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he main difference is that although these countries have universally accessible health-care systems, they also allow people to receive private medical services by paying outof-pocket or purchasing insurance. Their systems result in better overall care, for two main reasons. First, competition from private hospitals and medical practices provides an incentive for the public system to improve. As the C.D. Howe Institute's Åke Blomqvist and Colin Busby argue in a policy paper released last month, in Canada, "lack of competition between provincial health insurance plans and privately financed medicine has lessened the pressure on publicsector managers and politicians to improve an inadequately performing system."

Having a parallel private alternative also helps reduce wait times in the public system. Last year, Canadians waited an average of 9.8 weeks to receive medically necessary treatments after seeing a specialist - three weeks longer than what most doctors consider to be "reasonable." In the Commonwealth Fund study, Canada ranked dead last in terms of "timeliness of care," while the U.K. came in third and Australia sixth. (The U.K. and Australia also ranked first and second respectively in terms of quality of care.) Fears of a mass migration of doctors into the private system are easily answered. In the U.K., doctors trained in public universities are required to work in the National Health Service (the public system) for at least two years before they can move into the private system. Doctors who receive NHS funding are also allowed to set up parallel private practices, but must work 40 hours a week for the NHS.

Fortunately, Canadian provinces have quite a bit of leeway to experiment with allowing more privately delivered medical services. As Mssrs. Blomqvist and Busby argue, "Although this is not widely understood, the [Canada Health Act] does not rule out transactions in which providers are paid privately for their services. There is also no prohibition on private insurance that covers the same services as those under the public plans, provided these services are supplied entirely independent of publicly funded services." Indeed, all that is needed is for provincial governments to take the initiative and remove some of their restrictions on private health services.

The health-care debate in this country has traditionally focused on comparing our system with that of the United States. Yet the truth is that we have much more in common with European and other industrialized countries. As many of these countries have shown us, it is possible to provide world-class health care that is accessible to all people, while allowing those who choose to pay for private services to do so here at home, rather than travelling overseas.

The first is funding for the care of patients at home.

The Liberals promised to negotiate a new health accord with the provinces and have committed $3 billion to home care specifically.

They plan to make it easier to find and cheaper to hire home care professionals, but also promise to extend EI benefits to family members who decide to stay home to care for loved ones themselves.

The next is the Liberal commitment to help coordinate bulk prescription drug purchases by the provinces.

Although this isn’t as good as a national pharma care plan, it will go a long way to reducing the costs of drugs for provinces, which should free up money for other health areas.

The third is allowing scientists to freely share their findings with the public.

Fourth is restoring the long-form mandatory census, which was eliminated in 2010.

Last is the Liberal promise to regulate trans fats

Hundreds of thousands of patients on B.C. waiting lists know that role is not being fulfilled. The health minister and premier recently admitted that patients were waiting inappropriately long times, and a health region spokesperson reported some "life-saving" procedures were being delayed. Provincial health commissions were the brainchild of Tommy Douglas, who believed they should be chaired by doctors and never subject to political influence. But the MSC is always chaired by a politicallyappointed civil servant. Douglas supported premiums and felt they made the public cost-conscious, creating a sense of individual responsibility. He would never have condoned the practices of raising premiums to compensate for fiscal failures, nor reporting low-income earners, delinquent with their payments, to collection agencies. The commission is wasting health care funds as it displays contempt, in terms of its fiscal and social accountability, toward taxpayers.. In one example of carelessness and incompetence, I received cheques from them totalling hundreds of thousands of dollars, for services on patients that I had never seen. I also received confidential personal information on hundreds of patients unrelated to me or our clinic. When informed of their error, they responded: "Just mail them back." They were not inclined to investigate.

In Canada, health providers are compelled by law to share confidential patient files with government employees armed with the right to inspect and copy patients' files. Your health record is considered public property; you cannot block government access. Consent is not needed, and you are not notified when Big Brother is looking. Privacy rights have been legislated away. I witnessed a defeated provincial cabinet minister's medical file being reviewed by a newly elected government. In the 1989 tainted blood inquiry, Justice Horace Krever was "shocked by the inadequate laws, the abuses of confidentiality, and the fact that so many people - except the patient - had access to medical records." Little has changed.

