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Imagine if a Canadian diagnosed with cancer were told she could receive chemotherapy paid for by the health-care system, but would have to cough up the cash herself if she needed radiation. Or that she could have a few weeks of treatment, and then be sent home even if she needed more. That would never fly. If doctors, say, find a tumour in a patient's colon, the government kicks in and offers the mainstream treatment that is most effective. But for many Canadians diagnosed with a mental illness, the prescription is very different. The treatment they receive, and how much of it they get, will largely be decided not on evidence-based best practices but on their employment benefits and income level: Those who can afford it pay for it privately. Those who cannot are stuck on long wait lists, or have to fall back on prescription medications. Or get no help at all. But according to a large and growing body of research, psychotherapy is not simply a nice-to-have option; it should be a front-line treatment, particularly for the two most costly mental illnesses in Canada: anxiety and depression - which also constitute more than 80 per cent of all psychiatric diagnoses.

Why aren't we providing evidence-based care?" .. The case for psychotherapy Research has found that psychotherapy is as effective as medication - and in some cases works better. It also often does a better job of preventing or forestalling relapse, reducing doctor's appointments and emergency-room visits, and making it more cost-effective in the long run.

Therapy works, researchers say, because it engages the mind of the patient, requires active participation in treatment, and specifically targets the social and stress-related factors that contribute to poor mental health. There are a variety of therapies, but the evidence is strongest for cognitive behavioural therapy - an approach that focuses on changing negative thinking - in large part because CBT, which is timelimited and very structured, lends itself to clinical trials. (Similar support exists for interpersonal therapy, and it is emerging for mindfulness, with researchers trying to find out what works best for which disorders.) Research into the efficacy of therapy is increasing, but there is less of it overall than for drugs - as therapy doesn't have the advantage of well-heeled Big Pharma benefactors. In 2013, a team of European researchers collated the results of 67 studies comparing drugs to therapy; after adjusting for dropouts, there was no significant difference between the most often-used drugs - selective serotonin reuptake inhibitors (SSRIs) - and psychotherapy.

The issue is not one against the other," says Montreal psychiatrist Alain Lesage, director of research at the Douglas Mental Health University Institute. "I am a physician; whatever works, I am good. We know that when patients prefer one to another, they do better if they have choice." Several studies have backed up that notion. Many patients are reluctant to take medication for fear of side effects and the possibility of difficult withdrawal; research shows that more than half of patients receiving medication stop taking it after six months. A small collection of recent studies has found that therapy can cause changes in the brain similar to those brought about by medication. In people with depression, for instance, the amygdala (located deep within the brain, it processes basic memories and controls our instinctive fight-or-flight reaction) works in overdrive, while the prefrontal cortex (which regulates rational thought) is sluggish. Research shows that antidepressants calm the amygdala; therapy does the same, though to a lesser extent.

But psychotherapy also appears to tune up the prefrontal cortex more than does medication. This is why, researchers believe, therapy works especially well in preventing relapse - an important benefit, since extending the time between acute episodes of illnesses prevents them from becoming chronic and more debilitating. The theory, then, is that psychotherapy does a better job of helping patients consciously cope with their unconscious responses to stress.

According to treatment guidelines by leading international professional and scientific organizations - including Canada's own expert panel, the Canadian Network for Mood and Anxiety Treatments - psychotherapy should be considered as a first option in treatment, alone or in combination with medication. And it is "highly recommended" in maintaining recovery in the long term. Britain's independent, research-guided scientific body, the National Institute for Health and Care Excellence, has concluded that therapy should be tried before drugs in mild to moderate cases of depression and anxiety - a finding that led to the creation of a $760million public system, which now handles therapy referrals for nearly one million people a year.

In 2012, Canada's Mental Health Commission estimated that only about one in three adults and one in four children are receiving support and treatment when they need it. Ironically, anti-stigma campaigns designed to help people understand mental illness may only make those statistics worse. In Toronto, for instance, putting up posters in subway stations in 2010 had the unexpected effect of spiking the volume of walk-ins at nearby emergency rooms by as much as 45 per cent in 12 months. Dr. Kurdyak treated many of them at CAMH. The system, he says, "has been conveniently ignoring this unmet need. It functions as if two-thirds of the people suffering won't get help." What would happen if the healthcare system outright "ignored" two-third of tumour diagnoses?

Essentially, argues Dr. Lesage, adding therapy into the health-care system is like putting a new, highly effective drug on the table for doctors. "Think about it," he says. "We have a new antidepressant. It works as well as many others, and it may even have some advantages - it works better for remission - with fewer side effects. The patients may prefer it. And [in the long run] it doesn't cost more than what we have. How can it not be covered?" ..

A heavy price This isn't just a medical issue; it's an economic one. Mental illness accounts for roughly 50 per cent of family doctors' time, and more hospital-bed days than cancer. Nearly four million Canadians have a mood disorder: more than all cases of diabetes (2.2 million) and heart disease (1.4 million) combined.

Mental illness - and depression, in particular - is the leading cause of disability, accounting for 30 per cent of workplace-insurance claims, and 70 per cent of total compensation costs. In 2012, an Ontario study calculated that the burden of mental illness and addiction was 1.5 times that of all cancers, and more than seven times the cost of all infectious diseases. Mental illness is so debilitating because, unlike physical ailments, it often takes root in adolescence and peaks among Canadians in their 20s and 30s, just as they are heading into higher education, or building careers and families. Untreated, symptoms reverberate through all aspects of life, routinely trapping people in poverty and homelessness. More than one-third of Ontario residents receiving social assistance have a mental illness. The cost to society is clearly immense.

Yet, when family doctors were asked why they didn't refer more patients to therapy in a 2008 Canadian survey, the main reason they gave was cost. For many Canadians, private therapy is a luxury, especially if families are already wrestling with the economic fallout from mental illness. Costs vary across provinces, but psychologists in private practice may charge more than $200 an hour in major centres. And it's not just the uninsured who are affected.

Although about 60 per cent of Canadians have some form of private insurance, the amount available for therapy may cover only a handful of sessions. Those with the best benefits are more likely to be higherincome workers with stable employment. Federal public servants, notably, have one of the best plans in the country - their benefits were doubled in 2014 to $2,000 annually for psychotherapy. Many of those who can pay for therapy are doing so: A 2013 consultant's study commissioned by the Canadian Psychological Association found that $950-million is spent annually on private-practice psychologists by Canadians, insurance companies and workers compensation boards. The CPA estimates t

These are the patients that family doctors juggle, the ones who eat up appointment time, and never seem to get better, the ones caught on waiting lists. Sometimes, they have already been bounced in and out of the system, received little help, and have become wary of trying again. A 40-something mother recovering from breast cancer, suffering from chronic depression post-treatment, debilitated by fear her cancer will return. A university student, struggling with anxiety, who hasn't been to class for three weeks and may soon be kicked out of school. A teenager with bulimia removed from an eatingdisorder program because she couldn't follow the rules. They are the ones dangling on waiting lists in the public system for what often amounts to a handful of talk-therapy sessions, who don't have the money to pay for private therapy, or have too little coverage to get the full course of appointments they need.

