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This Senate has already sent a report back to the Commons, saying the Liberal bill should be amended to allow advance directives from those who wish assistance in dying and are still able to let their wishes be known.When the bill comes back to the Senate, independent Liberal James Cowan will push for an amendment broadening restrictions on eligibility.

The B.C. Civil Liberties Association says every provincial medical regulator has issued “detailed, comprehensive” guidelines for doctors under the high court ruling. Doctors’ conscientious objection rights are protected and, under provincial guidelines, two doctors are required to confirm the patient’s eligibility and consent.The real danger may lie in future court challenges — if assisted deaths are allowed under the Supreme Court wording that would be denied under the federal legislation, the government will have a problem.We shouldn’t be here after 16 months. Canadians deserved better. They deserve a better law.

Canada has catching up to do compared to other OECD countries. Canadians have difficulty accessing primary care, particularly after hours and on weekends, and are more likely to use emergency rooms.

only 32 per cent of Canadians had access to more than one primary health care provider

In Peterborough, Ontario, for example, a region-wide shift to team-based care dropped emergency department visits by 15,000 patients annually and gave 17,000 more access to primary health care.

We believe that jurisdictions are now turning the corner on primary health care

Sustained federal funding and strong jurisdictional direction will be critical to ensuring that we can accelerate the update of electronic health records across the country.

The creation of a national pharmaceutical strategy was a critical part of the 10-year plan. In 2011, today, unfortunately, progress is slow.

Your committee has produced landmark reports on the importance of determinants of health and whole-of- government approaches. Likewise, the Health Council of Canada recently issued a report on taking a whole-of- government approach to health promotion.

there have also been improvements on our capacity to collect, interpret and use health information

Leading up to the next review, governments need to focus on health human resources planning, expanding and integrating home care, improved public reporting, and a continued focus on quality across the entire system.

John Wright, President and CEO, Canadian Institute for Health Information

the Canada Health Act

Since 2008, rather than repeat annual reporting on the whole, the Health Council has delved into specific topic areas under the 2003 accord and the 10-year plan to provide a more thorough analysis and reporting.

We have looked at issues around pharmaceuticals, primary health care and wait times. Currently, we are looking at the issues around home care.

John Abbott, Chief Executive Officer, Health Council of Canada

I have been a practicing physician for 23 years and a CEO for 10 years, and I would say, probably since 2005, people have been starting to get their heads around the fact that this is not sustainable and it is not good quality.

Much of the data you hear today is probably 18 months to two years old. It is aggregate data and it is looking at high levels. We need to get down to the health service provider level.

The strength of our ability to report is on the data that CIHI and Stats Canada has available, what the research community has completed and what the provinces, territories and Health Canada can provide to us.

We have a very good working relationship with the jurisdictions, and that has improved over time.

One of the strengths in the country is that at the provincial level we are seeing these quality councils taking on significant roles in their jurisdictions.

As I indicated in my remarks, dispute avoidance activity occurs all the time. That is the daily activity of the Canada Health Act division. We are constantly in communication with provinces and territories on issues that come to our attention. They may be raised by the province or territory, they may be raised in the form of a letter to the minister and they may be raised through the media. There are all kinds of occasions where issues come to our attention. As per our normal practice, that leads to a quite extensive interaction with the province or territory concerned. The dispute avoidance part is basically our daily work. There has never actually been a formal panel convened that has led to a report.

each year in the Canada Health Act annual report, is a report on deductions that have been made from the Canada Health Transfer payments to provinces in respect of the conditions, particularly those conditions related to extra billing and user fees set out in the act. That is an ongoing activity.

Senator Eaton

How many government programs have been created as a result of the accord?

The other data set is on bypass surgery that is collected differently in Quebec. We have made great strides collectively, including Quebec, in developing the databases, but it takes longer because of the nature and the way in which they administer their systems.

I am a director of the foundation of St. Michael's Hospital in Toronto

Not everyone needs to have a family doctor; they need access to a family health team.