The MSC is also charged with defining what services are "medically necessary" - and therefore publicly insured. They have never created a definition, but have arbitrarily designated clearly essential services such as ambulance, drugs, physiotherapy, artificial limbs, and dentistry as unnecessary, creating a true two-tier structure of care. The government's last action in delaying our constitutional challenge on patient rights resulted from a "last minute" discovery of 300,000 documents they were legally bound to provide. After a delay of more than seven years, the plaintiffs in the coming June trial will confirm that the Supreme Court of Canada's 2005 finding - that patients are suffering and dying on waiting lists - applies in B.C. Supporters of a system that limits timely access are complicit in such outcomes.

Our public sector health system (MSC included), is grossly overstaffed with non-clinical workers. A 2011 study revealed that Canada has 11 times as many public health bureaucrats per capita as Germany, where there are no waiting lists. Canada has 14 ministries of health, each with bloated bureaucracies and commissions scavenging dollars that should go to patient care. The mentality that cost inefficiencies can be balanced by increased taxes or "premiums" is responsible for our escalating charges. Independent health groups in Europe rated Canada as last in value for money compared to hybrid public-private systems that have accessible public systems. The Commonwealth Fund, a non-profit foundation focused on issues affecting lowincome groups, ranked Canada 10th of 11 health systems in developed nations.

What specific changes would I incorporate if I were minister of health? Apart from incorporating the best practices of other hybrid systems (including private-sector competition), I would dismantle the ministry and its committees and commissions. Then I would resign. The finance ministry could fund patients directly (thus empowering them), and also assign budgets to the newly emancipated, self-regulated health organizations, allowing them to cater directly to patient needs. Maybe our June constitutional court challenge will point us in that direction. Dr. Brian Day is an orthopedic surgeon, medical director of the Cambie Surgery Centre, and a former president of the Canadian Medical Association.

Dr. Brian Day says bureaucrats at the Medical Services Commission sent him cheques totalling hundreds of thousands of dollars for services on patients he had never seen.

Simon said the ministry played no role in strengthening registry data during the last year. "I don't know what other strengthening of data the ministry would be involved in because they're not involved in day-to-day decision making around registration," she said. "I'm not clear on what they're specifically talking about ... We're always refining our registration process." One such process, Simon said, has been figuring out how to remove names from the registry. Why would a name need to be removed?

The organization at the heart of this controversy, the Ontario Community Support Association, has been paid more than $5 million by the health ministry since 2011 to create and maintain the registry. The association's CEO, Deborah Simon, told the Star it "is absolutely not true that anybody could register." Simon said the agency checked educational backgrounds by requiring a certificate when applying to the registry. She said staff would then check to make sure the school listed on the registrant's application existed. The result, she said, is a "major achievement" in that the registry has provided "very valuable demographic information that's never been aggregated before."

"For a number of reasons," Simon said. "For data we're aware is not correct. For concerns that have been raised around issues that a personal support worker might be involved in." Neither Simon nor the ministry has said how many names had to be removed from the list since it became operational in 2012. By March 18, 2016, there will be no trace of the registry online. That day won't come soon enough for Gélinas.

"It has done nothing but make the OSCA richer," she said. The registry "has all of the DNA of e-health," Gélinas said, referring to the scandal that saw provincial government spend more than $1 billion trying to create electronic health records with little to show for it.

After a very lengthy review, where all parties had a chance to make their case, the province's Health Professions Advisory Council agreed with CUPE and other front-line paramedic organizations to recommend to the minister of health that a regulatory college not be created. It vexes many of us why the motives of top managers of paramedic services who have consistently advocated for a regulatory college as an additional means of discipline and control over paramedics are not questioned.

Why the provincial government would allow them to interject and upend the current goodwill that exists between the province's paramedics who overwhelmingly oppose a college is also a mystery.

Equally confounding is why a small voluntary group that does not represent the vast majority of paramedics in the workplace with employers or at the government level is pushing for a regulatory college. That they could support a proposal that would open up the profession to workers operating pretend ambulances is not in the best interest of the public or the paramedic profession.

