plan has been on access. CHA would posit that it is at this juncture, the focus must be on quality and accountability.

safety, effectiveness, efficiency, appropriateness

Canada does an excellent job in providing world-class acute care services, and we should; hospitals and physicians have been the core of our systems for decades. Now is the time to ensure sufficient resources are allocated to other elements of the continuum, including wellness and continuing care.

Home care is one readily available yet underused avenue for delivering health promotion and illness prevention initiatives and programs.

four critically important themes: dignity and respect, support for caregivers, funding and health human resources, and quality of care

Nadine Henningsen, Executive Director, Canadian Home Care Association

Today, an estimated 1.8 million Canadians receive publicly funded home care services annually, at an estimated cost of $5.8 billion. This actually only equates to about 4.3 per cent of our total public health care funding.

There are a number of initiatives within the home care sector that need to be addressed. Establishing a set of harmonized principles across Canada, accelerating the adoption of technology, optimizing health human resources, and integrated service delivery models all merit comment.

great good has come from the 10-year plan

Unfortunately, there were two unintended negative consequences

One was a reduction in chronic care services for the elderly and

a shift in the burden of costs for drugs and medical supplies to individual and families. This was due to early discharge and the fact that often a number of provinces do not cover the drugs and supplies under their publicly funded program.

Stakeholders across Canada generally agreed that the end-of-life expectations within the plan were largely met

How do we go from having a terrific acute care system to having maybe a slightly smaller acute care system but obviously look toward a chronic care system?

Across Canada, an estimated 30 to 50 per cent of ALC patients could and should benefit from home care services and be discharged from the hospital.

Second, adopt a Canadian caregiver strategy.

Third, support accountability and evidence-informed decision making.

The return on investment for every dollar for home care is exponentially enhanced by the in-kind contribution of family caregivers.

Sharon Baxter, Executive Director, Canadian Hospice Palliative Care Association

June 2004

a status report on hospice, palliative and end-of-life care in Canada

Dying for Care

inconsistent access to hospice palliative care services generally and also to respite care services; access to non-prescribed therapies, as well as prescription drug coverage

terminated by the federal government in March of 2008

the Canadian Strategy on Palliative and End-of-Life Care

Canadian Hospice Palliative Care Association and the Canadian Home Care Association embarked on what we called the Gold Standards Project

In 2008, the Quality End-of-Life Care Coalition released a progress report

progress was made in 2008, from the 2004 accord

palliative pharmaceutical plan

Canadians should have the right to choose the settings of their choice. We need to look for a more seamless transition between settings.

In 2010, the Quality End-of-Life Care Coalition of Canada released its 10-year plan.

Seventy per cent of Canadians at this point in time do not have access to hospice palliative care

For short-term, acute home care services, there was a marked increase in the volume of services and the individuals served. There was also another benefit, namely, improved integration between home care and the acute care sector.

last summer, The Economist released a document that looked at palliative services across 40 countries

The second area in the blueprint for action is the support for family caregivers.

The increasing need for home-based care requires us to step up and strive for a comprehensive, coordinated and integrated approach to hospice palliative care and health care.

Canadian Caregiver Coalition

in Manitoba they have made great strides

In New Brunswick they have done some great things in support of family caregivers. Ontario is looking at it now.

we keep on treating, keep on treating, and we need to balance our systems between a curative system and a system that will actually give comfort to someone moving toward the end of their life

Both the Canadian Institute for Health Information and the Canadian Health Services Research Foundation have produced reports this year saying it is chronic disease management that needs our attention

When we look at the renewal of health care, we have to accept that the days of institutional care being the focus of our health care system have passed, and that there is now a third leg of the stool. That is community and home care.

Over 70 per cent of caregivers in Canada are women. They willingly take on this burden because they are good people; it is what they want to do. The patient wants to be in that setting, and it is better for them.

The Romanow report in 2002 suggested that $89.3 million be committed annually to palliative home care.

that never happened

What happened was a federal strategy on palliative and end-of-life care was announced in 2004, ran for five years and was terminated. At best it was never funded for more than $1.7 million.

