Group items tagged

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.

And the cooking's good here," jokes Donna Fox as Rodway stops in at the well-kept bungalow she shares with Bob, her husband of 62 years. Rodway, who's worked for ParaMed Home Health Care for 17 years, manages his symptoms and keeps him comfortable during his terminal illness. "It's very important because I couldn't exist without someone looking after me," Bob, a former marathon runner, says from the raised bed where he watches sports on TV or the awakening of spring outside his window. Suzanne, a Whitby breast cancer patient, credits a home-care nurse for possibly saving her life by sending her to hospital for a swollen hand caused by a blood clot. Now she gets shots of blood thinner at home.

"You're near the end, that's awesome," Rodway tells her after administering the day's needle, the 90th in a series of 100 prescribed injections. "You've been a trooper," she adds as Suzanne says, through tears, that her last chemo treatment is just days away. "There are many times I've cried with a client," Rodway says later. "People are appreciative because you're helping them feel better." Rodway, a mother of two young children, sees five or six patients a day in Whitby and Ajax. She says working 25 or 30 hours a week gives her a good balance of career, volunteer work and home life. "I get a lot of satisfaction." For RPN Max Hamlyn, it's all about the personal touch. "You've got the ability to spend time with the person and develop a closer bond," unlike hospitals where staff are too rushed, he says. "It's more than just running in and changing a dressing. I'll ask, 'How are you doing, are you eating OK?' And I say, 'What's the most important thing I can do for you today?' "

Hamlyn, who works in Ottawa for the government branch of Bayshore Home Health, covers up to 100 kilometres a day, seeing eight to 10 patients in private homes, retirement residences, detention centres and halfway houses. After 38 years in the profession - doing community care for the last 13 - he maintains "people do much better in their home" than in hospital. "I love it. I think home care is an amazing place for RPNs to work," says Hamlyn, whose youngest client is 23 and oldest, 102. He recalls the year he spent caring for a woman with colon cancer, meeting all her children and grandchildren and always staying for coffee and cake. "You become part of the family," Hamlyn says of many of his clients. "I get along really well with my people. I have a lot of fun with them - we laugh, we joke. They're such lovely people."

Doing so requires the business community to engage with the Department of Foreign Affairs, Trade and Development and EDC in the effective design and implementation of the government's new initiative. Done well, this initiative could leverage Canada's strengths in finance, natural resources, infrastructure construction and engineering to catalyze private investment that will accelerate the global push toward the United Nations' Sustainable Development Goals (SDGs). The initiative could also build on the skills and experience of Canada's large immigrant communities to strengthen trade and investment links with emerging and frontier markets - countries that are now responsible for the lion's share of global growth, but where Canada's business presence is tiny.

Senior fellow at the Jeanne Sauve Foundation and visiting scholar at Massey College in the University of Toronto. He tweets at @BrettEHouse. In its 2015 Economic Action Plan, the federal government announced its intention to create a $300-million, five-year "development finance initiative" to partner with private capital to create growth and jobs in low-income countries. The budget document anticipates that this initiative - to be located within an expanded Export Development Canada (EDC) - will provide a mix of financing, technical assistance and business advisory services to enterprises operating in line with the government's international assistance priorities.

As outlined in a submission to Parliament last summer by the Centre for International Governance Innovation and Engineers Without Borders, the experiences of Canada's G7 counterparts offer some important lessons for Ottawa's initiative. An effective initiative should address market failures; that is, it should fill gaps in the financial system that prevent good projects, sound businesses and effective entrepreneurs from obtaining the financing they need on reasonable terms. A classic example would be the situation of new immigrant entrepreneurs: They know their former countries well, they are ideally placed to build links between Canada and their birthplaces, but their lack of Canadian credit history makes it difficult for them to gain access to affordable borrowing to grow their businesses. Ottawa's new initiative will need to be empowered with a full range of financial tools - a variety of lending instruments, a mandate to take equity positions, the ability to write guarantees, the option to underwrite insurance products - that it can tune flexibly to take projects from their early days to full bankability.

It needs to be risk-loving and clear-eyed about the fact that some projects will fail, and maintain a long horizon on investments that typically take many years to pay out returns and development impact. This new development finance initiative should also embrace open competition. The most successful DFIs work with the most effective firms on the most innovative projects.

They're not limited to working with their own nationals. Both Canada and developing countries will benefit most if this initiative is made accessible to the best people, ideas and execution. Finally, Canada's new development finance initiative needs to take poverty reduction just as seriously as profit generation. Most other DFIs do this imperfectly, at best; some don't even monitor the impact of their projects on development. This makes no sense. Development is good for business and business can be good for development.