Ontario needs dedicated paramedic services exclusively focused on providing top-notch emergency medical response. We do not need a backdoor attempt to undermine the profession and we are saddened that some wish to revive this issue yet again. Fred Hahn President, CUPE Ontario JeffVan Pelt Chair, CUPE Paramedic Committee of Ontario

Wait times and coverage vary widely between and even within provinces, with only one in six hospitals offering surgical abortions and access is most difficult for women living in rural communities - including First Nations reserves - who may have to travel long distances to get an abortion. Prince Edward Island does not provide any abortion services at all, although it does cover the cost of the procedure for provincial residents who obtain an abortion at a hospital in Moncton, N.B., where no referral is needed, or in Halifax, where women need to be referred by a P.E.I. doctor.

Philpott was not available for an interview Tuesday to elaborate on what she has in mind, and spokesman Patrick Gaebel was unable to add many details. Prime Minister Justin Trudeau said last year that all Liberal MPs would have to vote along pro-choice party lines, but the campaign platform and his ministerial mandate letter to Philpott did not mention anything about improving access to abortion services.

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

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

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

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

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

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

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

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

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

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

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

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

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

A large portion of those profits are possible because of unregulated "hospitality" fees, and an operational funding model that does not require government funds for front-line staffto actually go toward staffpay. No regulation exists for staff-to-patient ratios or to ensure patient and family councils are welcomed at each facility. Contracts between these providers and the government are confidential, meaning Albertans do not have the right to know how much public money is being doled out or what the terms of the contract are, and whether or not care is the No. 1 priority in these arrangements. This "wild west" model of continuing care providers was set up by the previous PC government, but it remains in place under the NDP government. However, there is hope positive change is coming. While the PC government significantly expanded the role of for-profit corporations in continuing care, the new government has taken a different position. Responding to promises from the previous government to open new care beds in Alberta, on Nov. 19, 2014, then-opposition leader Rachel Notley said in the legislature, "We don't argue with the need for more spaces for seniors; we do think that they should be publicly funded, publicly delivered."

In the same spirit, the NDP's election platform promised to open 2,000 public long-term care beds and "end the PCs' costly experiments in privatization, and redirect the funds to publicly delivered services." The previous government not only stopped building new public beds, but also unnecessarily closed hundreds of functional public long-term care beds and often funded the construction of replacement beds owned by for-profit corporations. Some of the closed facilities are currently empty and could still be reopened for public use.

In light of the problems the previous government created by funding private, for-profit care, the new government should begin by standardizing and limiting fees charged to residents, disclosing the amounts these corporations are being given and spending on direct care and how much of the public money is going to their shareholders, and setting standards for staff-topatient ratios. The most meaningful sign the new government can send would be to make good on their promise to open 2,000 public long-term care spaces, where profit is not a factor and care is the No. 1 priority. Fulfilling that promise should be the government's first step to phasing out private, for-profit continuing care. Our public health care dollars should not be given to corporate shareholders; it should be spent on care for Albertans. Private, for-profit care facilities are no more acceptable than Ralph Klein's short-lived private, for-profit hospitals. Noel Somerville is the chair of Public Interest Alberta's Seniors Task Force. Sandra Azocar is the executive director of Friends of Medicare.

And on Dec. 2, Ambulance NB administrators across the province received new directions on how to fill vacant shifts. If a person calls in sick, or someone has requested vacation time and they must be replaced, the manager in charge of scheduling that shift would offer the shift to anyone with bilingual qualifications in the person's station, typically first part-time or casual employees. Unfortunately, there is a shortage of bilingual part-time or casual employees in many parts of the province. So the next group to receive offers is bilingual full-time employees, who would be called in for an overtime shift. If nobody is available, the offer is extended to bilingual paramedics from other jurisdictions.

That's not fair to the many dedicated unilingual paramedics across the province, says Trent Piercy, a paramedic with Ambulance NB and the secretary for paramedics' union CUPE Local 4848. "They are going to get offers, but it's going to come after that process has been exhausted," he said. Piercy said he understands that Ambulance NB has a legal obligation to offer service in both official languages.

But he said that if an ambulance arrives at the scene of an accident, makes the offer of service in both languages and learns that it can't provide care in the language requested, he believes Ambulance NB is still meeting its legal requirement if those unilingual paramedics request another crew with bilingual capabilities to respond to the scene. While they wait for them to arrive, he said, they can use existing translation services until that backup arrives.