Because our publicly funded focus has been on hospitals and one provider — physicians, for the most part — we have not considered how to bring the other pieces into the equation.

Just as one example, in the recent recession where there was special infrastructure funding available to stimulate the economy, the health system was not allowed to avail itself of that.

As part of the 10-year plan, first ministers agreed to provide first dollar coverage for certain home-care services, based on assessed need, by 2006. The specific services included short-term acute home care, short-term community mental health care and end-of-life care. It appears that health ministers were to report to first ministers on the implementation of that by 2006, but they never did.

One of the challenges we find with the integration of mental health services is

A lot of eligibility rules are built on physical assessment.

Very often a mental health diagnosis is overlooked, or when it is identified the home care providers do not have the skills and expertise to be able to manage it, hence it moves then over to the community mental health program.

in Saskatchewan it is a little more integrated

Senator Martin

I think ideally we would love to have the national strategies and programs, but just like with anything in Canada we are limited by the sheer geography, the rural-urban vast differences in need, and the specialized areas which have, in and of themselves, such intricate systems as well. The national picture is the ideal vision, but not always the most practical.

In the last federal budget we got a small amount of money that we have not started working with yet, it is just going to Treasury Board, it is $3 million. It is to actually look at how we integrate hospice palliative care into the health care system across all these domains.

The next 10-year plan is about integration, integration, integration.

the Canadian Patient Safety Institute, the Health Council of Canada, the Canadian Health Leadership Network, the health sciences centres, the Association of Canadian Academic Healthcare Organizations, the Canadian College of Health Leaders, the Canadian Medical Association, the Canadian Nurses Association, the Canadian Public Health Association, the Canadian Agency for Drugs and Technologies in Health and Accreditation Canada

We are all meeting on a regular basis to try to come up with our take on what the system needs to do next.

most people want to be cared for at home

Family Caregiver Tax Credit

compassionate care benefit that goes with Employment Insurance

Have you done any costing or savings? Obviously, more home care means more savings to the system. Have you done anything on that?

In the last federal election, every political party had something for caregivers.

tax credits

the people we are talking about do not have the ability to take advantage of tax credits

We have a pan-Canadian health/human resource strategy in this country, and there is a federal-provincial-territorial committee that oversees this. However, it is insufficient

Until we can better collaborate on a pan-Canadian level on our human resources to efficiently look at the right mix and scope and make sure that we contain costs plus give the best possible provider services and health outcomes right across the country, we will have problems.

We have not as a country invested in hospital infrastructure, since we are talking about acute care settings, since the late 1960s. Admittedly, we are moving away from acute care centres into community and home care, but we still need our hospitals.

One of the challenges is with the early discharge of patients from the hospital. They are more complex. The care is more complex. We need to train our home support workers and our nurses to a higher level. There are many initiatives happening now to try to get some national training standards, particularly in the area of home support workers.

We have one hospital association left in this country in Ontario, OHA. Their CEO will constantly talk about how the best thing hospitals can do for themselves is keep people out of hospitals through prevention promotion or getting them appropriately to the next place they should be. Jack Kitts, who runs the Ottawa Hospital, and any of the CEOs who run hospitals understand one hundred per cent that the best thing they can do for Canadians and for their institutions is keep people out of them. That is a lot of the language.

We have an in-depth brief that details a lot of what is happening in Australia

I would suggest that it is a potentially slippery slope to compare to international models, because often the context is very different.

Ontario faces a tough challenge ahead: do they expand traditional hospital-focused per-patient funding to try and reduce stubborn wait lists?

By introducing per-patient funding approaches that also integrate payments across hospitals, physicians and community care providers, Ontario can begin to tackle the triple challenge of access, cost and quality rather than passing the buck from one health care sector to the other.