Five years from now, development gains will be just as important as profits in making the case for renewed funding of this initiative. All these lessons need be adapted to both the needs of Canadian business and Canada's specific development objectives. The Canadian Chamber of Commerce and Canadian Council of Chief Executives have both been important supporters of this project. Now it's time for the businesses that stand to benefit directly from this initiative to get involved ensuring its success.

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.

Extendicare has also announced a big share buyback, so some of the money may be used for that as well. The first reason the stock is down is likely that it had attracted a lot of "hot" money - hedge funds and other traders hoping the sale of the U.S. business would bring a quick buck in the form of a special dividend. The sale price ended up being on the low end of the expected range, which frustrated these traders. But worse, in their eyes, was that the company plans to reinvest the proceeds rather than paying out a big fat dividend.

It didn't take long for the acrimony to start flowing, with irate investors calling out management for supposedly poor decision-making. On paper, their arguments are plausible. The U.S. operations are bigger than the Canadian business, so it's easy to believe arguments that the dividend is at risk because once you take out the U.S. division there's not enough cash flow coverage for the current dividend. But that's a false argument because it assumes the $220-million net proceeds from the sale can't be put to work to generate more cash to support the existing dividend - and perhaps increase it. By way of example, Extendicare just acquired the home health care division of Revera, a smaller competitor, for $83-million. That values the assets at 6.5 times projected earnings before interest, taxes, depreciation and amortization, a good multiple. Analyst Doug Loe at Euro Pacific Canada likes the deal, noting it's a good bolt-on acquisition for Extendicare's existing home-care operations and that home care is increasingly touted by experts as a way to reduce the overall cost of health care in Canada.

Mr. Loe also believes that this acquisition goes some way to reduce the risk to the dividend. While the U.S. operations are strained by compressing margins and rising insurance costs, Extendicare still generates more than half its cash flow from south of the border. But this accretive acquisition adds about 10 cents of cash flow per share. The dividend is 48 cents, so assuming half the funds for the dividend are coming from the United States, the company has already replaced a good proportion of it with an investment of $80-million. It has another roughly $200-million to deploy so it appears that the fears of a dividend cut are overblown as long as the company can deploy funds in a reasonable way, whether by acquisition or re-investment in its existing operations to increase revenue and profits. I have to think that with an aging population and growing demand for such services, Extendicare should not have much difficulty making judicious decisions with its cash and I'm happy to collect a nice dividend while I wait to see what they do with that big war chest of cash. Fabrice Taylor, CFA, publishes the President's Club investment letter, for which he and The Globe and Mail have a distribution agreement. He holds shares of Extendicare. Extendicare (EXE) Close: $6.45, down 5C/

Skyrocketing hydro rates are making Ontario less attractive to manufacturers, making it harder to replace the good jobs being lost at Bombardier or Ontario Northland, he said.

"Hydro rates started going up after Mike Harris and the Conservatives started privatizing generation, and they shot up with the Liberals' private energy deals, like the sole-source Samsung contract for wind," he said. "This will get much worse with the sale of Hydro One to private interests. We'll also lose the oversight of public accountability officers like the Auditor General." Hahn was speaking to a crowd of North Bay residents calling on Queen's Park to take action to stop the loss of good jobs and quality public services in their community.

The rally organized by the North Bay and District Labour Council, began at the Ontario Northland building, then made its way to City Hall. Speakers included Canadian Labour Congress President Hassan Yussuff, new Ontario Federation of Labour President Chris Buckley, NDP MP Charlie Angus (Timmins-James Bay), NDP MPP John Vanthof (Temiskaming-Cochrane) and Sharon Richer, vice-president of the Ontario Council of Hospital Unions

"It's Kathleen Wynne listened to Ontarians. Almost 85 percent of the public and 194 municipalities oppose the Hydro One sell-off," said Hahn. "The Liberals need to listen to the people, not to Bay Street. We need quality public services and good jobs in our communities. We need at-cost, not-for-profit electricity. We need profitable corporations to pay their fair share so working-class people don't pay any more for disastrous Liberal austerity and privatization schemes."

CUPE is Ontario's community union, with more than 250,000 members providing quality public services we all rely on, in every part of the province, every day. CUPE Ontario members are proud to work in social services, health care, municipalities, school boards, universities and airlines.

The VON was trapped, and ultimately crushed, by that contradiction. It was not the first - the Canadian Red Cross Society's legendary blood transfusion service flamed out in an even more spectacular fashion with the taintedblood scandal in which 20,000 recipients contracted hepatitis C or HIV - and it will not be the last. Canadian Blood Services has taken over the former Red Cross role.