"If we have another crew coming, is that not offering the service? If we offer translation, or have somebody come from one of our crews to translate on a call, is that not offering the service? Other avenues, I don't think, have been explored enough." Piercy said Ambulance NB has set a goal to have 60 per cent of its paramedics be able to offer service in both official languages. He believes that only about 35 per cent of the province's paramedics are currently bilingual. "It's going to take a very, very long time to get up there and the costs are going to go up," he said. The paramedics' union has filed a grievance about new hiring practices introduced in August 2014, which place new weight behind a candidate's linguistic abilities.

After having already expressed frustration with the challenges posed by those changes, he said, the provincial ambulance service has now made it more difficult for unilingual paramedics to find meaningful employment in the province, rather than trying to work through a long list of suggestions submitted by the union as potential alternatives to the new scheduling protocols. The union suggested finding ways to screen calls by language, making it possible to send ambulances with bilingual staff to scenes where a specific language is requested, and to explore translation equipment for use in provincial ambulances. Other ideas involved lowering the language requirements to a conversational level of French or English, alter the deployment protocols to keep unilingual ambulances away from areas that might require them to provide care in their weaker language, or improve language training resources for existing paramedics. Currently Ambulance NB has offered to cover the costs of distance-education language training from the Université de Moncton or Rosetta Stone, though the employee must complete the work on his or her own time.

But Piercy said so far the provincial service hasn't been willing to commit to exploring any of these ideas. "We will continue to work with stakeholders to find solutions that will best meet the needs of our patients and employees, while respecting our legal obligation," he said. The Daily Gleaner requested an interview with Katherine d'Entremont, the commissioner of official languages for New Brunswick, but was informed she declined to comment on this story.

While speaking with the paper about Ambulance NB's push to improve its language capabilities in August 2014, d'Entremont said the legal obligation to provide service in both official languages has been in place since before Ambulance NB launched in 2007. Back then, she said it wasn't her job to tell the provincial ambulance service or the Department of Health how the organization should reach its language goals, but simply to make recommendations on how to address deficiencies identified by the public. "I'm interested in the results of a plan as opposed to the means to get there," she said at the time. "My mandate is very specific in this regard. So once I've made recommendations, the rest is up to the institutions concerned."

Both Dominic Cardy, leader of the New Democratic Party of New Brunswick, and Kris Austin, leader of the People's Alliance of New Brunswick party, attended a rally co-ordinated by frustrated paramedics in Fredericton this week. Afterwards, Austin said he feels the way Ambulance NB is bolstering its language capabilities is flawed, saying that it unnecessarily punishes many qualified francophone and anglophone paramedics by freezing them out in favour of the smaller complement of bilingual professionals. The newspaper asked the Department of Health if Health Minister Victor Boudreau wanted to comment on the paramedic protests, but was told he was unavailable.

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

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

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

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

Tammy Leach is CEO of the Alberta Continuing Care Association.

Currently 76,000 vulnerable seniors live in nursing homes. Thousands more are on regional waiting lists. Hospitals consider them "bed blockers." Private retirement residences aren't equipped to meet their needs. Their families can't take care of them or get enough home care to keep them clean, safe and stable. "I think we see nursing homes as a symbol of failure - failure of the individuals to care for themselves, of families to care for older people, of the medical system to cure them," Armstrong said. "It's something we don't want to think about because we intend to avoid such places when we grow old." That attitude has led to underfunding, understaffing, low wages and high turnover in nursing homes. Care providers don't have time to listen to residents, respond to their needs, help them eat, talk to them or alleviate their boredom. Food service workers lock the dining room between meals. Clothes vanish in the laundry. Government-required paperwork takes precedence over caregiving. It is not unusual to see a dozen seniors - some with dementia, some in wheelchairs, some heavily sedated - lined up in front of a television staring vacantly at a rerun of I Love Lucy.

"They deserve better," Armstrong thought. So she pulled together a team of 26 researchers from six countries (Canada, Britain, Sweden, Germany, the United States and Australia) to reimagine institutional long-term care. Could it be a humane, dignified, financially viable option? The team included doctors, pharmacists, architects, economists, psychologists, social workers, historians, philosophers and communication experts. It began by collecting success stories from Europe and North America and identifying the most promising practices and best ideas in the field. That was five years ago. Armstrong and her colleagues have now done 25 site visits in 10 jurisdictions; interviewed thousands of long-term care residents, workers, managers, policy-makers and advocates for seniors; published 50 academic papers and released an 86-page public report entitled "Promising Practices in Long-Term Care."

