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In England, the government requires hospitals to report all C. diff cases, underpinning a regulatory campaign that has slashed infections more than 50% since 2008. A new C. diff reporting rule for U.S. hospitals isn't scheduled to take effect until 2013.

England and other European countries also require health care institutions to have antibiotic control programs and meet targets for reducing C. diff. There are no such rules for U.S. facilities: The federal government doesn't track antibiotic use in hospitals, nursing homes and other care settings, and there is no penalty under Medicare and Medicaid for facilities that have high C. diff rates.

Thirty-four states now require hospitals to publicly report their rates of infections, but fewer than a quarter of those include C. diff

Reporting requirements for nursing homes are even less common.

Hospitals have cut housekeeping budgets up to 25% in recent years, according to the Association for the Healthcare Environment, an arm of the American Hospital Association. And the group's surveys show that many hospitals spend as little as 18 minutes cleaning a patient's room. That's well below the 25-30 minutes the group's studies have identified as optimal.

Other health care infections have been stemmed

Strategies to combat C. diff are more complicated and costly. Successful initiatives often require interdisciplinary teams.

Though infection control programs are shown to save facilities money in the long run, Jarvis, the former CDC infection control chief, says administrators often balk at the upfront investments because they worry about operating margins."Saving money is not the same as making money," he adds.

In a 2009 survey of 2,000 infection prevention specialists from U.S. hospitals, 41% said their facility had cut spending on infection control.

The U.S. Centers for Medicare and Medicaid Services has begun reducing reimbursement to hospitals for care tied to certain health care infections it deems preventable, such as those related to catheter use. But C. diff is not on that list.

It's difficult to hold facilities accountable for C. diff because it can be impossible to know where a patient was infected

That hasn't been a roadblock in England, where hospitals must meet strict targets for reducing infection rates or face sanctions. In fiscal 2011-12 through March, the country had just 18,000 C. diff cases — 17% below the prior year.

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 health region is not laying off staff and is working with the employees' union to find jobs elsewhere in the organization. Blakley said new jobs can be found in housekeeping and medical records. The laundry facility was home to 56 full-time employees, 17 part-time employees and 27 casual staff.

Replacing the facility now could cost between $15 million and $30 million

Currently, the health region is shipping its laundry to the Regina Qu'Appelle Health Region and North Sask Laundry Ltd. in Prince Albert at a cost of $300,000 per month.

In 2007, when the facility was last shutdown due to a similar workplace accident, the provincial government gave the health region permission to start planning for a new facility, but those plans have been on hold for three years.

higher acute care (and rehabilitation4) hospital payments are not the whole story on investor-owned care. For-profit hospitals and dialysis clinics have high death rates.5,6 Investor-owned nursing homes are more frequently cited for quality deficiencies and provide less nursing care,7and investor-owned hospices provide less care to the dying,8than non-for-profit facilities.

fraud, the payment of kickbacks to physicians and overbilling of Medicare

For-profit executives reap princely rewards, draining money from care.

Investor-owned hospitals spend much less on nursing care than not-for-profit hospitals, but their administrative costs are 6 percentage points higher14

High administrative costs and lower quality have also characterized for-profit HMOs,15 now the dominant private insurers in the United States. Such plans take 19% for overhead, versus 13% in non-profit plans, 3% in the US Medicare program and 1% in Canadian medicare.16,17

Why do for-profit firms that offer inferior products at inflated prices survive in the market? Several prerequisites for the competitive free market described in textbooks are absent in health care.19,20

Privatization creates vast opportunities for powerful firms, and also redistributes income among health workers. Pay scales are relatively flat in government and not-for-profit health institutions; pay differences between the CEO and a housekeeper are perhaps 20:1. In US corporations, a ratio of 180:1 is average.22 In effect, privatization takes money from the pockets of low-wage, mostly female health workers and gives it to investors and highly paid managers.

But Canada’s federal government has been silent, declining to post current information about superbugs online or warn the Canadian public about the true extent of the problem, according to critics. The Association of Medical Microbiology and Infectious Disease Canada, a group of respected infectious disease specialists, last fall openly accused Ottawa of hiding the data it collects about instances of hospital-acquired infections. The association got a hold of the data and released it in order to inform the public (see sidebar).

The power of cleaning

Those in charge of infection control need to examine what the situation is in their own hospitals and make the necessary changes to ensure standards are met and maintained. Canadians are fully justified in expecting hospitals to clean up their acts.