Canada's investment does not match that burden. Only about 7 per cent of health-care spending goes to mental health. Even recent increases pale when compared to other countries: According to a study by the Canadian Mental Health Association, Canada increased per-capita funding by $5.22 in 2011. The British government, meanwhile, kicked in an extra 12 times that amount per citizen, and Australia added nearly 20 times as much as we did. Falling off a cliff, again and again

In Winnipeg, Dr. Stanley Szajkowski watched for months as his patient, a woman in her 80s, slowly declined. Her husband had died and she was spiralling into a severe depression. At every appointment, she looked thinner, more dishevelled. She wasn't sleeping, she admitted, often through tears. Sometimes she thought of suicide. She lived alone, with no family nearby, and no resources of her own to pay for therapy. "You do what you can," says Dr. Szajkowksi. "You provide some support and encouragement." He did his best, but he always had other patients waiting.

hat 30 per cent of private patients pay out-ofpocket themselves. When the afflicted don't seek help, the cost isn't restricted to their own pocketbook. People with mental-health problems are significantly more likely to abuse drugs and alcohol, and to become physically sick, further increasing health-care costs. A 2014 study by Oxford University researchers found that having a mental illness reduced life expectancy by 10 to 20 years, roughly the same as did smoking and obesity. A 2008 Statistics Canada study linked depression to new-onset heart disease in the general population. A 2014 U.S. study found that women under the age of 55 are twice as likely to suffer or die from a heart attack, or require heart surgery, if they have moderate to severe depression. The result: clogged-up doctors' offices, ERs, and operating rooms. And an inexorable burden for the patients' families forced to fill the gaps in caregiving - or carry on when they lose a loved one.

Patients refer to it as falling repeatedly off a cliff. And they can only manage the climb back up so many times. Family doctors interviewed for this story admitted that they are often "handholding" patients with nowhere else to go. "I am making them feel cared for, I am providing a supportive ear that they may not get anywhere else," says Dr. Batya Grundland, a physician who has been in family practice at Toronto's Women's College Hospital for almost a decade. "But do I think I am moving them forward with regard to their illness, and helping them cope better? I am going to say rarely." More senior doctors have told her that once in a while "a light bulb goes off" for the patients, but often only after many years. That's not an efficient use of health dollars, she points out - not when there are trained therapists who could do the job better. However, she says, "in some cases, I may be the only person they have."

Family doctors aren't the only ones struggling to find therapy for their patients. "I do a hundred consultations a year," says clinical psychiatrist Joel Paris, a professor at McGill University and research associate at the Montreal Jewish General, "and one of the most common situations is that the patient has tried a few anti-depressants, they have not responded very well, and from their story it is obvious they would benefit from psychotherapy. But where do they go? We have community clinics here in Montreal with six-to-12-month waiting lists even for brief therapy." A fractured, inefficient system

"You fall into the role that is handed to you," says Antoine Gagnon, a family doctor in Osgoode, on the outskirts of Ottawa. He tries to set aside 20-minute appointments before lunch or at the end of the day to provide "active listening" to his patients with anxiety and depression. Many of them are farmers or self-employed, without any private coverage for therapy. "Five of those minutes are spent talking about the weather," he says, "and then maybe you get into the meat of the problem, but the reality is we don't have the appropriate amount of time to give to therapy, even to listen, really." Often, he watches his patients' symptoms worsen over several months, until they meet the threshold of a clinical diagnosis. "The whole system could save on productivity and money if people were actually able to get the treatment they needed."

But these issues aren't insurmountable, as other countries have demonstrated. Britain, for instance, has trained thousands of university graduates to become therapists in its new public program, following research showing that, as long they have the proper skills, people don't need PhDs to be effective therapists. Australia, which has created a pay-for-service system, also makes wide use of online support to cost-effectively reach remote communities.

Except for a small fraction of GPs who specialize in psychotherapy, few family doctors have the training - or the time - to provide structured therapy. Saadia Hameed, a GP in a family-health team in London, Ont., has been researching access to psychotherapy for an advanced degree. Many of the doctors she has interviewed had trouble even producing a clear definition of therapy. One told her, "If a patient cries, than it's psychotherapy." Another described it as "listening to their woes." A 2007 survey of 163 family doctors in Ontario found that almost four out of five had not received training in cognitive behavioural therapy, and knew little about it. "Do family doctors really need to do that much psychotherapy," Dr. Hameed asks, "when there are other people trained - and better trained - to do it?"

What further frustrates treatment for physicians and patients is lack of access to specialists within the system. Across the country, family doctors describe the difficulty of reaching a psychiatrist to consult on a diagnosis or followup with their patients. In a telling 2011 study, published in the Canadian Journal of Psychiatry, researchers conducted a real-world experiment to see how easily a GP could locate a psychiatrist willing to see a patient with depression. Researchers called 297 psychiatrists in Vancouver, and reached 230. Of the 70 who said they would consider taking referrals, 64 required extensive written documentation, and could not give a wait-time estimate. Only six were willing to take the patient "immediately," but even then, their wait times ranged from four to 55 days. Psychiatrists are in increasingly short supply in Canada, and there's strong evidence that we're not making the best use of these highly trained specialists. They can - and often do - provide fee-for-service psychotherapy in a private setting, which limits their ability to meet the huge demand to consult with family doctors and treat the most severe cases.

A recent Ontario study by a team at CAMH found that while waiting lists exist in both urban and rural centres, the practices of psychiatrists in those locations tend to look very different. Among full-time psychiatrists in Toronto, 10 per cent saw fewer than 40 patients, and 40 per cent saw fewer than 100 - on average, their practices were half the size of psychiatrists in smaller centres. The patients for those urban psychiatrists with the smallest practices were also more likely to fall in the highest income bracket, and less likely to have been previously hospitalized for a mental illness than those in the smaller centres.

And those therapy sessions are being billed with no monitoring from a health-care system already scrimping on dollars, yet spending a lot on this care: On average, psychiatrists earn $216,000 a year. There is nothing to stop psychiatrists from seeing the same patients for years, and no system to ensure the patients with the greatest need get priority. In Australia, Britain and the United States, by contrast, billing for psychiatrists has been adjusted to encourage them to reduce psychotherapy sessions and serve more as consultants, particularly for the most severe cases, as other specialists do.