Last week, she and co-author Donna Baines, of the University of Sydney in Australia, led a panel discussion in the dining room of Hart House at the University of Toronto. "The reception was very positive. People are excited by the possibilities." It will take many more community forums - and a lot of public pressure - to change the mindset at the ministry of health and long-term care. It regards the elderly as a financial burden and nursing home workers as an expense to be controlled. For one evening, Armstrong and Baines managed to change the public dialogue from failures and shortcomings to promising practices. They provided proof that nursing homes don't have to be grim, depressing places. They offered hope to desperate families, exhausted caregivers and aging boomers contemplating their future.

Armstrong acknowledged afterward that it will take a prodigious effort and a significant public investment to reach the level of long-term care regarded as normal in countries such Germany, Sweden and Britain. But even without a cash infusion, she argued, there are ways to make life better for the residents of Ontario's nursing homes: Label their clothes properly before sending them to the laundry; allow them to make a cup of mid-afternoon tea or go to the fridge for a beer; let them eat chocolate or ice cream if they wish; make the decor less hospital-like and more like a home. Give personal care precedence over paperwork. Reorganize who does what to bolster teamwork and reduce staff turnover. These reforms are not costly. Three principles are vital for high-quality long-term nursing care, the researchers concluded: It fosters person-to-person relationships. It respects individual differences, while striving for equity. It offers dignity to older citizens regardless of their infirmities.

One of the biggest impediments to progress, Armstrong said, is the province's knee-jerk response to scandals. Any time something goes wrong in one of Ontario's 629 nursing homes, the ministry of health imposes blanket regulations. These one-size-fits-all rules reduce the ability of care providers and nursing managers to tailor their practices to the needs of residents. "We've become so obsessed with safety and standardization that we've taken the life out of living." So far, there's been no sign of interest in the project from Queen's Park. That is not likely to change until Ontarians open their eyes and raise their voices. Instead of complaining after their elderly parent is admitted to a nursing home, they need to speak out for everyone's parents. Instead of giving up on long-term care, they need to push back when policy-makers offer visiting part-time help.

Stakeholders throughout the province's health-care system have been lobbying successive provincial governments for at least a decade, urging them to lift restrictions that force the province's roughly 35 advanced-care paramedics to work below their full scope of practice. In February, the provincial government announced it had set aside $580,000 for a new pilot project, which will help New Brunswick figure out how best to make use of these valued health-care providers.

Health Minister Victor Boudreau said two committees have been formed to complete the behind-the-scenes work that is needed to introduce them to the existing ambulance service. So far, he said, things are going well, though he's not sure when advanced-care paramedics will be ready to use their skills on the streets. "We're still trying to put a pilot project together, making sure that we're respecting all the different moving parts to this," he said. "The money is still in the budget for this year. It's just sometimes these things prove to be a little more difficult than you'd like to put together. But it's certainly still on the table."

Chris Hood, executive director of the Paramedic Association of New Brunswick and a participating member of the committee tasked with sorting out the clinical issues around such a change, said that work is progressing nicely and he expects to see advanced-care paramedics in use within the provincial ambulance service soon. "I know the meetings have been happening and, by all indications, we're getting close," he said.

"The committees are still meeting. I've missed the last two meetings, but we had a representative there. They're getting into discussions about the protocols for practitioners, what they'll be following. From what we hear, it sounds like full-steam ahead. They accelerated the meeting times and it seems like everything is on the right track ... All of the prep-work that is necessary is, I would say, probably 80 per cent done, 85 per cent done." Ambulance New Brunswick is also completing some preparatory work, said Hood.

"They're looking at curriculum - refresher programs and things like that. From the clinical side of the business, which is what we're concerned with, that stuff is almost complete," he said. "If form follows function, we should be moving forward rather quickly."

When asked if the province's advanced-care paramedics are excited they'll finally be able to put all of their training to use in this province, Hood said many are still frustrated from the long struggle to lift these restrictions on their scope of practice. "I think many ACPs are still a bit, 'I'll believe it when I see it.' But some are very excited about it. We've had a couple of people enquire about attending ACP school and I know that the requests for enrolments in ACP classes both in New Brunswick and in the state of Maine are increasing," he said.