Ontario is among Canada's lowest provincial funders for hospital care. Based on the latest figures from the Canadian Institute for Health Information (CIHI), Ontario government funding for hospitals is $1,395.73 per capita. The rest of Canada, excluding Ontario, spends $1,749.69 per capita. In other words, provincial and territorial governments outside of Ontario spend $353.96 more per person on hospitals than Ontario does. That is a whopping 25.3 per cent more than Ontario. "BGH is not alone in racking up a deficit. Every hospital in Ontario is struggling because hospital funding is far too low," says Hurley. Research done by CUPE has found that average Ontario hospital funding for the population the size of Brockville in 2005/6 would have been about $1.04 million less than average funding for the same population outside of Ontario. But by 2015/16 the funding shortfall for a population the size of the City of Brockville would have exploded to $7.74 million.

"$7.74 million a year for the Brockville hospital would have them operating solidly in the black. This hospital is struggling valiantly to provide services through eight consecutive years of provincial funding cutbacks. The solution here isn't a supervisor and more cuts to care, staff and programs but to increase this hospital's funding," says Hurley.The views expressed in any and all content distributed by Newstex and its re-distributors (collectively, the "Newstex Authoritative Content") are solely those of the respective author(s) and not necessarily the views of Newstex or its re-distributors. Stories from such authors are provided "AS IS," with no warranties, and confer no rights. The material and information provided in Newstex Authoritative Content are for general information only and should not, in any respect, be relied on as professional

The provincial government has only exercised the right to appoint a supervisor to Ontario hospitals 21 times since 1981. But CUPE, which represents more than 300 BGH front line staff, called the move "an optics exercise to distract from the significant provincial funding shortfall." The union said it relied on the latest figures from the Canadian Institute for Health Information (CIHI), to conclude the Ontario government's funding for hospitals is $1,395.73 per capita. The rest of Canada, excluding Ontario, spends $1,749.69 per capita, the union added. CUPE's own research shows that average Ontario hospital funding for a population the size of Brockville in 2005-06 would have been about $1.04 million less than average funding for the same population outside of Ontario. By 2015-16, the union adds, the funding difference would have reached $7.74 million.

That much more money every year would put an end to BGH's financial distress, added Hurley. "We're advocating for the hospital to receive an infusion of funding," he said. Leeds-Grenville MPP Steve Clark has also pointed to the provincial funding model as a "primary factor" behind BGH's fiscal woes. Staffat the Ministry of Health and Long-Term Care did not immediately respond on Friday to a question about CUPE's funding figures, but defended the appointment of a supervisor.

In an email to The Recorder and Times, spokesman David Jensen said the supervisor's appointment is based on a recommendation by the South East LHIN, which cited "ongoing concerns about the hospital's financial situation and organizational challenges." Jensen cited local media coverage "regarding the organization's financial challenges as well as other organizational issues facing BGH. "The appointment of a supervisor will help to move the hospital forward to achieve its goals and foster the development of more positive relationships," wrote Jensen. At this stage, added Jensen, the supervisor appointment is still a recommendation to be made by Health Minister Dr. Eric Hoskins.

"If appointed, a hospital supervisor would work with the hospital and government to support robust governance and management at the facility," wrote Jensen. The minister has notified BGH of his intention to recommend to the Lieutenant Governor in Council that a hospital supervisor be appointed, added Jensen. The Public Hospitals Act provides for a 14-day notice period, after which the supervisor can be appointed.

The bad news is that after years of inattention and chronic underfunding, significant issues still need to be addressed. We need a broad public discussion about our expectations and priorities to ensure we get future continuing care right: These are community decisions that ought not to be left entirely to our health bureaucrats, able though they are. As we enter this discussion, we should focus on the real issues and not waste time on red herrings. For example, recent research by the Health Quality Council of Alberta (HQCA) has confirmed that quality of care is not affected by whether the provider is private, non-profit, faithbased or public, or whether the staffare unionized. There is plenty of evidence that all types of providers are responsible, committed and caring. On the other hand, the report identified five concerns of families and residents: the need for more staff; timely help and supervision for basic needs; cleaner and bettermaintained facilities; access to related services; and quality, varied and nutritious food.

This is a telling list because these concerns are primarily driven by funding and continuing care is falling behind. Current rates of funding are actually below what was received in 2011, after inflation and cost increases are factored in. For the past three years, funding increases for continuing care have been zero, between zero and two per cent, and zero. At the same time, overall healthcare funding has increased at six per cent a year.