As the Canadian system exists now, says Benoit Mulsant, the physician-in-chief at CAMH and also a psychiatrist, the doctors in his specialty "can do whatever they please. If I wanted, I could have a roster of actor patients who tell me entertaining stories, and I would be paid the same as someone who is treating homeless people. ... By treating the rich and famous, there is zero risk of being punched in the face by a patient." Left out in all this, by and large, are other professionals who can provide therapy. It doesn't help that the rules are often murky around who can call themselves psychotherapists. While psychologists and social workers are licensed under their professional associations, in some provinces a person can call himself a marriage counsellor or music therapist with no one demanding they be certified. In 2007, Ontario passed a law to regulate psychotherapists, requiring them to register with a provincial college that would set standards and handle complaints. Currently, however, the law is in limbo, although the government has said it will finally bring it into force by December. The brain keeps many secrets

Science, however, has yet to find depression's equivalent of insulin. Despite being scanned, poked and stimulated over and over and over again, the brain keeps its secrets. The "chemical imbalance" theory is now viewed as simplistic at best. It may not do much for patients, either: A 2014 study published in the journal Behaviour Research and Therapy suggested that, rather than reassuring them, focusing on the biological explanation for depression actually made patients feel more pessimistic and lacking in control. SSRIs work by increasing the amount of serotonin, a chemical that helps deliver messages within the brain and is known to influence mood. But researchers aren't sure why the drugs help some patients and fail with others. "Basically, it's like we have a bucket of water and we pour it over the patient's head," says Dr. Georg Northoff, the University of Ottawa's Michael Smith chair of Neurosciences and Mental Health. "But you want a drug that injects the water in a very specific brain regions or brain system, which we don't have."

Critics of therapy have argued that it's basically "good listening" - comparable to having a sympathetic friend across the kitchen table - and that in the real world of mercurial patients and practitioners of varying abilities, a pill just works better. That's true in many cases, especially when the symptoms are severe and the patients is suicidal: a fast-acting medication is safer, and may even be necessary before starting talk therapy. The staunchest advocates of therapy do not suggest it should be the first course of treatment for psychosis, or debilitating chronic depression, or mania - although, in those cases, there is evidence that psychotherapy and medication work well in tandem. (A 2011 meta-analysis found that patients with severe depression who received a combination approach had higher recovery rates and were less likely to drop out of treatment.) But drugs also don't work as well as the manufacturers would like us to think. Roughly one-third of patients given a drug will see no benefit (although they often respond to a second or third medication). In randomly controlled trials, drugs often perform only marginally better than sugar pills.

Yet it's talk therapy that the public often views most skeptically. "Until you go to a therapist, or a member of your family has a serious psychological problem, people are unsympathetic [about therapy]," says Dr. Paris, the Montreal psychiatrist. "They are very skeptical, and they don't believe the research. It's amazing, because pharmaceutical trials will get approval for a drug on the basis of two clinical trials that they paid for. And we have 100 clinical trials and no one believes us."

Dr. Ajantha Jayabarathan, an assistant professor at Dalhousie University's medical school, spent her early years as a family doctor in Spryfield, N.S., trying to manage an overload of mental-health cases. Most of her patients had little insurance; there was one reduced-cost counselling service in town, but the waiting lists were long. In 2000, her group practice became a test site for a shared-care project, which gave the doctors access to a mental-health team, including weekly in-person consultations with a psychiatrist. "It was transformative," she says. "We looked after everything in-house.

Over time, Dr. Jayabarathan says, she learned how to properly assess mental illness in patients, and how to use medication more effectively. "I just made it my business to teach myself what to do." It's the kind of workaround GPs are increasingly experimenting with, waiting for the system to catch up. Who would pay - and how?

The case for expanding publicly funded access to therapy is gaining traction in Canada. In 2012, the health commissioner of Quebec recommended therapy be covered by the province; it is now being studied by Quebec's science-based health body (INESSS), which is expected to report back next year. A new Quebec-based organization of doctors, researchers and mental-health advocates called the Coalition for Access to Psychotherapy (CAP) is lobbying the government.

In Manitoba, the Liberal Party - albeit well behind in the polls - has made the public funding of psychologists one of its campaign platforms for the province's spring 2016 election. In Saskatchewan, the government commissioned, and has since endorsed, a mental-health action plan that includes providing online therapy - though politicians have given themselves 10 years to accomplish it. Michael Kirby, the former head of the Canadian Mental Health Commission, has been advocating for eight annual sessions of therapy to be covered for children and youth in need.

There are significant hurdles: Which practitioners would provide therapy, and how would they be paid? What therapies would be covered, and for how long? Complicating every aspect of major mentalhealth change in Canada is the question of who should shoulder the cost: the provinces or Ottawa. In a written statement in response to questions from The Globe and Mail, federal Health Minister Rona Ambrose lobbed the issue back at her provincial counterparts, pointing out that the Canada Health Act does not "preclude provinces and territories from extending public coverage to other services or providers such as psychologists."

One result can be overloaded family doctors minimizing mental-health problems. "If you have nothing to offer someone," asks Dr. Anderson, "how much are you going to dig around to find out what is going on?" Some doctors also admit that the lack of resources can lead to physicians cherry-picking patients who don't have mental illness. And yet family physicians alone bill about $361million a year for counselling or psychotherapy in Canada - 5.6 million visits of roughly 30 minutes each. This is a broad category, and not always specifically related to mental health (some of it includes drug counselling, and a certain amount of coaching is a necessary part of the patient-doctor relationship). When it is psychotherapy, however, doctors admit it's often more supportive listening than actual therapy.

So how would Canada pay for access to such therapy? It wouldn't be cheap, in the short term. The savings would come from what Canadians would not have to spend in the long term: in additional medical and drug costs, emergency-room visits and hospital stays, and in unnecessary disability payments, to say nothing of better long-term health outcomes for patients given good care earlier. Some of the figures being tossed around sound staggering. Rolling out a version of Britain's centre-based program across Canada would cost $950-million. Michael Kirby's plan would amount to $1,000 annually per patient. A 2013 report commissioned by the Canadian Psychological Association calculated that, based on predicted need, and assuming no coverage from private health-care plans, providing an average of six sessions of therapy a year would cost an estimated $2.8-billion annually.

But any of those figures would still be a fraction of the roughly $210-billion that Canada spends annually on health care. Figuring out how to make the system most costeffective is, according to sources, currently delaying the INESSS report to the Quebec government. "You need to facilitate the government," says Helen- Maria Vasiliadis, a professor of community health at the University of Sherbrooke. "You can't be going to policymakers and showing them billions and billions of dollars. People start having heart attacks. With evidence in hand, we have to present possible solutions."