Gilles Lanteigne, the CEO of the Champlain CCAC where Cranney is receiving care, says his experience is unusual. “We have a very structured process to ensure that any patient or family can make a complaint [or escalate it] … the process works very well for most people,” he says, adding that they track and publicly report on complaints. He says a 60-hour-a-month cap isn’t unusual for a regular case – someone that isn’t receiving palliative care, for example. PSWs may provide homemaking services if there is time, and the CCAC can link clients with homemaking providers, but there is a co-payment for those.

Whilst the paper details significant concerns about the one star food hygiene rating, the cleanliness issues identified by the CQC last year and ongoing employee relations issues, there are also a range of ‘hard FM’ issue the Trust continues to push Carillion to resolve.

Since December 2011, Carillion have been in an industrial relations dispute with a Trade Union following concerns raised by housekeeping staff about holiday entitlement, working practices and other allegations. This dispute has resulted in a large number (circa 50) employment tribunal claims lodged against Carillion by their own staff. This process is still ongoing with currently no timescale for resolution and it is clear distraction from the day to day service we require and pay for.

The Trust has lost confidence in Carillion’s ability to resolve these issues and the Trust continues to pursue all means necessary to ensure they remain focussed on addressing them”

Significantly, the report also includes the following:

The report drives a coach and horses through the notion that private companies such as Carillion should have any role to play in the health service and is a damning indictment of the Private Finance Initiative

The Trust does not hold a contract with Carillion. Instead, through the PFI, Carillion are contracted to provide these services by Semperian effectively the ‘owners’ of the building under the PFI agreement.

This therefore means that Carillion’s failings are an issue not only for the Trust in how we protect patients and maintain the quality of patient care, but also for Semperian PPP Investment Partners who we pay for the hospital and to sub-contract the hard and soft FM services.

The ongoing problems we have experienced with Carillion and their inability to resolve some of the more long running issues therefore reflect poorly on both Carillion itself and Semperian.

The important point for the Board to focus on, is not simply this being a contractual issue between companies, but this is a fundamental issue of ensuring the quality of care and treatment we provide to patients is the best it can be. It is also a reputational issue for the Trust in so far as the continual issues with poor quality are adversely impacting on our reputation amongst patients and key stakeholders.

Concerns about food hygiene and cleanliness, have posed a potential risk to patients, visitors and staff which is completely unacceptable. It is the view of the Executive Team that issues have not been taken as seriously as they should be by Carillion as resolving these outstanding issues is slow and any improvements made are not being consistently maintained.

Despite senior meetings between the three main parties on these and other issues (the Trust, Carillion and Semperian PPP Investment Partners who contract Carillion) there remain serious concerns about Carillion’s ability to deliver services to the required standard.

There is clearly a risk to quality and safety which needs to be addressed and Carillion have not demonstrated the ability to adequately resolve any one of these major issues to the required standard, let alone all of them together.

The two towers of the development look very much like an upscale residential development. They are connected with a gracious lobby manned around the clock by attentive concierges. There's a gym - complete with personal trainers - on an upper floor, as well as a communal kitchen that can be used for cooking demonstrations. There is enough polished stone and fancy millwork in the suites to satisfy even the most sophisticated of tastes. Outside, residents can putter in the gardens or host a barbecue on the terrace.

The executive chef - who previously worked at high-end Vancouver restaurant Italian Kitchen - sources produce directly from the nearby UBC Farm and refreshes the menu quarterly, with input from the residents.

A community shuttle can take people around to various neighbourhood destinations, although grocery shopping, banking, and medical appointments are all within very easy walking distance. A private car with driver can also be booked for an additional cost.

The meal options at Tapestry may be where it differs the most significantly from other seniors' facilities. Residents can cook for themselves in the fully-equipped kitchens in their individual suites, have meals brought to their suites, meet up with friends at the on-site pub, or entertain friends and family at the restaurant-style dining room. There are no set meal times and there is no assigned seating. The cost of the restaurant meals are debited individually from a monthly credit, much like the dining plan used by students living in dorms.

However, the services available go far beyond what you might find in most condo buildings. People can also take advantage of a beauty salon and spa, play a couple of rounds in a golf simulator, or engage in some mental stimulation in the brain fitness centre. Housekeeping is provided weekly, with medical staff on call around the clock. Medical treatments are delivered privately in the homes of residents, rather than requiring people to move to a hospital wing if they are ill.

"A lot of facilities come from a nursing or hospital style approach," explains Catherine Wallbank, vice-president of operations for Leisure Care. That firm manages Tapestry for developer Concert Properties. "We think about it from the hospitality perspective, and offering opportunities to enjoy life to the fullest."