The family doctors in our hospital feel like second-class citizens, and they should not. Unfortunately, although 25 years ago the family doctor was everything to everybody, today family doctors are being pushed into more of a triage role, and they are losing their ability.

The problem is that the family doctor is doing everything for everybody, and probably most of their work is on the social end as opposed to diagnostics.

At a time when all our emergency departments are facing 15,000 increases annually, Peterborough has gone down 15,000, so people can learn from that experience.

I have to be able to reach my doctor by phone.

They are busy doing all of the other things that, in my mind, can be done well by a team.

That is right.

if we are to move the yardsticks on improvement, sustainability and quality, we need that alignment right from the federal government to the provincial government to the front line providers and to the health service providers to say, "We will do this."

We want to share best practices.

it is not likely to happen without strong direction from above

Excellent Care for All Act

quality plans

with actual strategies, investments, tactics, targets and outcomes around a number of things

Canadian Hospital Reporting Project

by March of next year we hope to make it public

performance, outcomes, quality and financials

With respect to physicians, it is a different story

We do not collect data on outcomes associated with treatments.

which may not always be the most cost effective and have the better outcome.

We are looking at developing quality indicators that are not old data so that we can turn the results around within a month.

there has been progress. In some cases, there has been much more than in others.

There are different types of benchmarks. For example, there is an evidence-based benchmark, which is a research of the academic literature where evidence prevails and a benchmark is established.

The provinces and territories reported on that in December 2005. They could not find one for MRIs or CT scans. Another type of benchmark coming from the medical community might be a consensus-based benchmark.

universal screening

A year and a half later, we did an evaluation based on the data. Increased costs were $400 per patient — $1 million in my hospital. There was no reduction in outbreaks and no measurable effect.

A thorough research of the literature simply found that there are no evidence-based benchmarks for CT scans, MRIs or PET scans.

The evidence is pretty clear for the high acuity; however, for the lower acuity, I do not think we know what a reasonable wait time is

If you are told by an orthopaedic surgeon that there is a 99.5 per cent chance that that lump is not cancer, and the only way you will know for sure is through an MRI, how long will you wait for that?

colorectal screening

the next time they do the statistics, there will be a tremendous improvement, because there is a federal-provincial cancer care and front-line provider

adverse drug effects

over-prescribing

There are no drugs without a risk, but the benefits far outweigh the risks in most cases.

catastrophic drug coverage

a patchwork across the country

with respect to wait times

The interesting thing about Saskatchewan is that, on a three-year trending basis, it is showing positive improvement in each of the areas. It would be fair to say that Saskatchewan was a bit behind some of the other jurisdictions around 2004, but the trending data — and this will come out later this month — shows Saskatchewan making strides in all the areas.

In terms of the accord itself, the additional funds that were part of the accord for wait-times reduction were welcomed by all jurisdictions and resulted in improvements in wait times, certainly within the five areas that were identified as well as in other surgical areas.

We are working with the First Nations, Statistics Canada, and others to see what we can do in the future about identifiers.

Have we made progress?

I do not think we have the data to accurately answer the question. We can talk about proxies for data and proxies for outcome: Is it high on the government's agenda? Is it a directive? Is there alignment between the provincial government and the local health service providers? Is it a priority? Is it an act of legislation? The best way to answer, in my opinion, is that because of the accord, a lot of attention and focus has been put on trying to achieve it, or at least understanding that we need to achieve it. A lot of building blocks are being put in place. I cannot tell you exactly, but I can give you snippets of where it is happening. The Excellent Care For All Act in Ontario is the ultimate building block. The notion is that everyone, from the federal, to the provincial government, to the health service providers and to the CMA has rallied around a better health system. We are not far from giving you hard data which will show that we have moved yardsticks and that the quality is improving. For the most part, hundreds of thousands more Canadians have had at least one of the big five procedures since the accord. I cannot tell you if the outcomes were all good. However, volumes are up. Over the last six years, everybody has rallied around a focal point.