An insurance-based plan is the proposal that has emerged from the Quebec-based CAP group, which sent its proposal to Quebec's health minister last month. In its design, the system would work much like Quebec's public drug plan - Quebeckers not covered through work plans would contribute to a provincial insurance program for therapy. That would be similar to the system that Germany has used for decades. One step forward, one step back

Last year, the Sherbrooke clinic where Marie Hayes works received provincial funding for a part-time psychologist and a full-time social worker. With a roster of 25,000 patients, the clinic team laid out clear guidelines for the psychologist, who would consult on cases and screen patients, and be limited to a mere four sessions of actual counselling with any one patient. "We wanted to be careful she didn't become a waiting list - like everything in the system," says Dr. Hayes. The social worker helps guide patients into services such as housing and addiction counselling. They have also offered group sessions for depression management at the clinic. As stretched as those new professionals are in such a large practice, Dr. Hayes says the addition of that mental-health team is improving the care she can provide patients. Recently, for instance, the 32- year-old mother with anxiety attended sessions with the psychologist. "She is making progress," says Dr. Hayes, "slowly."

At Women's College Hospital in Toronto, Dr. Grundland is not so lucky. Asked to describe a difficult case, the family-practice physician mentions a patient suffering from depression after a lifechanging accident. Every month, doctor and patient would repeat the same conversation they'd already had more than a dozen times - and make little real headway. Her patient, says Dr. Grundland, needs a trained therapist: someone she can see regularly, to help her move past her frustration, counsel her about addiction, and ease the burden on her family.

But there's no extra money in the patient's budget for a psychologist. "I do my best," Dr. Grundland says, "but it's not my area of expertise." Meanwhile, the patient isn't getting better, and in the time that it takes to make it through one appointment with her, Dr. Grundland could see three other people with problems she was actually trained to treat. "But," says Dr. Grundland, "she has nowhere else to go." Erin Anderssen is a feature writer at The Globe and Mail. OPEN MINDS How to build a better mental health care system

The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. While CAMH professionals are quoted in this story, the organization had no involvement in the creation or production of this, or any other story in the series. $20.7-billion The cost, according to a 2012 Conference Board of Canada report, of lost productivity each year due to mental illness. What else does $20-billion represent?

$20B: Canadian spending on national defence, 2012-13 $20B: Market valuation of Airbnb, 2015 $21B: Kitchener-CambridgeWaterloo region's GDP, 2009 $21B: Amount food manufacturing contributed to the economy, 2012

The 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.

Patients suffering in pain on wait lists for surgery have once again been denied their Charter right to access health care outside of the government's cruel, inefficient, and unaccountable monopoly. In 2005, the Supreme Court of Canada famously declared in Chaoulli vs. Quebec that "access to a waiting list is not access to health care." But last week, the Alberta Court of Appeal refused to apply and follow the Chaoulli precedent, citing a lack of evidence in the case of Darcy Allen vs. Alberta.

until September 2010 - a date later pushed back to June 2011. No longer able to work to support himself and his family, unable to perform ordinary day-to-day tasks, and experiencing pain so severe that not even the strongest drugs were effective, he spent $77,000 of his own money on surgery in Montana. Dr. Allen's surgery immediately and significantly reduced his pain, and started his slow journey back to better health. Apart from paying out of pocket, Dr. Allen's only other option was to suffer two years of extreme pain, waiting for the Alberta government's monopoly system to provide necessary surgery.

Dr. Allen's experience with medical wait times is, unfortunately, not unique. While patients in France, Germany, Japan and dozens of other developed democracies count their medical wait times in days and weeks, the government health monopolies in Canadian provinces subject patients to wait times that are counted in months and years. The international evidence demonstrates that there is simply no need for government to impose a monopoly over health care in order to ensure that health services are available to all members of the public. In Chaoulli, the Supreme Court held that while government has every right to create health-care programs, it does not have the right to create a monopoly that prevents patients from accessing health care outside of that government monopoly.

Last week's Court of Appeal decision, as well as the trial decision under appeal, declared that Dr. Allen had not brought forward enough evidence to support his claim. Curiously, neither decision refers to the extensive evidence put before the court about Alberta's long wait lists, and how wait times hurt patients, even killing them in some cases. While refusing to consider - or even mention - this abundant evidence, the court declared that Darcy Allen should have introduced expert reports and expert witnesses to testify about the fact that wait lists exist, and the fact that wait lists inflict suffering - and sometimes death - on patients. The Alberta government has not disputed either of these two facts. They are the same facts on which the Supreme Court relied in Chaoulli.

Following the court's logic, Darcy Allen should have spent $77,000 out-of-pocket on his medically necessary surgery, and then an additional $200,000 to $400,000 to assert his Charter rights, by paying a panoply of experts to "prove" basic facts that have already been admitted by the Alberta government. So much for access to justice.

To respect Charter rights, governments have only two options: ensure that a monopoly system provides real access to health care (not just access to a waiting list), or allow Canadians the freedom to access health care outside of the government's system. A law that creates a government monopoly over health care, by banning private health insurance, complies with the Charter only if that monopoly does not inflict pain and suffering - and a real risk of death - on waiting patients.

Ignoring the evidence before them about Alberta's long and painful waiting lists, Alberta's courts have refused to deal with the violation of Darcy Allen's Charter rights. Hopefully the Supreme Court of Canada will not refuse to do so. National Post Calgary lawyer John Carpay is president of the Justice Centre for Constitutional Freedoms (Jccf.ca) and acts for Darcy Allen.

The trial was set to begin on Monday but now has been postponed as both sides examine the newly found ministry files. NDP health critic Judy Darcy says she hopes the government will throw everything it can at Dr. Day, because if he wins, she believes, British Columbia will be opening the door to a new twotiered health-care system for the country. She isn't convinced the B.C. Liberals wanted to fight this battle. "I think the government is under tremendous pressure to defend the Canada Health Act," she said in an interview. But at least at the outset, the province needed some prodding to engage.

The B.C. Nurses' Union led the charge in 2003, challenging the provincial government to enforce the law and stop private clinics from treading on publichealth turf. It was 2008 when the province finally sought an audit of the books of Dr. Day's two clinics. The two sides then spent four years arguing about the scope of the audit. Finally, in 2012, the Medical Services Commission concluded the clinics were extra billing patients and threatened an injunction, which is still up in the air. The audit was limited to a small sampling of a few hundred cases. "The only thing we saw was a one spot-check audit and it showed $150,000 worth of extra billing in a single month," Ms. Darcy said.

"So we are talking about millions of dollars over the years, and nothing has been done about that." The B.C. Health Coalition is an intervenor in the case. While the province may have been slow to get started, Steven Shrybman, a member of the group's legal team, says he is impressed with B.C.'s case as it stands now. "The province has demonstrated a very serious commitment to this case," he said. "I can't fault them for the job they have done in defending the validity of our medicare model under the Charter." Dr. Day has been angling for this day in court for many years, and all the while he says his case has grown stronger as the province's surgical waiting lists have grown.