It's an approach that suits 73-year-old Carol Byram and her 68-year-old husband Adrian. They purchased a home at Tapestry at Wesbrook after Adrian decided to return to school, and after Carol read a September 2010 Vancouver Sun profile of the project. After a long tech and entrepreneurial career in the U.S., Adrian is now working

toward a PhD in neuroethics at UBC. Carol is busy on the strata council and various committees for the building, as well as her work with Ballet BC "I tell people that living here is like being on a cruise ship or at the Four Seasons with all your friends," the former communications director for Sony Electronics says. "There is something to do all the time if you want to."

With isolation being a known hazard for seniors, Byram says she doesn't understand people who hang on to living in single-family homes until the bitter end. Activities at Tapestry include movie nights, day trips, fitness classes, and musical performances. She also says there is no shortage of people to go for a walk or meal with.

Byram enjoys being part of the larger community at UBC, saying there is a noticeable energy on campus as students stream in and out of classes. She volunteered to be a subject for a study examining the effects of companionship and exercise on aging. She is also involved in Project Chef, where students from a nearby elementary school come and cook with residents.

She often runs into her neighbours Yul and Joanne Kwon in the gym. Yul is 79, and Joanne is 77.

Yul has qualified to run the Boston Marathon next year, and is an adjunct professor of economics at SFU, after decades teaching at the University of Regina and a university in Australia. He tends to have his daughter accompany him on his longer runs through Pacific Spirit Park. "I am writing a book, so I am too busy to take advantage of all of these programs right now," he laughs. "But Joanne participates, and as time goes on, we appreciate that the events are available to us." They purchased their home three years ago at the urging of their son, and at the time, had no idea it was even a seniors residence. He and Carol agree that downsizing directly to Tapestry was the right choice to make, because of all of the amenities and the peace of mind offered by the staff.

Seniors must find help for house cleaning, shopping or errands elsewhere, either by paying privately, relying on family and friends or turning to a replacement program funded by the United Way called Better at Home, which has received $22 million from the province. Vancouver-Mt. Pleasant NDP MLA Jenny Kwan says Mayer's story is similar to those she's heard from other seniors in her riding during the last month. At least five couples and individuals - most of them Chinese-speaking - contacted her about having their weekly home care hours cut in half. Most have gone from two hours to one, just enough time for a bath. "The government wants seniors to live longer at home, but if you don't provide the supports for them to live successfully and safely, how are they going to manage? That will only mean they are going to need hospitalization, residential care or assisted living," Kwan said. "It's pay now or pay later and pay more," she added, noting that a day in an acute care hospital bed costs taxpayers about $1,500, enough to pay for plenty of routine in-home care. The change in home support hours from Vancouver Coastal Health is part of a move to follow provincial rules more closely, said Bonnie Wilson, director of home and community care for the health authority.

Home support is supposed to help clients with daily needs including bathing, dressing, using the toilet, taking medication or setting up a meal. These are considered medical services. Home support workers are paid only to do those tasks and not a wider range of duties that were covered before policy changes about 10 years ago: visiting, transportation, light yard work, minor home repairs, light housekeeping and grocery shopping. "VCH's home support guidelines are consistent with the Ministry of Health and other health authorities. Historically the mandate for home support services used to be broader, but this was sometime before 2004 (the guidelines that preceded our current ones)," Wilson explained in an email. "This was at a time when there was no distinction between medical and non-medical support services, and when clients went to residential care much sooner than they are now."

The complex medical problems experienced by some of Canada's oldest residents reflect a growing trend: people are living much longer, but not necessarily in good health. They can often stay at home - and avoid the high cost of either private or publicly funded nursing in residential care - but home support workers are being called upon to deliver some services that formerly fell to nurses. Doing laundry or picking up groceries are long gone from their to-do list. Exceptions to that, says Wilson, are allowed if it's unsafe for workers or the client to be in the home because of the mess, or if a client risks eviction or has been refused other government-subsidized services such as HandyDart because of a lack of cleanliness.

In British Columbia, home care is typically provided and subsidized - depending on income - by a local health authority that contracts the duty to a handful of accredited private companies. Clients with higher incomes often hire their own help. In 2013-14, B.C's health authorities spent $1.1 billion on home support for about 39,000 clients. That compares to $1.8 billion spent on residential care for 27,308 seniors. In 2012-13, the province funded 7.37 million hours of home support, according to the Ministry of Health, 23 per cent more than three years earlier. B.C.'s Office of the Seniors Advocate is planning to survey all recipients of publicly funded home support in the province about their experiences for an upcoming report. The Minister of Health was unavailable for comment by press time.