Just as schools need teachers, funding for spaces has to come with funding for care. In Alberta, continuing care is funded at 19 per cent below the national average. In comparison, acute health care in Alberta gets 33-percent more than the national average. Under these conditions, the HQCA conclusion that there has been "no significant change" in quality of continuing care is a credit to the commitment of our care providers.

It's not just the quantity of funding that needs to be addressed. Our current patchwork system of funding, program models and regulations needs to be revisited. Changes are needed - not to reduce standards, but to allow the system to be more client-and resident-centred, giving providers the flexibility to innovate and respond to the changing needs of clients and residents, and to reflect changes in the scope of practice of our health-care professionals. We need to ask ourselves whether a 30-yearold model of care is acceptable for our loved ones. The NDP government has taken some initial steps toward getting things back on track, but there is urgency to tackling these issues as quickly as possible. The number of Albertans needing home care, supportive living or long-term care is going to increase significantly. Will we be ready? Continuing care providers want to work with the government and all Albertans to build the best possible system. The Alberta Continuing Care Association looks forward to working with government as it takes its next steps to strengthen care and supports.

Tammy Leach is CEO of the Alberta Continuing Care Association.

The overall trend, she said, is a home care budget that doesn't live up to expectations.

"Verbally we see a commitment to shifting more care towards the home," Henningsen said in a telephone interview. "What we noticed from putting this report together is that the percentage of the public funding certainly didn't reflect those messages or that direction."

The report said demand for home care is soaring as Canada's baby boomers enter their twilight years. About 1.4 million people accessed home care services in 2011, up 55 per cent from 2008.

Henningsen said the association would like to see all orders of government redistribute their health care budgets to make home care a higher priority

She said new cash would not be necessary, adding reallocating funds currently devoted to other areas would go a long way towards addressing the shortfall.

Every year there has been an increase, but it's health care facilities and hospitals who make the decisions on how they're going to staff." "She is completely wrong," Hurley replied in a release. "Blame goes to her government's health policies and too low funding for hospitals. "Throwing hospital administrators under the bus for provincial government funding decisions is, in our view, unprincipled."

North Bay's hospital, built as a private-public partnership (P3) facility, is more expensive to operate than a typical hospital, Hurley said. During the 2003 election, the provincial Liberal's promised to cancel the North Bay P3 and to build the hospital as a publicly owned entity. "They reneged on that promise and yet have provided no special support for the significantly higher costs of this model. Now they are blaming them for cuts," said Hurley.

OCHU says successive Ontario Liberal health ministers have made no bones about downsizing hospital care. Since the Liberals were elected over a dozen years ago, funding for hospitals has fallen compared to other provinces. In the past several years, Ontario hospital funding "has lagged well behind the cost pressures associated with an aging population and inflation, OCHU says. This too low funding - well under the hospitals' real operating costs - has resulted in serious cuts to staff and services at North Bay and many other hospitals province-wide.

That's the root of blame for hospital staffing and program cuts," said Hurley. Provincial funding at its current levels has meant that in the past five years alone, North Bay has cut $20.7 million, OCHU says. The 2016 provincial budget gives hospitals a one per cent increase, it adds. However costs, driven by drugs and medical technologies will be closer to four per cent, "so another round of cuts is coming. It is completely unfair and below the premier to blame the managers of the hospital for this," said Hurley.

Wynne said the province is in the midst of a transformation of health care. "People want health care at home. People are looking for care for themselves and for their parents or grandparents. They want to know we are going to continue to invest in home care."

When asked what types of investment the province will commit to long-term care, Wynne acknowledged there are gaps in long-term care beds. "A review of the province's longterm care beds has been done by the Ministry of Health and Long-Term Care and decisions will be out soon." © 2016 Postmedia Network Inc. All rights reserved.

According to CIHI, Ontario government per capita funding for hospitals is $1,395.73. The rest of Canada, excluding Ontario, spends $1,749.69 per capita on hospitals. In other words, provincial and territorial governments outside of Ontario spend $353.96 more per person on hospitals than Ontario does, or roughly 25 per cent more. According to the findings, these numbers have increased steadily over the years and in 2005-2006 the gap between Canada and Ontario was at just 4.3 per cent.