"This is a case about patients being able to care for their own health when the government won't provide it," he said. The B.C. Supreme Court will hear, possibly later this spring, his argument that Canadians have a right, under the Charter, to access necessary and appropriate health care within a reasonable time - something he says does not exist in B.C. "The only way the government can win, in my view, is if they can show that wait lists are not a problem." Health Minister Terry Lake told reporters last week that the reason some waiting lists are growing is because the healthcare system is doing more surgeries. "But I have asked our provincial surgical advisory committee to look at the situation, because I think we can do better ... One of my real desires is to reduce those wait times."

That's why those freshly discovered Health Ministry files may be revealing, and if nothing else, Dr. Day's battle may drive the provincial government to find not just the desire, but the means, to take aim at surgical waiting lists.

However, there are concerns. Organ solicitations have been criticized as unfair, because they enable donation to identified recipients rather than to a recipient on a waiting list. Celebrity status and access to resources clearly provide increased opportunities to find a donor. A person with a high profile or more appealing story may be perceived as getting ahead in the transplant system, which could influence the public against organ donation.4 Recipients who are computer literate, social media savvy or English-speaking have enhanced access to potential donors beyond their local community and are more likely to find a donor than those without these characteristics.2 Publicity surrounding personal stories involving organ solicitation can be misleading and encourage offers to the solicitor, without considering donations to those with greatest need.5 However, all living donation is inequitable in that the donor chooses to whom to donate — generally someone they know — without any requirement to donate to the wait-list recipient with the greatest need.

One concern with public solicitations for organs is the potential for exposure of the recipient to harms from a donor who is unknown to them, which may in turn damage the reputation of transplant programs.3 Canadian law requires a minimum donor age for living donors, voluntary consent and no exchange of goods for an organ.6 Public solicitation may increase the potential for exchange of valuable considerations for an organ, because the donor is unknown to the recipient.

Two recent, well-publicized Canadian cases focused attention on these issues. The owner of the Ottawa Senators hockey team, who needed a new liver, used his public profile to solicit an anonymous donor.7 In the other case, the family of a young girl who needed a liver transplant made a public appeal through a Facebook page.8 The solicitation was fuelled by media attention surrounding this touching story, whereby the child’s twin had received liver tissue donated by their father, who could only donate once. The solicitation received more than 500 responses from people willing to donate.8 These two public solicitations for organs received markedly different public responses: one faced criticism9 and the other garnered sympathy. The difference in public perceptions was likely due to the different recipient profiles. In both cases, anonymous donors came forward, were screened and donated a part of their livers.

There are no guidelines for public solicitation of organs in Canada. Canadian transplant programs have had to address this issue on a case-by-case basis, often without consensus. Within Canada, different responses to organ solicitation by potential donors may be producing inequity of access to organs. Transplant programs and their patients could benefit from guidance on how to address the challenges raised by public solicitations. Many transplant doctors would be comfortable with public solicitation only if the donor became a nondirected altruistic donor, by which the organ is allocated to the next suitable recipient on the waiting list rather than to the actual solicitor (unpublished survey data, July 2015). Transplant doctors consider the next best thing to be to ensure that a relationship existed between the recipient and the solicited donor before donation occurs.

Donors who respond to public solicitations should be considered for transplantation. However, transplant programs must ensure that the motivation for donation is based on altruism rather than secondary intention, and that donors meet medical and psychosocial criteria for living donors, provide informed consent and agree to meet the requirements of the program regarding contact with the recipient. Although they should not be dissuaded from donating to the intended recipient, solicited donors should be made aware of alternatives such as donating to the recipient with the greatest need. A model is Canada’s National Kidney Paired Donation program. This program is the best option for candidates who have living kidney donors who are willing to donate and medically able, but who are incompatible with their intended

recipient. The program coordinates a chain of multiple transplants so that a willing donor’s organ can find its way to a compatible recipient while the intended recipient also receives an organ.10 This system allows the most people in need of an organ to get one. Even if the solicited donor and recipient are compatible, they can still choose to enter the National Kidney Paired Donation program as a pair, to benefit the greater transplant community, because a critical number of pairs are required for the overall success of the program.10 Whether donors from a public solicitation should remain anonymous to their recipients is a decision best left to the transplant program.

Donations of living organs are valued. Solicited organ donation helps to identify willing donors. It is an important facet of living donation and should be promoted. However, solicited organ donors should be encouraged to consider anonymous nondirected organ donation within systems, such as the National Kidney Paired Donation program, to maximize the number of patients in need who receive a transplant from a willing altruistic donor.

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.

Gaétan Barrette, the head of the province's association of medical specialists, said he is considering legal action if the health minister can't prove his claims. "This is one step shy of defamation," he said.

Bolduc said he will work closely with Quebec's College of Physicians to comb through waiting lists for irregularities.

Today that statistic has fallen considerably, with the average wait at 208 days and the median wait time 81.

But the push to not build or expand any long-term care homes -- an expensive undertaking -- also comes from the belief by those holding the purse strings that they have a better formula for budgeting those coveted health-care dollars.

"We are no longer, to the extent possible, having people make the decision to go to a long-term care home from hospital," said LeClerc.

This not only has relieved a burden on the wait lists, but also a burden on the hospital.

Seniors were more and more frequently taking up hospital beds to a high in January 2011 when 51 seniors were waiting at the Cornwall Community Hospital to go into care elsewhere. Now, LeClerc said, there are 14.

"We actually found that if we were to provide a range of services in the community, that up to a third of the people on the waiting list could come off the waiting list and be cared for in the community," said LeClerc.

So the focus has become trying to keep seniors in their homes -- with the help of community programs -- for just a few months longer, shortening the average long-term care home stay to less than three years where possible.

e care has concerned Cornwall Coun. Andre Rivette, who has said that home care places too high of a burden on families providing care. "They're saying that 82% of residents in Glen-Stor-Dun (Lodge) have dementia or Alzheimer's," he said. "Home care is not going to be of any use for the (82%)."

In their recent CMAJ article, Morgan and colleagues present just such a study.2 Using recently available national data on drug use and costs, they report an economic model that estimates the cost of implementing national public drug coverage. The model anticipates several key evidence-based consequences of universal pharmacare. Patients who were previously unable to access drugs would now receive them, which would drive up costs. However, the greatly enhanced purchasing power of a single national third-party payer would be expected to confer an ability to negotiate substantial reductions in the prices of many drugs, as other countries have experienced and as Canadian provinces are already trying to achieve through collaboration. The model also assumes that patients would incur modest copayments, as is the case in other countries with universal pharmacare.