The health-care advocacy group Friends of Medicare said the neardemise of the VON is proof that "experiments in private care must be ceased." But the VON's story is much more complicated than the "public, good; private, bad" and "notfor-profit, good; for-profit, bad" narrative. For a long time, governments funded not-for-profit groups in the health and social services sectors - hospitals, home care, group homes, the Red Cross and so on - in a pretty loosey-goosey fashion. These groups did good, and they were funded relatively well.

But as budgets soared, new accountability measures were put into place. In the home-care sector, for example, competitive bidding was introduced. Stodgy old organizations such as the VON were not ready, and did not adapt. Their market share fell from more than 90 per cent to about 20 per cent. On the surface, this is a good thing. Canadians spend $219-billion a year on health care, including about $10-billion on home care, and, as consumers and taxpayers, they deserve to get value for money.

While we like to preach the gospel of value-for-money, we don't measure it well - the ultimate irony being that expensive bureaucracies have been built to ensure home-care agencies are lean and mean. The VON had many disadvantages in a competitive market.. place - first and foremost that it never provided just home care to its clients. It delivered hot meals, made friendly visits (especially to veterans), ran adult daycare programs, provided respite care to families, visited new mothers and babies, did flu shots at home and did countless other little things that never had a place in the accounting ledger. Some were covered by government payments, but many were not. The VON supplemented its funds from government contracts with charitable donations. It had more volunteers (9,000) than staff (6,000). The VON also paid its workers a decent, living wage. The work force - mostly nurses and therapists - is unionized, salaried and they have benefits, including a pension plan.

In the brave new home-care industry, piecework is the norm, meaning nurses get paid per visit, and few have benefits, pensions or stable employment. It is also in the interest of workers (and employers) to get visits done quickly, and cram as many as possible into a day. While this is a cost-effective business model, anyone with a loved one in home care knows that there is little continuity of care. The relationships that are so important to intimate acts such as health-care delivery to frail seniors living at home are virtually non-existent. When you have a strict business model, when all that matters is the much-vaunted bottom line, none of that gets counted.

The real tragedy in the VON's unravelling is not that another home-care business is biting the dust (after all, there are hundreds more out there), but that the "old-fashioned" way of delivering care - taking the time required to talk and listen to patients and treating them as people, not "units of service" for example, not just changing their dressings, but feeding them and filling the fridge - is falling by the wayside. With the VON's collapse, we have a home-care system that may be more efficient - at least in theory - but one that has less heart.

The Ontario government should bolster employment, and hence domestic demand in the economy, by increasing investment in public services and social programs

Drawing on post-2008 public investment measures adopted in China, Brazil, Australia and Kenya, the paper demonstrates how the Ontario government can be a leader in bringing the Ontario economy out of economic crisis for the common good, including eventually eliminating the deficit and debt.

the Ontario government should commit financial resources to create an additional 9,000 permanent full-time equivalent RN positions by the end of fiscal year 2014-2015 in order to begin addressing the particularly low RN-to-patient ratios in Ontario relative to other Canadian provinces.

mass construction of low-income housing in Ontario

In the long-term care sector, a minimum staffing standard should be funded and regulated at an average of 3.5 worked hours of nursing and personal care per resident, per day, including 0.68 RN hours per patient per day.

not substituting or replacing RNs with registered practical nurses

increase state revenue through taxation of corporations and the wealthy, beginning with cancelling the reduction of the corporate tax rate to 10 per cent.

work with the federal government to establish job creation targets in various areas. This should include job-intensive green job creation and fully subsidized skills training programs

For the full research paper see:http://www.ona.org/publications_forms/research_series.html

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.

the deal offered by Mr. Harper’s government is reasonable. It is fiscally responsible, tying spending increases to inflation

It is also politically astute, for a host of reasons:

* It avoids the sordid scene we saw in 2004 when provincial premiers ganged up on prime minister Paul Martin and extorted $41-billion in additional health dollars and a spendthrift 6-per-cent escalator clause on transfers.

* It is a 10-year deal, just as the provinces demanded, allowing some certainty in budgeting.

* It respects Mr. Harper’s election promise to maintain 6-per-cent increases beyond 2014 – at least nominally. (Those who wanted 6 per cent per annum were dreaming in Technicolor.)

* It puts the onus on the provinces to justify why health-care spending should exceed inflation, something they have never been able to do.

* It places no restrictions on how the provinces spend the $40-billion a year they receive in federal health transfers (along with another $20-billion in social transfers for education and welfare programs.)