The transfer money is a huge sum. The provinces and territories are using the funds to roll out their programs and as they best see fit. To what extent are the provinces and territories accountable to not just the federal government but also Canadians in terms of how effectively they are using that money? In the accord, is there an opportunity to strengthen the accountability piece so that we can ensure that the progress is clear?

In health care, the good news is that you do not have to incent people to do anything. I do not know of any professionals more competitive than doctors or executives more competitive than executives of hospitals. Give us the data on how we are performing; make sure it is accurate, reliable, and reflective, and we will move mountains to jump over the next guy.

There have been tremendous developments in data collection. The accord played a key role in that, around wait times and other forms of data such as historic, home care, long term care and drug data that are comparable across the country. Without question, there are gaps. It is CIHI's job to fill in those gaps as resources permit.

The Health Council of Canada will give you the data as we get it from the service providers. There are many building blocks right now and not a lot of substance.

send him or her to the States

Are you including in the data the percentage of people who are getting their work done elsewhere and paying for it?

When we started to collect wait time data years back, we looked at the possibility of getting that number. It is difficult to do that in a survey sampling the population. It is, in fact, quite rare that that happens.

Do we have a leader in charge of this health accord? Do we have a business plan that is reviewed quarterly and weekly so that we are sure that the things we want worked on are being worked on? Is somebody in charge of the coordination of it in a proper fashion?

Dr. Kitts: We are without a leader.

Mr. Abbott: Governments came together and laid out a plan. That was good. Then they identified having a pharmaceutical strategy or a series of commitments to move forward. The system was working together. When the ministers and governments are joined, progress is made. When that starts to dissipate for whatever reason, then we are 14 individual organization systems, moving at our own pace.

You need a business plan to get there. I do not know how you do it any other way. You can have ideas, visions and things in place but how do you get there? You need somebody to manage it. Dr. Kitts: I think you have hit the nail on the head.

The Chair: If we had one company, we would not have needed an accord. However, we have 14 companies.

There was an objective of ensuring that 50 per cent of Canadians have 24/7 access to multidisciplinary teams by 2010. Dr. Kitts, in your submission in 2009, you talked about it being at 32 per cent.

there has been a tremendous focus for Ontario on creating family health teams, which are multidisciplinary primary health care teams. I believe that is the case in the other jurisdictions.

The primary health care teams, family health care teams, and inter-professional practice are all essentially talking about the same thing. We are seeing a lot of progress. Canadian Health Services Research Foundation is doing a lot of work in this area to help the various systems to embrace it and move forward.

The question then came up about whether 50 per cent of the population is the appropriate target

If you see, for instance, what the Ontario government promotes in terms of needing access, they give quite a comprehensive list of points of entry for service. Therefore, in terms of actual service, we are seeing that points of service have increased.

The key thing is how to get alignment from this accord in the jurisdictions, the agencies, the frontline health service providers and the docs. If you get that alignment, amazing things will happen. Right now, every one of those key stakeholders can opt out. They should not be allowed to opt out.

the national pharmaceutical strategy

in your presentation to us today, Dr. Kitts, you said it has stalled. I have read that costing was done and a few minor things have been achieved, but really nothing is coming forward.

The pharmacists' role in health care was good. Procurement and tendering are all good. However, I am not sure if it will positively impact the person on the front line who is paying for their drugs.

The national pharmaceutical strategy had identified costing around drugs and generics as an issue they wanted to tackle. Subsequently, Ontario tackled it and then other provinces followed suit. The question to ask is: Knowing that was an issue up front, why would not they, could not they, should not they have acted together sooner? That was the promise of the national pharmaceutical strategy, or NPS. I would say it was an opportunity lost, but I do not think it is lost forever.

The Standing Senate Committee has asked Canadians to answer the question: Excluding increased funding, what are the three most important areas of government responsibility (either federal or provincial) that need to be improved to ensure adequate and timely access to needed mental health services?