The bottom line? The best estimate would require the federal government to spend an extra $1 billion per year. That’s a lot of money, but considering that federal transfers for health care to the provinces and territories amount to $35 billion — not to mention everything the federal government spends directly on health — relatively speaking, it’s not that much of an increase. As with all modelling studies, these estimates rely on assumptions, and the associated uncertainties mean that costs could be higher — as much as $5.4 billion per year in the worst imaginable case. Equally, though, national pharmacare could well result in net savings for government — perhaps as much as $2.9 billion per year.

Morgan SG, Law M, Daw JR, et al. Estimated cost of universal public coverage of prescription drugs in Canada. CMAJ 2015;187:491–7. Abstract/FREE Full Text

A small number of drug classes are key drivers of overall costs and would continue to be so with or without pharmacare. Some (e.g., biologic agents) represent classes in which many emerging new therapies are expected to arise. Thus, the $1 billion estimate might not be stable going forward. But knowing this information may now enable policy-makers to develop specific interventions focused on reducing the impact of these key cost drivers even further.

Although the Canada Health Act has long enshrined the value of equitable, public health care coverage for all Canadians, its enactment by governments to date has been hypocritical in the absence of pharmacare. Canada has the dubious distinction of being the only country with universal health care coverage, but not universal pharmacare. As we have said before,3 the time to end this hypocrisy is long overdue; all of our peer nations have already done so. The moral case for universal pharmacare has always been apparent. With a strong economic case for pharmacare also evident, there can be no more excuses for delay. In this election year, it is especially timely for Canadians to demand that their next government enact national pharmacare.

Tang KL, Ghali WA, Manns BJ. Addressing cost-related barriers to prescription drug use in Canada. CMAJ 2014;186:276–80. FREE Full Text

Even more striking are the potential benefits to the private sector: no matter what, it would save a lot of money from pharmacare. Currently, nearly half of all drug expenditures in Canada are incurred by the private sector, divided almost evenly between individuals, whose costs would drop by more than half under pharmacare, and private drug plans, whose current costs for nearly all prescription drugs would disappear completely. Of note, a big chunk of public savings would arise from what governments presently spend on private drug coverage, such as for civil servants. With projected savings like these, one would expect that private companies, governments and individuals alike should be clamouring for pharmacare.

tanbrook MB, Hébert PC, Coutts J, et al. Can Canada get on with national pharmacare already? CMAJ 2011;183:E1275. FREE Full Text

The distinction drawn between the procedural advantage now accorded to non-DCO refugee claimants and the disadvantage suffered by DCO refugee claimants ... is discriminatory on its face," wrote Justice Keith M. Boswell in a 118-page decision. "It also serves to further marginalize, prejudice and stereotype refugee claimants from DCO countries which are generally considered safe and 'non-refugee producing.'

"This is another Charter loss for the Harper government," noted Lorne Waldman, president of the Canadian Association of Refugee Lawyers, a party to the legal challenge against the DCO regime. The government said it will appeal the decision and ask the court to set it aside while it is under appeal. "Reforms to our asylum system have been successful resulting in faster decisions and greater protection for those who need it most," said a spokesperson for Immigration Minister Chris Alexander.

"We remain committed to putting the interests of Canadians and the most vulnerable refugees first. Asylum seekers from developed countries such as the European Union or the United States should not benefit from endless appeal processes." The latest court decision means all failed refugee claimants, whether on the list or not, are entitled to appeal negative asylum decisions at the Immigration and Refugee Board's refugee appeal division, better known as the RAD. "This is a very important victory for refugees," said Jared Will, counsel for the refugee lawyers association. "Every refugee deserves to have their claims determined on their own merits."

This is another example of how the Stephen Harper government "flagrantly" overreaches its authority and disregards the Charter rights, he said, and "the court decision is confirming that." Calling the issues "complex," a spokesperson for the refugee board said it will respect the court ruling and "take the necessary time to examine the decision and its potential impacts." In December 2012, the federal government overhauled the asylum system in order to eliminate the growing backlog and expedite the processing of claims.

Not only do claimants face tighter timelines in filing their claims and scheduling a hearing and removal, those from DCO are ineligible to work for six months, appeal a rejected claim or receive a pre-removal risk assessment within three years after an asylum decision. Three refugee claimants - only identified in court by their initials - challenged the constitutionality of the DCO regime after they were denied asylum and subsequently the opportunity to appeal to the newly established refugee appeal tribunal.

Lawyers for the trio criticized the arbitrariness of the country designation process, arguing the DCO regime subjected some claimants to an "inferior determination process" - and discrimination - by limiting their access to opportunities and benefits that are afforded to others. They also argued that the government's branding of DCO claims as bogus, and the use of refugee statistics to trigger designation, feeds into the stereotype that their fears are less worthy of attention. In its defence, the government contended that it does not draw distinctions among claimants based on their national origin but rather whether they come from regions that are generally safe.

The government said the expedited processing for DCO claims is legitimate and conforms to Canada's international obligation. It explained that it limits the access to an appeal to the RAD only on the basis of a thorough assessment of the country conditions. However, Justice Boswell rejected its arguments: "This is a denial of substantive equality to claimants from DCO countries based upon the national origin of such claimants." He sent all three claims involved in the case to the refugee appeal tribunal for redetermination.

The acquiescence and complacency of the medical community to the sacred cow of Canadian "medicare" astonish me as much as the complacency of deluded Canadians (including doctors) who think the system is irreproachable. Many surgical specialists are available and eager to work.

The Canadian public system does not offer enough operating time for them to establish a viable practice. Should not this talented resource help to ease the wait lists and minimize prolonged pain and disability? Denise Pugash Vancouver

"We've been managing our budgetary costs for years," she said, "but this is the first year we've considered staffing restructuring as a practice to balance the budget's bottom line." Since PSWs are trained for a smaller scope of work than RPNs, they are compensated at a lower rate. Wilson-Trider said it should be made clear that there will still be RPNs on the hospital's team. Though there will be fewer RPNs, the team of PSWs will work to lighten their workload by taking care of certain tasks. The restructuring of the care model for the hospital's Rosamond Unit is just one aspect of the changes made to the AGH's budget this year. During the winter months, AGH conducted an internal comprehensive review of the hospital's revenues and expenditures, looking for efficiencies and asking for suggestions from staff.

The review, Wilson-Trider said, had a target figure of a five per cent change to the budget's bottom line, either in increased revenue or decreased expenditures. The cuts to RPN positions will account for some of that five per cent change, but the review also found other areas to cut costs, such as supply cost savings and energy management practices. Also, the hospital reviewed their service costs and found that they were charging below the average for private rooms, something they've adjusted for 2015. "These changes are a way of living within our means from a budget standpoint while providing the least impact to current patient care and the patient experience," Wilson-Trider said.