It should be an instrument for improving health-care delivery, and in that regard, Mr. Flaherty’s offer fails miserably

What the public should expect from Ottawa is that federal funds be used to exercise leadership and foster innovation

The reason Ottawa transfers money to the provinces in the first place (because health is a provincial responsibility constitutionally) is to ensure some semblance of equity coast-to-coast-to-coast. But there are areas, such as catastrophic drug coverage and homecare, where there are gross regional disparities.

This accord will force the provinces to rein in health spending, which is not a bad thing in itself. But one of the consequences will likely be greater disparities in the quality of care and breadth of coverage between the have and have-not provinces.

The great failure here is not refusing to increase transfers by 6 per cent, it is failing to attach strings to the monies.

With this deal, Mr. Harper has shown himself to be politically astute and fiscally prudent, but he has failed to show a commitment to strengthening health care, and medicare more specifically.

Canute, seated at the sea's edge, was making a witty point to flattering courtiers, showing he could do nothing at all to prevent the waters from rising. One might well gain the impression, however, that our present rulers are responsible for making the waters ebb and flow. Take that Economic Action Plan. We taxpayers have forked over well above $100 million just for ads touting the wing of bat and eye of newt that were supposed to work their magic for us and, of course, for the Harper administration as well. But the economy is presently on a serious downturn, largely thanks to the recent precipitous drop in the price of oil, and in the value of our loonie. We shouldn't blame Harper for all that, of course, even if his emphasis on oilsands development has made us somewhat vulnerable to this sort of thing. But let's be consistent. Why should he then reap unqualified praise when the economy is doing well? Not that our leaders are completely helpless, of course. Within limits, they can moderate the harmful effects of downturns, if they so choose. The question really becomes, whose harm should they address? That's what these federal budgets are all about. They aren't mere balance-sheets, but a statement of values and priorities. And here there are real choices to be made.

Reflecting those conflicting moral options, some think-tanks have demanded low corporate taxes, to improve profit margins and encourage investment. Others, currently being audited by the Canada Revenue Agency, want taxes to rise, to pay for quality public services such as food inspection and post-Lac-Mégantic rail safety and a national child care program and the increased demands upon medicare and Canada Pension Plan reform. It's fair to say that this government has chosen its path, and it's not one leading to the door of that "ordinary Canadian." The new budget maintains that direction.

It's a pre-election document, with the flash and dazzle of deficit elimination. But to accomplish that, the government announced spending that won't come fully into force for years, and also made off with two-thirds of the contingency fund - intended for real national emergencies, not political manoeuvring. The much-ballyhooed family income-splitting measure, already making its way through Parliament, stands to benefit the very richest 15 per cent of Canadian families. Now the Tax-Free Savings Account will have the maximum contribution nearly doubled, to $10,000 per year - once again disproportionately benefiting the well-to-do who can afford such contributions, while costing the government billions in revenue losses. Under Prime Minister Stephen Harper, we've seen fewer unemployed workers than ever before able to qualify for employment insurance benefits. There is nothing in the budget to remedy this, and no serious job-creation measures to ease unemployment.

Given the current poor health of the economy, the burden of inequality continues to be borne by those Canadians least able to withstand it. The budget, like its predecessors, doesn't even pretend to address that fundamental issue. The "ordinary Canadian," once again, has been left on the sidelines. Nothing new here: move along. John Baglow is an Ottawa writer, researcher and consultant.

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

Sousa reckons that Ontario is coming out of the economic slump. Progress is slow and uneven. But the government estimates, with some justification, that matters are beginning to look up, that more people are being employed and that government tax receipts will therefore rise. The reasons are well-known. The oil price slump may be bad news for Alberta. But it's good news for the consumers and manufacturers of this province. More important, the U.S. economy is on the rebound - which helps Ontario exporters. And finally the dollar has slipped. That's tough for those buying, say, Florida oranges. But again it's good news for Ontario manufacturers, who now have a built-in price advantage in the U.S. market. Interestingly, Sousa's budget shows that the growth-driven gains in tax revenues will contribute far more to the elimination of the province's deficit than either spending cuts or asset sales. Which suggests two things: First, budgets do often balance themselves - when the business cycle picks up. Sousa calculates that Ontario will reap

$10 billion in new revenue over the next two years, more than enough to eliminate the current $8.5-billion deficit. Second, many of the other things the Wynne government has done to balance the books may not have been necessary. Which is the confusing part of this budget. Why is Wynne's government going out of its way to cause itself to political grief? Exhibit A: the proposal to sell to private investors 60 per cent of Hydro One, the publicly owned electricity transmission utility. After paying off Hydro One's debts, the province expects to net $4 billion from the sale. The government says it wants to use the proceeds to build transit infrastructure over the next 10 years. But by selling a chunk of the electricity monopoly, Queen's Park is also giving up close to $5 billion in guaranteed revenue over the next 10 years. It would be cheaper to hold onto