Three Priorities for Action

1) Act outside of the traditional health care sector: Ensure access to housing, supportive housing, income, and employment.

2) Include mental health in health care reform initiatives.

Expand coverage under the Canada Health Act

include home care under the Act and to ensure public funding for the costs of medications prescribed outside of institutions

reinforce the work already underway by First Ministers to expand home care to people with mental illness

include people with concurrent disorders and addictions in any national home care program

3) Develop a National Action Plan on Mental Health.

Menendez has claimed he and Melgen have been friends for years and that he did nothing illegal. Melgen also is charged in a separate indictment in Florida accusing him of multiple counts of Medicare fraud. Medicare is the government-funded program providing health care coverage to the elderly. A federal judge in Newark has set a trial date for October.

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

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

Six areas, in fact, were identified by CHA

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

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

safety, effectiveness, efficiency, appropriateness

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

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

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

Nadine Henningsen, Executive Director, Canadian Home Care Association

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

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

great good has come from the 10-year plan

Unfortunately, there were two unintended negative consequences

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

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

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

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

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

Second, adopt a Canadian caregiver strategy.

Third, support accountability and evidence-informed decision making.

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

Sharon Baxter, Executive Director, Canadian Hospice Palliative Care Association

June 2004

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

Dying for Care

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

terminated by the federal government in March of 2008

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

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

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

progress was made in 2008, from the 2004 accord

palliative pharmaceutical plan

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

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

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

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

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

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

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

Canadian Caregiver Coalition

in Manitoba they have made great strides

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

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

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

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

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

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

that never happened

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

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

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

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

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

A lot of eligibility rules are built on physical assessment.

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

in Saskatchewan it is a little more integrated

Senator Martin

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

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

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

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

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

most people want to be cared for at home

Family Caregiver Tax Credit

compassionate care benefit that goes with Employment Insurance

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

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

tax credits

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

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

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

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

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

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

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

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

we have three recommendations

Patient-centred care, inter-professional care and comprehensive care are all things that deserve and require additional investment and attention.

We need a pan-Canadian human resources for health observatory function to provide evidence and data on which to plan. Our workforce science in Canada is at a very primitive stage, and we are lurching from one crisis in one locality or one specialty to another.

The second recommendation

Our third recommendation

Canada needs an injury prevention strategy to elevate in the public's attention and bring resources to bear to reduce needless injuries in our life. The reason for this is that injuries cause a lot of loss of life, disability, long-lasting disability and painful disability, and they cost a lot of money.

Jean-François LaRue, Director General, Labour Market Integration, Human Resources and Skills Development Canada

foreign credential recognition

Marc LeBrun, Director General, Canada Student Loans, Human Resources and Skills Development Canada

Canada student loan forgiveness for family physicians, nurses and nurse practitioners, as introduced in Budget 2011

Robert Shearer, Acting Director General, Health Care Programs and Policy Directorate, Strategic Policy Branch, Health Canada

in 2004 the federal government committed to the following: accelerating and expanding the assessment and integration of internationally trained health care graduates across the country; targeting efforts in support of Aboriginal communities and official language minority communities to increase the supply of health care professionals in these communities; implementing measures to reduce the financial burden on students in specific health education programs, in collaboration with our colleagues in other federal departments; and participating in HHR planning with interested jurisdictions

Canada does not have a single national health human resources plan

Health Canada plays a leadership role in HHR by supporting a range of targeted projects and initiatives of national significance.

Pan-Canadian Health Human Resource Strategy

Internationally Educated Health Professionals Initiative

Health Canada supports collaborative efforts as co-chairs of the federal-provincial-territorial Advisory Committee on Health Delivery and Human Resources known as ACHDHR. This committee was created by the conference of deputy ministers of health back in 2002, to link issues of primary health care, service delivery and HHR.