Protest Anita Comfort, one of the RPNs whose job is being eliminated, has been working at AGH for 21 years. She's among one of many soon-to-be-laidoff RPNs who have been at the hospital for decades, and she says that level of dedication can't be replaced. "We know our hospital, we know our patients and we know how to care for them," she said. "There's simply not going to be the same level of care without us." Comfort was one of more than 30 demonstrators who marched the street in front of AGH on March 16, asking for honks of support from passing cars.

Affected RPNs, friends, family, union representatives and even patients came out to show their support, holding signs boasting messages such as "Cuts hurt everybody," and "My skills are vital to patient care." Linda Melbrew, president of the local chapter of the Canadian Union of Public Employees (CUPE), which represents the RPNs, was present for the demonstration, showing the union's support for saving their jobs. "We're asking the hospital to reconsider their decision," she said, "and we're also asking for the province to provide better funding for our hospitals so something like this doesn't have to happen at all." Representatives from the Ontario Nurses Association also showed their support during the demonstration, holding signs and marching among the affected RPNs.

Cathy Porteous, another of the RPNs who will lose her job because of the cuts, also mentioned the hospital's appearance on the Sunshine List: a list of employees whose annual salary rates are $100,000 or more. She said she heard there are 10 such employees with the AGH. "Why can't they make cuts in that area," that's what we want to know," she said. "Instead of cutting from the front lines of patient care, maybe they should take a look at their own salaries." When asked about the Sunshine List later in an interview, Wilson-Trider said the hospital doesn't have 10 employees being paid more than $100,000 annually - instead, they have nine.

Those employees, she explained, are all high-level employees and not all of them are paid by AGH itself. Among those on the Sunshine List are the director of care for the hospital's Fairview Manor (FVM) and the manager for Lanark County Ambulance Services. "These managers are already stretched," she said. "Between managing the hospital and their accountability to the LHIN (Local Health Integration Network) and the ministry, they're stretched." Many of the demonstrators voiced another concern as well: that patients will not receive the same level of care with a team of PSWs than they would with RPNs. "The don't call it complex care for nothing," said Debbie Tipping, whose husband, like Marie Campbell's, receives care in the Rosamond Unit, also called the Complex Continuing Care Unit.

Since PSWs don't go through the same level of training as RPNs and therefore are not qualified to perform certain tasks, Tipping said she is concerned her husband's care could suffer. "We don't want to lose the nurses we've come to know and love," Campbell said. Patient care While Wilson-Trider said the AGH is appreciative of the work the affected RPNs have put in over the years, she also said that she thinks the new care model will benefit patient care. "I actually think that this will be good for patient care," she said. "The new PSWs will be there to support the RPNs, who will be working at their full scope of practice."

"Patient care," she added, "is of the utmost importance here, and we have taken every measure to ensure that that level of care is maintained." Over the next few months, as the new model of care is phased in and positions are jostled around, Wilson-Trider said that the AGH will be following the union's collective agreement and working with the union the whole way through. "We appreciate the commitment and high quality of care that all of our staff has demonstrated and continues to demonstrate," she said, "and we're also very appreciative of the care they've given to our patients." Illustration: • Kelly Kent, Metroland / On Monday, March 16, more than 30 demonstrators took to the street outside Almonte General Hospital (AGH) to protest the hospital's new model of care that will cut 10 registered practical nurse (RPN) positions from its team of sta . AGH's new model of care comes in light of budget challenges passed down from the province's freeze on funding. Some of the a ected RPNs, above, held signs reading "My skills are vital to patient care."

The intervenor coalition includes Canadian Doctors for Medicare, Friends of BC Medicare, Glyn Townson, who has AIDS, Thomas McGregor, who has muscular dystrophy, and family physicians Dr. Duncan Etches and Dr. Robert Woollard, both professors at the University of British Columbia. A second intervenor group representing four patients also warned that the Charter challenge would lead to an inequitable health system across Canada. “This case is indeed about the future of the public health care system, in its ideal and actual forms,” said the group’s lawyer Marjorie Brown, according to a report in The Globe and Mail. Cambie and its co-plaintiffs, who made their opening argument last week, say the BC law barring extra billing, so-called dual or blended practices and the use of private insurance for publicly covered services violates Sections 7 and 15 of the Canadian Charter of Rights and Freedoms.

A successful Charter challenge in BC would mean an inequitable health system, where those who can pay get priority service, states an intervenor coalition.

Moreover, they claim the prohibitions exacerbate the under-funded public system’s problems, especially waiting lists for various treatments and surgeries. Allowing a “hybrid” system would relieve the strain. The coalition brief, echoing the BC government’s lengthy opening argument, said there’s no evidence that creating a two-tier system would reduce wait times. But there is a risk of hollowing out the public system as resources migrate to the more lucrative private alternative. Those who couldn’t afford private insurance could still find themselves waiting for treatment, thus undermining the principles of universality and equity spelled out in the Canada Health Act, Latimer said in her submission. Latimer also questioned whether the legislation falls within the scope of the Charter, more often invoked to overturn criminal laws, not those with socio-economic objectives.

“This legislation is intended to protect the right to life and security of the person of all British Columbians, including the vulnerable and silent rights-holders whose equal access to quality health care depends upon the challenged protections,” Latimer stated. There’s also a risk of sapping the public system of not only doctors but nurses, lab technicians, administrators and others drawn to the more lucrative private market, the brief said. Dual practices could also foster “cream-skimming,” where private clinics handle simpler but profitable procedures, leaving complex cases to the public system. The British Columbia Anesthesiologists’ Society, intervening to support the challenge, will be making arguments later in the trial, which is due to last at least until February 2017. The federal government is expected to begin making arguments in several months.

choices than British Columbians or Quebecers do," answered Kenney. Health Minister Sarah Hoffman has an answer: if Kenney wants a policy brawl over the injection of more private options, he's welcome to it. "I'm not surprised that he's trying to find ways to expand privatization in the health-care system," she said in an interview. "Certainly, that's unfortunate." As you'd expect from a federal Conservative, Kenney blames centralized decision-making. "I just believe that local management of resources is a lot more sensible than hyper-centralized control," he told the Herald. "You know, when hospitals are given a limited budget for a limited number of hours they can service people, that gets out of alignment with the actual local demand."

But Hoffman figures Albertans don't want another major shift in how health care is run, after watching a pack of failed experiments in the PCs' waning years. She has doctors and officials working on two related problems - how to get more use out of the city's publicly owned MRI machines, and how to make sure everyone on the list really needs the test. I asked if she eventually plans to fold the province's vast array of private clinics, including imaging centres, under the government wing through public ownership.