100 per cent of Hydro One and use the utility's profits to fund infrastructure. In a press conference Thursday, a jovial Sousa was asked about Hydro One. In effect, he answered that selling most the utility was a good deal for the government. He didn't really explain why. Other matters mentioned in, but not seriously addressed by, the budget include Wynne's decision to fight climate change through a so-called cap-and-trade system, her proposed Ontario Retirement Pension Plan and the Liberal promise to cut auto insurance premiums by 15 per cent. On cap-and-trade, the budget confirmed that crucial details have not yet been decided. On pensions, it revealed that the government has talked to a lot of people and heard a lot of different things. Auto insurance? Two years ago, the insurers grudgingly agreed to cut rates, but only if they were allowed to provide accident victims with fewer benefits. The government was fine with this. According to the budget, it still is.

"Rotund, funny and occasionally pompous, Dr. Porter was everyone's friend and nobody's confidante, the life of the party and an agile dancer, both in political circles and around a ballroom floor. A member of Air Canada's board of directors, he travelled the world free. His former friend Prime Minister Stephen Harper had him sworn in as a member of the Privy Council so he could serve as chairman of the Security Intelligence Review Committee, or SIRC, the country's spy watchdog agency. "And he was close to Quebec Premier Philippe Couillard, a relationship that began in 2004 when the politician, a neurosurgeon by training, was provincial health minister. Like many of Dr. Porter's friendships, theirs ended with the news of the hospital's megacost overrun and a $22.5-million fraud inquiry connected to the MUHC's decision to award the construction contract to a consortium led by the Montreal-based engineering firm SNC-Lavalin Group Inc.

""In a way, Arthur was like Icarus, who came crashing down to earth when his wax wings melted because he flew too close to the sun," Jeff Todd, an Ottawabased journalist who first met Dr. Porter in the Bahamas and co-authored the memoir, said. ""He told me that if he did anything wrong, it was to go way too fast," Mr. Todd continued. "There was never a peak he didn't want to climb and if there was a huge challenge, he always thought he would simply fly over it. But he couldn't always do that." "The first indication was in November, 2011, when the National Post revealed he had signed a commercial agreement the year before with Ari BenMenashe, a Montreal-based Israeli security consultant and arms dealer, all while he was head of both the MUHC and Canada's spy watchdog. Mr. BenMenashe was to secure a $120million grant from Russia for "infrastructure development" in Sierra Leone. In return, a company called the Africa Infrastructure Group, which was controlled by Dr. Porter's family, would manage what he wrote were "bridges, dams, ferries and other infrastructure projects" built with the Russian money.

"Within days, he was gone from SIRC. Less than a month later, he resigned from the MUHC, departing on the grounds that he had accomplished what he had set out to do in 2004: bring together a private-public partnership and get a long-dreamed-of facility built. "Unbeknownst to the public at the time, under his watch, a planned project deficit of $12million had somehow escalated to $115-million. "The following year, fraud charges were laid, but by then Dr. Porter was on to other projects and living in a gated community in the Bahamas, where he had maintained a home for years. After Interpol issued a warrant for his arrest, he and his wife, Pamela Mattock Porter, were detained June, 2013, by authorities at Tocumen International Airport in Panama City. "Despite claiming he could not be arrested because he was on a diplomatic mission for Sierra Leone, he was soon confined to overcrowded quarters in a wing reserved for foreigners in filthy La Joya prison. Toting an oxygen tank, he became known there as "Doc," ministering to inmates who included drug dealers and murderers. The man who had begun his ascent to the top as a doctor beloved by his patients would end at the bottom as a doctor beloved by his patients again.

"He was smart, perhaps too smart for his own good, and affable, with an ability to zero in on the most powerful person in the room with laser-like focus. His long-time friend and former teacher Karol Sikora, who partnered with Dr. Porter in a Bahamian medical clinic and is also the medical director of their joint private health-care company, Cancer Partners UK, said he was uncannily good at getting people together everywhere he touched down, even if they had opposing views. ""People like that are rare and they are very good at running big institutions," Dr. Sikora said. ""Arthur reached the peak of his career in 2010, when he was all glowing and bigger than sliced bread. Then it all went wrong." "Although Dr. Porter claimed the money from SNC was payment for other consulting work he'd done for them, his friend opined that the truth will probably never come out now. ""I'd like to think Arthur was never part of this monkey business, but we'll never know," he said.