ACHDHR will be providing a written brief

The federal government also participates on ACHDHR as a jurisdiction that directly employs health care providers and has responsibility for the funding and delivery of certain health care services for populations under federal responsibility, such as First Nations and Inuit, eligible veterans, refugee protection claimants, inmates of federal penitentiaries, and serving members of the Canadian Forces and the Royal Canadian Mounted Police.

Shelagh Jane Woods, Director General, Primary Health Care and Public Health Directorate, First Nations and Inuit Health Branch, Health Canada

Dr. Brian Conway, President, Société Santé en français

account for over a million Canadians who need access to quality health services in their own language.

Acadian and francophone communities outside Quebec

Senator Eggleton

I am interested in the injury prevention idea. We hear of it from time to time. Do you have some specific thoughts on what an injury prevention program or strategy might look like and how it might fit in with the health accord? One of the things the Health Accord brought about in 2004 was the federal government saying to the provinces, “If you do this and you do that we will give you money here and there.” Maybe we should be doing that here. Maybe we should ask the federal government to provide an incentive for the provinces to be able to do something. It would be interesting if you could come up with a vision of what that strategy might look like.

To defend and improve Medicare, the federal government must also: 

Today is the last day for Parliament to pass legislation governing medically assisted dying before a deadline imposed by the Supreme Court. It won't happen. On Friday, the Senate sent the bill to its legal affairs committee for study. The committee meets today but won't be able to report on the bill until the full Senate resumes tomorrow. And it still could be weeks before any federal law is in place.

The repeal legislation created a commission to examine the issue of long-term care, but it ended the appetite of many in Congress to resolve the issue. The Clinton health plan made another attempt at improving long-term care, but the bill failed.

The program’s end is a blow to middle-class hopes, though its modest benefit would have covered only about a quarter of nursing home care.

Senator Judd Gregg, Republican of New Hampshire, succeeded in adding an amendment requiring the administration to certify that the program would be self-sustaining for 75 years before enacting it. The administration concluded that it could not make that certification, killing the program.

Less than 3 percent of Americans now buy private long-term care insurance. The government’s version of long-term care insurance shared a basic flaw with commercial options: It was voluntary, with benefits to be paid entirely by premiums.

Senator Edward M. Kennedy made passing the Class Act one of his last priorities

“I was middle class, but I’ll be impoverished eventually,” he said.

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.

“I do not presume to claim today that the Canadian system is perfect or that we do not face significant challenges,” Martin told the committee on Tuesday. “The evidence is clear that those challenges do not stem from the single-payer nature of our system. Quite the contrary.”

Moving away from a single-payer system and introducing more private health care is not a solution and would likely exacerbate wait times in the public system by drawing health-care resources away from it, she told the senators.

Sitting next to Martin was another Canadian, Sally Pipes, who is now an American citizen and leads a think-tank in San Francisco that advocates for the free market. Pipes gave a decidedly different view of Canada’s health-care system.

“On average, how many Canadian patients on a waiting list die each year, do you know?” he pressed her. “I don’t sir, but I know there are 45,000 in America who die waiting because they don’t have insurance at all,” Martin shot back.

What about Williams going to Florida for surgery, he asked her, what does that signify? Martin noted that the doctors who pioneered the surgery he had done actually work in Toronto.

Though the committee meeting was partisan at times, she said it is a positive sign that the U.S. is looking at international examples.

It is a fact that public sector employees, MPPs, MPs and senators can access health-care services and benefits above and beyond what is available through their provincial health plans. In his words, a form of two-tier health care plan. Premiums to these complementary health plans are subsidized in part by government, in other words by public funds. My question to the Liberal leader is simple: "If you form the next government, will you maintain the present two-tier health-care system for public sector employees including MPs and senators, or will you direct Treasury Board to stop the partial payment of the premiums and direct participants to absorb the full cost of the plan, or will you subsidize access to such plans for all Canadians?"

A reminder for Trudeau, the Charter is not a buffet where one chooses the articles that suit his or her agenda. Canadians, public sector employees and non public sector employees, deserve equal treatment. In his own words, it is a question of rights. Pierre Drouin Ottawa