"With working in the hospital you see reductions and they may seem small at first, but year-to-year you really see their growing impact," said Rodrigues. "Our front line workers hear the frustrations. They also hear about being sent home too early and see the readmissions." According to the report, Ontario has the fewest number of hospital beds in

any province and the length of hospital stays continue to be reduced for this reason. This decrease leads to an increase in readmissions. "We have a drop in admissions and an increase in readmissions," explained Hurley. "In terms of readmissions, Ontario is higher than the rest of Canada and Kingston is actually higher than the rest of Ontario. From our point of view, readmissions represent failures of the system to actually repair people properly."

The report also looked at funding for homecare and long-term care, an area the government has claimed they are expanding to meet growing needs. "We have been told that investments are being made in those areas," said Hurley. "But long-term care is 7.2 per cent behind the rest of the country and for homecare and community care we spend 14.3 per cent less. We have the fewest number of hospital beds, so you think we would have the most vibrant homecare system, but in fact we underspend."

Overall, Hurley emphasized that while hospitals require about a three per cent increase year to year to keep up with inflationary needs, hospitals in Ontario and in Kingston are only receiving about one per cent. "The increase should actually be around five per cent when you take into account additional pressures like population growth and aging and we are nowhere near that," he said. "Because of that we see nursing and staff cuts as a result and that is not acceptable." In terms of staffing, the reports conclude that in Kingston, across all hospitals, approximately 137 registered nurses and about 407 other staff would need to be added to equal comparable staffing in other provinces like Manitoba or New Brunswick.

That is a lot of people," said Hurley. "This lack of staffing means there is less care in the hospital for mothers who have just given birth, or people recovering from surgery and than again leads to readmissions and complications." So what can be done about these issues?

"People can talk to their Member of Provincial Parliament about these issues. That would be really appreciated," said Hurley. "We are doing these reports in every major community in the province and we are hoping to get some traction with the government to increase the funding." Illustration:

Mandy Marciniak / Michael Hurley, president of the OCHU (left) and Mike Rodrigues, president of CUPE 1974 (Kingston General Hospital).

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

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

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

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

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

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

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

of the Wait Time Alliance

Dr. Simpson

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

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

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

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

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

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

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

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

look at the total wait time experience

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

a patient charter with access commitments

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

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

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

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

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

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

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

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

A similar problem exists following discharge from hospital.

Poorly integrated and coordinated care leads to readmission to hospital

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

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

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

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

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

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

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

no one is quite sure where those five areas came from

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

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

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

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

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

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

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

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

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

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

the issue of appropriateness

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

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

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

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

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

I am not saying to turn off the tap.

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

Canada currently spends about the same amount as OECD countries

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

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

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

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

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

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

Ontario is leading the way here with their home first program

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"We are asking for the reopening of the chronic beds and alternative level of care beds which have been closed because of the funding freeze. We are asking that the provincial government stop the closure of acute care beds and to put funding back into the public sector and not the private sector," said Richer. According to Sudbury District Health Unit data, Sudbury/ Manitoulin has greater rates for obesity, arthritis, and high blood pressure and death than the Ontario average.

"They are decreasing the funding to the hospital and they are increasing the amount of funding they are putting into home care, but we have yet to see that," Richer said. "Many patients who are in hospital who need home care, their family is asked if they are able to perform any type of care for them and as soon as the family says yes, then that is when home care is very much decreased. "The patients in Northern Ontario, that need cleaning of wounds or changing of dressing, many of them have to go into a clinic, nobody is able to go into their homes so that definitely is an issue for the rest of the family members who have to book off time to get their loved ones into a clinic. "We are currently seeing no extra funding put into home care for these individuals and when they are on a list, the list is very significant, so when they are actually able to receive care it's sometimes too late."