People are starting to feel more comfortable in spending the money to upgrade their skills, to take the education they need. But with the existing practitioners, I think, it's a wait-and-see mentality." Judy Astle, president of paramedics' union CUPE Local 4848, said she's anxious to learn what the pilot project may look like and how advanced-care paramedics will be used alongside primary-care paramedics across the province.

It's going to be a positive," she said. "But we're still waiting to find out the details."

They allocated billions of dollars for five kinds of procedures, all disproportionately afflicting seniors who, after all, vote in elections more than young people and use the health-care system more. The procedures were: hip and knee replacements, hip-fracture repairs, cataracts, and radiation. More than a decade and billions of dollars later, how are we doing? What did all that money and effort produce? In a nutshell: middling results. Initial data were released in 2006. From then until 2015, some improvements occurred, according to a recent report (www.cihi.ca») from the Canadian Institute for Health Information (CIHI). Between 2011 and 2015, wait times shrank for some procedures in some provinces, but increased for other procedures elsewhere.

One challenge is obvious: the population is aging. Ergo: more need for cataracts, more falls causing hip fractures, more joints giving out, more youthful athletic injuries becoming painful in later years. Aging puts governments on a treadmill. More money and improved allocation of medical resources result in more procedures but demand keeps growing. For example, between 2011 and 2015, 25 per cent more hip-replacement operations were done, but the number of patients being treated within "benchmark" time frames actually fell.

What are these benchmark time frames? Governments establish them to measure progress or lack thereof, based on what medical experts think are appropriate times to wait before procedures are undertaken. The benchmarks are rather generous and can be irritating to patients in pain. They are also somewhat misleading. The hip and knee benchmarks are six months. That period measures only the time between when surgery is recommended and the surgery occurs. It does not measure what is often the most aggravating part of the health-care system: getting an appointment with a specialist who might then recommend surgery.

Combine the two waiting times - see a specialist, have surgery - and Canada's record looks less than average compared with other advanced industrialized countries. One challenge plaguing the Canadian system for joint-replacement surgeries is the endemic fight for operating time in hospitals. Orthopedic surgeries have to be slotted into ORs, which are needed for emergencies, life-threatening problems, very complicated surgeries for cancer or neurological procedures. Orthopedic surgeries, except for hip fractures that have to be repaired swiftly, can wait, and wait.

Here's a telling irony. A surplus of orthopedic surgeons now exists in some parts of Canada. There's not a surplus of surgeons versus demand for their services but rather versus the OR time they are allocated. In other words, more surgeries could be done because surgeons are available but operating-room time is not. The result is that some young surgeons are going to the United States or working part-time. Trying to fit surgeons and patients into hospital OR allocations on a timely basis is made more difficult by the straitjacket of the Canadian system or at least the view, bordering on secular theology in some quarters, that everything must be done in a public hospital rather than in private clinics operating under funding arrangements with the state.

Saskatchewan has used this method - private delivery of publicly funded and regulated services - which partly explains why that province finishes first in the CIHI report for timeliness of procedures. Quebec also used this system, until the Liberal government, led by a neurological surgeon (current Premier Philippe Couillard), ended the experiment.

If the results are so-so in recent years for the five procedures identified in 2004, CIHI numbers suggest backsliding for diagnostic imaging. For six provinces that provided data, waiting times for MRIs increased "significantly" as they did for CT scans. Waiting times for cancer surgeries have remained stable.

Dryly and accurately, CIHI repeats what everyone who thinks about the future of health care knows: "With a growing and aging population in Canada ... demand for priority procedures will likely continue to increase."

Philpott said one of the misconceptions about the future of health care is that demographics - a silver tsunami related to an aging population - is going to bankrupt government coffers. While she acknowledged that seven per cent of $1,000-a-day hospital beds are taken up by seniors and 14 per cent of beds are occupied by patients who should be in alternate levels of care, Philpott threw cold water on the "doom and gloom" forecasts that an aging population means "massive infusions of cash" are needed to sustain public health care. Sticking to the federal government's commitment to inject another $3 million over four years into home care, she noted it's not only cost effective but preferred by patients and their families.

Federal health minister Jane Philpott said Tuesday a national pharmacare program is likely years away because of more pressing priorities like primary care, improved health for indigenous people, better care for those with mental illness, and more home care for seniors. "I do not want to promise anything I don't know I can deliver on," she told about 600 delegates and observers at the annual Canadian Medical Association meeting in Vancouver.