"Others were not so kind. Responding to news of his death, the MUHC issued a terse statement that extended condolences to his family and offered no further comment, while Mr. Harper suspended the protocol that would have seen the Peace Tower flag fly at half-mast to mark the death of a Privy Council member. "In prison, living in unsanitary surroundings and denied proper treatment in a hospital for the cancer that many doubted he had, Dr. Porter, who leaves his father, sister, wife and four daughters, was outwardly still full of bravado until near the end. ""I just have to survive and make do," he told CBC reporter Dave Seglins in a phone interview in March that revolved around his treatment at the prison and his successful complaint to the United Nations torture watchdog that his human rights were being trampled on. ""[The] water, food, bedding and the fact that one has to urinate in a bucket shared by about 50 to 100 people ... for someone who has an illness and needs treatment, it was pretty obvious, I presume, the UN clearly found in my favour." "In addition, Dr. Porter continued, his raspy voice rising, he had not had a single court hearing in 22 months.

"I've never left here to go into the city. I have no idea what the inside of a courtroom looks like, not in Panama, Canada, the Bahamas or anywhere," he cried. "I've never been to court in my life." "In the end, though, he seemed to be aware that the stain on his reputation would not be erased, not even in death. ""My entire life has been devoted to climbing, winning and succeeding," he wrote in his memoir. "But with the end drawing near, it is inevitable that I, like anyone else, wonder if what I have accomplished truly matters. I wonder how I will be remembered." "To submit an I Remember: obit@globeandmail.com Send us a memory of someone we have recently profiled on the Obituaries page. Please include I Remember in the subject field.

"In his memoir, Dr. Porter said his life was 'devoted to ... winning.' " "Arthur Porter, left, chats with Stephen Harper at Montreal General Hospital in 2006. The Prime Minister had Dr. Porter sworn in as a member of the Privy Council.

The average number of people on wait lists as of May, 2015, is 611. Some regions have shorter wait lists, such as Toronto Central, which currently has zero. Others are in the four digits, such as the Central East CCAC, which stretches east from Victoria Park Avenue in Scarborough and north to Algonquin Park, and has 1,516 children waiting for speech therapy. Waiting that long can have a large impact on a child's ability to do well in school, according to Anila Punnoose, a director of Speech-Language and Audiology Canada. During the months or years children are waiting to get speech services, they can quickly fall behind in school, she said. A 1996 study found children with language deficits are more likely to experience social difficulties including interacting with their peers, which impacts their behaviour. Other studies have shown that children who don't get speech therapy early are at a greater risk of problems in their academic performance and mental health.

A lot of speech problems carry over to literacy, because a knowledge of speech sounds is crucial when learning to read, Punnoose said. "It's all about what you hear in those sounds. ... Do you know the beginning sounds in that word? A child who doesn't have good phonological awareness doesn't understand any of that," she said. When looking at school performance, Punnoose said early struggles carry through to later years. A child with speech problems who has difficulties learning in the early years won't be able to build on those lessons in later years as effectively as their peers, she said. Early intervention can mitigate and prevent those problems, she said. "If children are having severe difficulties with speech in kindergarten, it's a predictor that there's going to be academic difficulties, and especially reading and writing difficulties, by Grade 3," she said.

Jocelyn Fedyczko, Eddie's speech pathologist, has worked in a range that includes children from preschool all the way to teenagers. She said early intervention is crucial with young children such as Eddie. "The earlier you can help a child out, the more progress you see," she said. When a child gets to the top of the wait list, they get assessed again, and receive a block of treatment, usually around 10 or 12 sessions, says Peggy Allen, president of the Ontario Association of Speech-Language Pathologists and Audiologists (OSLA). That's often not enough to treat even minor to moderate issues such as Eddie's. Fedyczko said she can get through two to three sounds in that time, depending on the child. Many children have problems with more sounds than that, she said. But when a child finishes their block of treatment and needs more, because they haven't worked through all the sounds, for example, they go back to the bottom of the wait list, Allen said.

A spokesperson for the Toronto Central CCAC said they do not have an upper limit to the number of sessions per block assigned by a speech-language pathologist. The pathologist determines three goals for a child to achieve and assigns the number of sessions according to that. If after these sessions more goals are identified, the child is re-referred to the program, the spokesperson said. Parents who are worried about the impact waiting can have on their child can go to private clinics, if they have coverage or can afford the sessions out of pocket. Trish Bentley, Eddie's mother, decided to go for private therapy with Eddie's older brother Oliver. He was put on a six-month wait list for speech problems slightly more acute than Eddie's.