Hurley said patients are suffering as hospital's try to balance their books. "What families experience when they are sent home is that they are asked 'is there anybody who can help with the patient,' and if you answer yes to that, then you don't actually get to access care because you don't need it, but if you need it, then you are put on a triage system and only the most urgent cases actually get access to home care -that's the sad reality," said Hurley "What people experience ... is that they are sent home by themselves, and often they are sent home when they are still acutely ill. They are sent home when they have needs like IVs, complex mobility issues which are far beyond the abilities of their aged spouses to deal with -that's what we do we just send them home and this then becomes individualized and becomes an individual problem of care."

Dan Lessard, media and public relations officer for Health Sciences North, said the freeze on the hospital's budget has had little to no effect on the organizations ability to treat patients. "One of the things that we have done, recognizing that hospital base budgets have been relatively static for the past four years, is we have really launched into an exercise of trying to find as many efficiencies as we can so that we get more use out of the dollars that we already have," said Lessard.

Lessard said that creating efficiencies means anything from eliminating vacancies for positions that have had little to no applicants, reducing overtime through better scheduling, and reorganizing the way supplies are ordered and managed. "I think we have been pretty good at maintaining our services so what we have really tried to do is look at areas where we can be more efficient and smarter in the way we do things so that we are not causing patient services to suffer," Lessard said.

"That's the last thing we want to do, that's the last thing our patients want us to do, certainly the last thing the community wants us to do is to put in place measures that is going to impact patient care. "I think we have done a pretty good job at maintaining our services and maintaining the quality of care that we are giving patients -it's not easy, it is challenging and demanding but we have very very smart people here working very hard to make that happen." Thibeault, the Sudbury MPP, did not return phone calls asking for comment.

• Sharon Richer, left, northeast Ontario vice-president of the Ontario Council of Hospital Unions (OCHU), and Michael Hurley, president of OCHU, hold a press conference in Sudbury on Monday.

Norm Peters, Island Health's executive director for surgical services, estimates it will take six to eight weeks to evaluate the proposals, choose one or more preferred proponents and hammer out agreements. "We're just in the start of the review stage," Peters said.

Depending on what's proposed, Island Health could be awarding one contract to a single company or two contracts to different companies on the south and central Island. B.C. Health Minister Terry Lake said the use of private clinics for publicly funded day procedures is strengthening the public system by increasing the number of more complex surgeries that can be carried out in hospitals.

Of 541,885 publicly funded surgeries in B.C. in 2013-14, 5,503 were done in private facilities. In 2013-14, Island Health funded 160 day surgical procedures to be performed in private clinics. That was less than the previous year when Island Health contracted out 511 publicly funded procedures for adults to private clinics and 31 for children for a total of 542.

Interior Health contracted out the most publicly funded day surgeries in 2013-14 to private facilities - 2,053 adult procedures and 173 pediatric procedures for a total of 2,226. If Island Health goes on to fund a maximum of 10,000 procedures annually over the next five years through private clinics, the health authority will lead the province in doing so.

Peters said with more day surgeries, such as varicose vein procedures, being performed by private clinics, more capacity is created in hospitals to perform hip and knee procedures, which also have long wait-lists. Edition: Final

Many of the clinics in Canada have long since dropped Planned Parenthood from their names, and even the ones that proudly maintain the title aren't officially tied to the outfit in the United States. But still the stigma remains, and many are struggling. Some have cut services; some have closed, or fear they will have to. "It's getting quite desperate.

We're all feeling the bite," said Lauren Dobson-Hughes, president of Planned Parenthood Ottawa, which recently put out an urgent appeal to its supporters for funds. Planned Parenthood Ottawa, which provided counselling and sex education to 8,500 clients last year (not to mention distributing 72,000 free condoms) has seen its government support slashed by 10 per cent in each of the past few years. The United Way in Ottawa cut all its funding a few years ago. Other grant applications have gone unanswered, and donors are spooked by the very words "sexual health."