The reality is I don't know how this is going to end up. A lot of this will come down to basic principles of fairness." While Canada spends more per capita than many other countries, Philpott said she's concerned about international rating systems that show Canada gets poorer outcomes compared to countries such as Australia, the United Kingdom, France and Germany. During a press scrum, a journalist noted that all those other countries have parallel public/private systems. But Philpott insisted the federal government is only interested in how those other countries deliver care within the publicly funded realm. "Our government is firmly committed to upholding the Canada Health Act. That act has principles around accessibility and universality and it means Canadians have access to care based on need, not on ability to pay," she said. "You cannot have a growing, thriving middle class unless you have a publicly funded universal health care system."

Philpott attempted to dissuade doctors of the notion that the federal role is merely to transfer money to the provinces ($36 billion this year), maintaining that the government and "this minister of health" is determined to be engaged in health system transformation. The provinces have begun the slow process of negotiations with the federal government on a renewal of the Canada Health Accord to be signed sometime next year. But some health ministers have complained that the feds have given no indication about how much money they can expect. It's been more than a decade since the provinces and the federal government negotiated transfer payments and Philpott said that while the last round led to improvements like shorter waiting times in some surgical areas, "it did not buy change. So we should use this opportunity to trigger innovation."

Philpott said real change will incorporate digital health records and the banishment of anachronisms like fax machines. Patients should be seamlessly connected, in real time, to their health care providers, hospital, home care, pharmacy and lab. "What is it going to take to get there? Pragmatism, persistence and partnership. Changes require courage and practicality." Doctors gave her enthusiastic applause for stating that low socioeconomic status represents one of the greatest barriers to good health and "that is why this government believes that the economy and jobs and a stronger middle class will reduce social inequity." She said in 2016, the federal government has earmarked $8.4 billion in spending on social and economic conditions for indigenous communities. Earlier Tuesday, on the second day of the three-day annual meeting, doctors passed numerous motions that will now go to their board for further discussion before becoming official policy.

Delegates passed a motion introduced by Ontario doctor Stephen Singh of the Canadian Society of Palliative Care Physicians that aims to distinguish between palliative care ("neither to hasten or postpone death") and medical assistance in dying. Most palliative care doctors don't want to serve as gatekeepers to doctor-assisted dying, but they do want to consult with patients who have life-limiting illnesses in order to help mitigate their suffering.

"The priority of the Medical Services Commission and the Ministry of Health is to uphold the Medicare Protection Act and the benefits it safeguards for patients in this province," B.C. Health Minister Terry Lake said in a statement on Tuesday. "We expect and require these clinics to come into full compliance with the law, and we remain fully committed to seeing out this case to its resolution." The ministry said it could not comment further because the case is before the courts. But the federal government is also watching the proceedings closely and has sought intervenor status in the case. In a statement from Ottawa, Health Canada said many provisions of the B.C. legislation mirror those of the Canada Health Act, "making this case of significant importance not only to British Columbians, but to all Canadians."

Given that Canadians "overwhelmingly" support universally accessible health care, "any challenge to a principle so fundamental to our health-care system is of significant concern to the Government of Canada." During a federal Liberal caucus retreat in Saguenay, Que., last week, Health Minister Jane Philpott said the case and the prospect of health-care privatization are a cause of "concern" for her. "I think I have made it very clear on repeated occasions that our government is committed to firmly upholding the Canada Health Act. The Cambie case deals specifically with that, with the provision of services," she told reporters. "It's fundamentally important to the health-care system in the entire country, not just in British Columbia, that we make sure that medically necessary services are universally insured and there are no barriers to access of those services." Ms. Philpott acknowledged that some health-care services in Canada are delivered privately, citing physiotherapy, which is largely carried out in private clinics because it is not included under the Canada Health Act.

But she said anything similar to a user fee is a barrier to people being able to receive medically necessary care. Ultimately, Dr. Day said, the law, facts and evidence are on the side of his argument that Canadians would best be served by a "hybrid" health-care system. "I kind of hope the judge doesn't hear that, and our lawyers would be nervous to hear that, but that's what I believe," he said. Within that system, public hospitals would offer private services and private hospitals would offer public services. He said he also wants to see competition between and within the systems. "Competition breeds excellence," Dr. Day said. © 2016 The Globe and Mail Inc. All Rights Reserved.