B.C.: Children's speech therapy is organized through the Ministry of Health, Ministry of Children and Family Development (MCFD) and through the Ministry of Education by way of school districts. Children are divided between preschool and school age. Preschool children go through regional health authorities. School-age children go through the school boards, but the pathologists there will often offer consultative services, rather than oneon-one speech therapy. B.C. also has a "no-wait-list" policy for children with autism, which translates to parents getting around $22,000 a year for therapy until the age of six, and $6,000 a year after that. Alberta: Health Services is in charge of speech therapy in that province. It offers both a preschool and a school program. The school program, unlike Ontario's, is done completely through the schools, with no CCAC-type system to refer out to. Saskatchewan: The school districts are responsible for speech therapy. Each school district divides up services slightly differently, though they all differentiate between children under three years, from three to five years, and from six to 18 years.

But the problems go deeper than a lack of funding, according to Allen. She said many of the issues in Ontario stem back to a series of agreements in the 1980s between the provincial Ministry of Long-Term Care, the Ministry of Education and the Ministry of Community and Social Services. These agreements divided up who is in charge of different treatments, between the school boards and the CCACs. At the time of their creation, these agreements made sense, but times and needs have changed, she said. "It's difficult when ministries make agreements that are frozen in time. It's very difficult to provide the kind of services that we all expect and want Ontarians to receive," she said. Dividing up the services is necessary when trying to manage resources, but the fragmentation is hurting children more than it's helping, Punnoose said.

Dividing services by language issues and other issues doesn't make sense when treating a child, she said. "You shouldn't be splitting up the kid," she said. Punnoose said she wants to see speech therapy come together under one roof. It would mean co-operation from all three ministries, as well as a major reorganization of the funding, but she believes it would be a better model for children. "Students are in schools the better waking part of their lives. Why wouldn't we have the services right there in an authentic environment where it's totally accessible," she said. There are changes coming.

Last December, the Ontario government announced more funding for preschool speech and language programs, as well as efforts to integrate speech services better, through its Special Needs Strategy. Punnoose says it's a good step. "The government recognizes that the system was broken," she said. For now, the choice for parents in many CCACs will be between long wait lists and paying for private service. Hunter-Trottier said many parents, even those with coverage, don't know about the latter option. "We sometimes get parents here in tears, saying, 'Oh my goodness, the services here, I wish I had known about that a year ago,' " she said. Bentley said she won't be looking at public services for Eddie, as she's happy with the service she gets at Canoe. "I'd be open to it, but I'm not going to actively seek that out," she said.

For Eddie, what matters is the progress he makes. Within 10 minutes of his trouble saying "lipstick," he was opening up a treasure chest, with a key. With little prompting, he used the same technique as before, separating the sounds of the word. "Kuh-ey," he said. Could he try it all together? He pauses for a second. "Key," he says, almost flawlessly, beaming at his success. SPEECH THERAPY IN EACH PROVINCE

Speech therapy, like all healthcare matters, is regulated differently in each province and territory in Canada. Information on how each system works is difficult to come by. But generally, most provinces have very similar systems - and challenges - according to Joanne Charlebois, CEO of Speech-Language and Audiology Canada. Charlebois said Ontario's wait times are probably worse than those in other provinces, but she's spoken to people across Canada who tell her similar stories. Here's a breakdown of how it works across the country. Ontario: Speech therapy for children falls under the responsibility of three ministries: the Ministry of Long-Term Care, the Ministry of Education and the Ministry of Community and Social Services. Children in Ontario are divided by age and by the nature of their speech problem. Children under school age qualify for Ontario's preschool speech and language program. Once in school, those children with language problems - major problems speaking or understanding words or sentences - go to a school speech pathologist, while any other problems, such as pronunciation, stuttering, voice and articulation are referred to the Community Care Access Centres, which employ contract speech pathologists.

Rather than wait those six months, Bentley took him to Canoe. "As time went on, we said enough of this, he's going to be past the point of catching the problem," she said. For families who don't have coverage and who can't afford private services, though, the only option is to wait. Finding the cause of the long waits is hard, but one thing is certain: It's not due to a lack of speech pathologists, according to Shanda Hunter-Trottier, the owner of S.L. Hunter Speechworks, another private clinic in Toronto. She used to have problems finding qualified speech pathologists, but now she's facing the opposite problem. "I've been practising for 26 years. ... In the last five years, [I] have more resumes than I can keep track of," she said. Rather, she says, it's a large web of problems that slows down the system. First among these is a lack of public funding. "There's a lot of speech pathologists that don't have jobs, but these places aren't hiring. The cutbacks have been atrocious," she said.