Schultz said they were not happy with what they see is a lack of commitment to supporting their concerns, and so decided to stage a rally outside his office. Yakabuski was in Toronto Wednesday, so wasn't in his constituency office to hear or speak to those gathered outside. About 60 health care workers and their supporters took part in the rally, which included those from Kingston, Smiths Falls, Perth and other places within Eastern Ontario. Following the rally, the group marched from 84 Isabella and through the downtown core before looping back.

Cindy Schulz, president of CUPE Local 1502 which representing Registered Practical Nurses, technical staff including x-rays and diagnostics and support staff at the PRH, said they decided to bring their message to Yakabuski in person because they feel let down by the MPP. "We first met June 19 with Mr. Yakabuski regarding stopping the closure of the CSR department and the bed cuts," she said, "and his response was what can he do about it?" Schulz said the MPP promised he would attend a town hall meeting on the matter which was held July 30, and he never arrived.

Federal NDP candidate Dan McCarthy also attended the rally, and said this shows the need for a national approach to health care, where local, provincial and federal levels of government respond and cooperate together to the needs. He said changes to the funding formula from the federal level has led to cutbacks right down the line, which is affecting everyone. "The NDP is the pioneer of public health care," McCarthy said, pledging that an NDP government would step up to see to it this Canadian tradition continues.

The cutbacks at the PRH began April 1, when the medical beds were reduced by five. This reduction was implemented in accordance with the hospital's 2015/2016 budget. Back in July, John Wren, senior vice-president of corporate and support services at PRH, told The Daily Observer the decision to reduce the number of beds in the hospital came after examining hospital services and the needs of the patients that PRH serves. He stated becoming more efficient in patient length of stay has resulted in the beds no longer being needed. According to Wren, the April 1 bed reduction was known about since February 2015 and the physicians have been actively engaged in working towards this eventuality.

Another aspect of the protest is a postcard campaign directed at the Minister of Health Eric Hoskins, asking him to intervene in the hospital's decision to outsource sterilization services. Schulz said this has been going well, with 7,000 of them signed so far, reflecting the public's opposition to the changes. She said they will be hand delivering these to Queen's Park once the fall session starts in September. Stephen Uhler is a Daily Observer multimedia journalist

Members of the Pembroke Regional Hospital staff and their supporters march down Church Street following a rally held Wednesday in front of 84 Isabella Street. They were protesting the contracting out of services and the closure of medical beds.

While the Canadian notion has no resonance in the United States, and is downright silly, the fact is that nativism is alive and well south of the border, and means that Canada could one day be side-swiped in other ways that are very damaging unless we manage the relationship well. So whoever's in Ottawa must be more American-savvy than ever before, and yet the opposition parties don't bring up the U.S. relationship at all. Canada's newest political entries pander to the status quo, and merely offer the electorate a roster of competing shopping lists: Tom Mulcair with his extravagant universal day care and Justin Trudeau with his infrastructure spending spree. This is housekeeping, not nationbuilding. Canada faces existential challenges that should be addressed. In the spirit of politically incorrect Donald, here a few major ones, not necessarily in order of importance:

.. What does Canada do for a living after most of the auto jobs have gone to Kentucky and Mexico or Silicon Valley in 15 years or so? ..What does Canada do for a living after fossil fuels are replaced by solar and other renewables after 2030? ..Should Canada become economically joined with the United States, given its technological dominance and wealth, so it's not left behind? ..How does Canada mitigate the ongoing Canadian brain drain and close its lengthening productivity and innovation gaps? (In the 20th century, the equivalent of the entire 1900 population of Canada emigrated to the United States and now roughly the population of Quebec City emigrates permanently every decade. Currently, roughly three million more have become U.S. citizens, are living there on visas, are illegally there or are snowbirds. Roughly 400,000 work daily in Manhattan, 250,000 in Hollywood and 300,000 in Silicon Valley.) ..Why can't Canada capitalize on its superior health-care system and allow the creation of a massive industry of health-care tourism serving Americans and the world?

.Why can't Canada create an Australian-style system of fast-track verification involving First Nations claims to stop the country's resource and pipeline quagmire, and to finance First Nations development? ..Why can't Canada scrap its costly farm supply management systems (poultry and dairy) and create worldclass, competitive agribusinesses like New Zealand has done instead of coddling and subsidizing these farms? ..Why doesn't Canada simply admit the Arctic is not properly monitored, protected or developed and create a U.S.-Canada navy in the face of Russia's aggressiveness?

.Why can't Canada scrap the Senate or replace it (if it must) with a legitimate, elected body? ..Why can't Canada merge the four Atlantic Provinces into one super province? These are just a few questions hanging over the country that are ignored because they are politically incorrect. Instead, the country drifts, thanks to politicians whose "vision" is restricted to taxing and spending initiatives. dfrancis@nationalpost.com