According to Planned Parenthood Ottawa, there has been a concerted effort by anti-choice advocates to badger agencies and donors who might otherwise provide financial support to clinics (even though they don't provide abortion services). As well, there is just a general leeriness around the subject of sex education - witness the vehement opposition to Ontario's new curriculum. Donors are risk averse in tough times. "For some donors, it's just easier to support something [such as] a cancer charity," said Ms. DobsonHughes. The result of dwindling funding is that the people at greatest risk suffer. One client, a pregnant sexual assault survivor in an abusive relationship, recently had to be turned away from the Ottawa clinic because there were no counsellors to see her.

This squeamishness may seem difficult to believe in 2015, but other sexual-health providers - the ones who give out free condoms, counsel nervous teens and pregnant women and offer screening tests for people who might not have a doctor - confirm that it's a dire time. In April, Health Initiatives for Youth Hamilton, the country's oldest birthcontrol clinic, had to shut its doors after it lost its local government funding. It had been running for 85 years.

In March of last year, it looked as if the doors of Victoria's Island Sexual Health Society would also shut when it faced a funding crisis. After a public appeal, it received a small boost from the province's health coffers. "The immediate threat is over, but we had to lay off staff and it's still a struggle," said Bobbi Turner, who's been the director of Island Sexual Health for 21 years.

Ms. Turner's clinic had 27,000 patient visits last year and provided sexual education for thousands of students. Like similar outfits, it offers education and pregnancy counselling and clinical services such as STI testing and cancer screening. One of the problems in Victoria, she said, is the lack of family doctors: "If we close, where are these people supposed to go?" Now the clinic is exploring "different revenue streams," including selling a line of sex toys. It's not exactly a viable alternative to stable, year-on-year funding, but desperate times calls for innovative measures.

In a tight-fisted world, it seems that women's health services - even with their long-term, quantifiable benefits - are the first and easiest things to cut. "Funding dollars are getting smaller and smaller," Ms. Turner said.

"It's the same old story. Prevention gets bumped to the bottom of the list, and it's not until we're about to close our doors that people take notice."

There is a strong case to be made for a return to the original 50/50 funding arrangement, which is one of the key reasons the provinces signed on to Medicare in the first place but which has steadily been eroded in the decades since. There is also a fair criticism that increased funding - from $124 billion in 2003 to $207 billion in 2012 - should have been used more deliberately to attempt to achieve the intended change in system performance or health outcomes for Canadians. So as the health ministers meet in Vancouver, how can they bend the curve toward a less costly and more effective health care system? How can they ensure the funds invested this time around will buy real improvements in health?

Some of the directions for this can be found in the Prime Minister's mandate letter to the Minister of Health, which included an exhortation to "support the delivery of more and better home care services." Investment in quality home care has been shown to improve patient experience while easing pressure on acute and long-term facilities.

The letter also encouraged Minister Philpott to "encourage the adoption of new digital health technology." If done right, electronic medical and health records can greatly expand our ability to effectively treat individuals and the population. A third major element described in the mandate letter was a call to "improve access to necessary prescription medications" by "joining with provincial and territorial governments to buy drugs in bulk," and "exploring the need for a national formulary." This falls short of a national pharmacare program, but does not close the door to the possibility.

Canada is the only nation with a universal health care system that doesn't include drug coverage; one in five Canadians reports being unable to afford to take necessary medications as prescribed. A national pharmacare program would eliminate that problem while saving Canadians approximately $6 billion per year in excess costs. Half measures in this area will not achieve the desired savings or accessibility. The directives from Trudeau to Philpott are helpful, but there are two key ingredients missing. The first is that the flow of health care funds needs to be connected to clearly articulated goals. Indiscriminately increasing fund transfers with no accountability for how they will be used is a recipe for continually increasing costs without improving the quality and accessibility of care. The second is that all levels of government need to move toward a Health in All Policies approach that understands all areas of government - policies affecting income, education, housing, food security, for example - impact health outcomes. Health care is the greatest cost driver in provincial governments, but it isn't the area in which spending has the greatest impact on health - and it's not where those costs can best be controlled.

The decisions emerging from this upcoming summit could change the landscape of health care policy in Canada. Ryan Meili is a family physician in Saskatoon, vicechair of Canadian Doctors for Medicare, an expert with EvidenceNetwork.ca and founder of Upstream: Institute for A Healthy Society.