Manitoba: School districts are also in charge here. The inschool speech-language pathologists offer services from classroom-based programming to individual therapy. Quebec: The system here is more like Ontario's. Speechtherapy services are offered through the local community service centres (CLSC), similar to Ontario's CCACs. The CLSCs are not obliged to provide speech therapy in English, though some, especially in areas with a large anglophone population, usually do. Nova Scotia: The province has 28 speech and hearing centres, with 35 pathologists in total. They assess and provide treatment for children and adults. School boards in the province also have speech-language pathologists who also have a teacher's certificate.

Prince Edward Island: The province provides free speech services for children until they enter school. Northwest Territories: Speech therapists are only able to visit some remote communities once or twice a year. Instead, the province offers a service called Telespeech, where pathologists can help people without having to be physically present. Nunavut: The territory had no speech pathologists in 2013, according to Statistics Canada.

Health Minister Eric Hoskins said in a statement that he endorsed the report and intended to follow its advice. He was not available for an interview Thursday. The Donner report comes after years of public complaints about how home and community care is delivered in Ontario, a province that is moving aggressively to keep patients out of expensive hospital and nursing home beds. To facilitate that, the Liberal government has, since taking office in 2003, doubled funding for the local Community Care Access Centres (CCACs) that coordinate and deliver care in the home. Total spending on home and community care reached $3.2-billion in 2013-14, or about 6 per cent of the province's health budget.

But in that same decade, the number of patients receiving services through CCACs has doubled, with a significant spike in the number of high-needs, longer-term patients seeking care, the report says. Dr. Donner and her colleagues point out in their report that Ontario's 14 CCACs "often have difficulty managing within their budgets due to the combined effect of higher volumes, higher needs and longer times on service than anticipated." Catherine Brown, the chief executive of the Ontario Association of CCACs, called that "absolutely accurate," and said local funding challenges are something the province must consider as it prepares to modernize the home-care system.

The CCACs themselves have come under fire for steep increases to executive salaries and for the amount of resources they dedicate to administration, rather than front-line care. The Auditor-General is scheduled to release an audit of the CCACs this spring. Dr. Donner said it was not within her mandate to say whether the CCACs should be salvaged or scrapped. France Gelinas, the NDP's health critic, called the report a vindication for the patients and caregivers who have called or visited her office to "just cry and cry and cry" about their struggles with the system. © 2015 The Globe and Mail Inc. All Rights Reserved.

The reality is that, when a loved one is in hospital, you cannot schedule your meals at normal hours. You need access to nutritious food, not to mention to the relief from the stress of sitting by the bedside of a loved one who is ill, whenever it is convenient, for example when your ill loved one is being looked after by the medical staff or when they drift off to sleep. It is therefore an important public service to provide the members of the public who have to make use of the hospital with access to good, nutritious food beyond the normal hours when the rest of us have breakfast, lunch, and dinner. These cafeterias are not really "commercial operations" but part of the public service of a hospital; as CUPE local President Norma Robinson pointed out, nutritious food is a necessary part of a patient's recovery. It is also a necessary part of a patient's family members' continuing health.

Alternatively, maybe the smart thing for Horizon Health to do is to accept that food service is part of the public service that our hospitals provide and therefore get on with providing food services to those who use our hospitals as a public service, not as "commercial operations." This means that the health network needs to accept that providing adequate food services, including by investing in new equipment and putting the cafeterias in better locations to increase visitorship, will cost the health network money. The harsh truth is that trying to balance Horizon Health's and the provincial government's books by reducing the hours of cafeterias that, in total, are losing $350,000 a year is the public finance equivalent of trying to get rich by looking for loose change behind your couch cushions.

If the government of New Brunswick wants to have the health care system contribute to reduced government expenditures and a balanced provincial budget, reducing the hours of hospital cafeterias is simply a side-show; it will have no meaningful effect on the provincial budget. If the provincial government wants to reduce expenditures on the health care system in a meaningful way, it and the health networks should engage in real health care reform.

As part of these reforms, they should either close or downgrade a number of hospitals to basic health care and triage centres and build the health-care system around a few full-service, high-quality regional hospitals. If the evidence of other provinces that had a plethora of small rural hospitals but rationalized their health care service delivery as part of a health care reform agenda is anything to go by, these reforms will also have valuable side-effect of providing New Brunswickers with better health care and making them healthier. As well as not saving any significant amount of public money, closing cafeterias in hospitals or substantially reducing their hours, on the other hand, will not do anything to make people healthier, either. If it cannot make a serious contribution to either public sector cost containment or health reform and will harm people in the process, why do it?

an Peach has worked in senior positions in federal, provincial, and territorial governments and at universities across Canada; he also served as vice-president, Policy for the New Brunswick NDP between 2012-15. His expertise is in constitutional law, federalism and intergovernmental relations, Aboriginal law and policy, and the policy-making process.