We're not planning on doing a full overhaul," she said. "In general, Albertans are proud of what we've got. I don't have any drastic plans for changing the way those programs are administered." As often happens, when you sift through the rhetoric the opponents are quite close together. Most New Democrats would agree with another Kenney statement (as long as they're weren't aware who said it): "We need to ensure our health care has adequate funding, that it's publicly administered, that it's universally available, that it complies with the Canada Health Act." The key point is not who owns the assets, but who pays the bill. If health care pays, it hardly matters whether you get the test in a public hospital or a private clinic.

The MRI dispute is a good example of how the public-private debate has become so futile and misleading. Nine MRI machines in Calgary are publicly owned. They perform the tests for people on the waiting list. But there are also three MRIs in privately owned clinics.

The province doesn't fund MRI tests in those private clinics. The PCs wouldn't, and now the NDP won't either. And yet, health care funds virtually every other imaging test, including X-rays, ultrasounds and mammograms. Those exams are done every day in the very same clinics that own the private MRIs. The cost of a private test is $750, which probably explains why those machines are underused despite the long public wait.

Simple answer, right? The province should just start funding tests on the private MRIs. Asked why she doesn't do that, Hoffman says, "Why would you pay to rent something when you already own it and you're only using it half the time?" OK then, why not use what you've got? Why does that have to be so ridiculously difficult? Health care in Alberta is extraordinarily complex, and because of that, far beyond the reach of simplistic rhetoric about private and public delivery. That debate is just a distraction from the real issue - making the system work. Do that, please. Don Braid's column appears regularly in the Herald dbraid@postmedia.com

After leaving that hospital in July, 2005, Mr. Georgiou took a top position with the province's procurement agency, Infrastructure Ontario. But outside of his day job, the former executive began working for a private family construction business, Toronto Engineering Company (TECO). By March, 2006 - and until December, 2007 - TECO was working for St. Joseph's hospital. During this period, Mr. Georgiou became involved in a scheme to defraud York University with bogus construction invoices.

Mr. Georgiou used two family businesses, including TECO, to invoice the university for $64,800 worth of renovation work he acknowledges his company never performed. (Mr. Georgiou was not charged criminally and reached a settlement with the university.) When The Globe presented evidence to St. Joseph's last September that the hospital had also done business with TECO, the health centre hired Deloitte to investigate. The firm completed its probe this past spring. Deloitte found that over the course of nearly two years, St. Joseph's Health Centre processed 18 TECO invoices worth about $223,000 for repairs, painting and project management. The report shows Ms. Bahl approved all but five. (The hospital's thenproject manager of redevelopment, Doug Wilson, signed off on the rest.)

Deloitte found no evidence that Mr. Georgiou declared his TECO ties to the hospital, although internal hospital e-mails suggest Ms. Bahl was aware of his connection, the review states. Through their lawyers, Mr. Georgiou and Ms. Bahl criticized the fairness of the reviews. The report was not a full-blown audit and drew no conclusions. Deloitte did not interview Mr. Georgiou, Ms. Bahl or any other former hospital employees or vendors.

In a letter to The Globe, Mr. Georgiou's lawyer, Gavin Tighe, said TECO's dealings with St. Joseph's began after Mr. Georgiou left, so there was no conflict, but that, regardless, his client disclosed those ties. "TECO competitively bid on work at St. Joseph's Health Centre," Mr. Tighe wrote, adding that "TECO did not at any time contract or pay BJ Quality Flooring or Darwin Fisher Flooring to perform work." Deloitte also determined that there "may also have been an attempt to conceal" the involvement of Ms. Bahl's husband in the renovation projects.

Travis Walker, a lawyer representing Ms. Bahl, wrote to The Globe that Ms. Bahl "denies any impropriety" and that "any potential conflict of interest was disclosed to senior management" and "no concerns were ever raised." It is not clear exactly what policies Mr. Georgiou and Ms. Bahl may have violated, because St. Joseph's has refused to comment on the rules it had in 2007. A hospital spokesperson said "gaps in the procurement process at the time are historical and have since been mitigated" and that Deloitte unearthed "no substantive findings that indicate any further exploration is required." St. Joseph's would not answer questions on the report. When Mr. Georgiou left St. Joseph's Health Centre, he was one of the most powerful and connected members of the hospital, having served as vice-president for five years and interim CEO for 10 months.

About a month before he began working for Infrastructure Ontario in January, 2006, Mr. Georgiou's family members registered TECO in Ontario. Mr. Georgiou's wife, Helen Saoulli, and her parents were listed as directors. Mr. Georgiou acted as a project manager for TECO, according to a statement he made during the York investigation. Over the next two years, TECO invoiced St. Joseph's for work that included installing a new security gate for the emergency department, wall patching and painting, and disposal of chemical waste, documents obtained through a Freedom of Information request show. BJ Quality Flooring, the company owned by Ms. Bahl's husband, Bojidar Danef, was listed as a subcontractor on seven of the quotes, the Deloitte review found.

The auditing firm noted there may have been an attempt to conceal Mr. Danef's involvement because, at some point in the process, BJ Quality Flooring was changed to "Darwin and Fisher" [sic] - except that the contact name, telephone number and price stayed the same. Doug McDonald, owner of Darwin Fisher, a commercial flooring company in Mississauga, says his company has never done business with TECO and he has no idea why TECO invoices would include it. Mr. McDonald noted that during that period, Darwin was doing extensive work for St. Joseph's, and that on some occasions, he hired Mr. Danef as a subcontractor. Last November, Mr. Georgiou's employment as vice-president of St. Michael's Hospital was terminated after The Globe revealed his involvement in the York fraud, and later the fact that he had private business ties to the president of a construction company that won a $300-million contract with the hospital that Mr. Georgiou had overseen and helped award. After those stories were published, Markham Stouffville Hospital - where Ms. Bahl was then a senior executive overseeing a redevelopment project - launched an internal probe when a whistleblower came forward with concerns. The findings brought a wave of departures, including those of Ms. Bahl and Mr. Wilson, who had left St. Joseph's and was working with Ms. Bahl in Markham. Mr. Wilson could not be reached for comment.

The Markham Stouffville review, which Deloitte also conducted, found that Ms. Bahl hired five of the hospital's contractors to renovate her 6,480-square-foot home, received favourable pricing from some and awarded renovation contracts at Markham Stouffville to her husband's flooring company and her late uncle's window-covering business. It appears Ms. Bahl also mixed her professional connections with her personal life when she was at St. Joseph's hospital. Deloitte found evidence that one of the hospital's furniture vendors "assisted Ms. Bahl in procuring office furniture for her home at a 50-per-cent discount from the list price," the report said. In another instance, Deloitte noted Ms. Bahl may have tried to circumvent hospital procurement policy by counselling an art supplier to invoice through a company that was already doing work for the hospital, rather than submit a payment request directly.

"This is the only way I can cover the cost," Ms. Bahl wrote to the art supplier in an e-mail obtained by Deloitte.