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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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Meanwhile on the East Coast, Nova Scotia posted the worst numbers for joint-replacement surgeries. The province has high obesity rates and an older population, which increase demand for these procedures. But so do several other provinces that performed better. "Nova Scotia, particularly on joint replacements, has historically had a difficult time getting all of the patients done within a timely fashion," Morris says. The battle to improve wait times for key surgeries began in 2004, with provinces setting targets for hip and knee replacements, hip-fracture repairs, cataract surgeries and radiation therapy. The goal is to ensure that 90 per cent of patients wait no longer than 48 hours for a hip-fracture repair, 182 days for the joint-replacement procedures, 112 days for cataract surgery and 28 days for radiation. The 2014 national numbers reveal that 98 per cent of people received radiation therapy within the benchmarked time. For the other procedures, the national averages ranged from 79 per cent (cataract surgeries) to 84 per cent (hip-fracture repairs). For the first time, CIHI was able to compare surgical wait times in Canada with those of several similar countries, including Britain, Finland, Australia and New Zealand.

The Canadian figures were among the best for waits for joint replacement and cataract surgeries, Morris notes. But that picture might not be as favourable if the time being measured included how long it takes for Canadian patients to see a specialist after their family doctor decides they need one of these five procedures. The wait-time clock starts ticking from the time a specialist orders the surgery. Critics have long argued that starting the clock from the visit to the family doctor would give a more realistic picture of the state of care in Canada. Morris says that is the next frontier in the campaign to reduce surgical wait times. "We know, overall, that Canadians wait much longer than people in other countries on average to see a specialist," she says. "So it's probably an area where there is opportunity to apply some of the same principles in terms of streamlining the steps and getting people in quickly."

Dr. Isabelle Leblanc, president of the pro-medicare group Médecins québécois pour le régime public, said the survey results show that radiologists in Quebec are increasingly choosing to work in the private sector to the detriment of the public system. "For us, this is the best example of how mixing the public and private systems can lead to decreased accessibility for most patients and increased accessibility for those who have the money to pay," Leblanc said. "Radiologists have no incentive to increase access in the public system, and in fact, they're draining resources from the public system." Leblanc explained that radiologists can earn more money charging patients for scans in private clinics than they would if they worked exclusively in hospital and billed the Régie de l'assurance maladie du Québec. Leblanc's group warned in a report three years ago that wait times for MRIs in hospital would increase.

"We're the province that has the highest number of MRI and CT scan machines per capita in the country - with a third of the machines in the private sector - and yet our public wait times are going up," Leblanc added. Health Minister Gaétan Barrette, a radiologist by profession who had worked in a private clinic before entering politics, was unavailable for comment. Officials with the Association des radiologistes du Québec could not be reached for comment, either. The Fraser Institute report observed little progress in cutting wait times for medically necessary surgery or treatments. The median wait time in Canada for treatment inched up to 18.3 weeks from 18.2 weeks last year. In Quebec, the median wait time for treatment by a specialist rose to 16.4 weeks from 7.3 weeks in 1993, when the Fraser Institute first started compiling such data. The median wait time denotes the midpoint for those waiting, as opposed to an average. In Quebec, the median wait time to see a medical specialist following referral from a general practitioner rose to 7.3 weeks from 7.1 weeks last year. The survey found that the longest median waits in Canada were for orthopedic surgery at 35.7 weeks, or almost nine months.

"These protracted wait times are not the result of insufficient spending but because of poor policy," Bacchus Barua, the author of the Fraser survey, said in a statement. "In fact, it's possible to reduce wait times without higher spending or abandoning universality. The key is to better understand the health policy experiences of other more successful universal healthcare systems around the developed world." aderfel@montrealgazette.com Twitter.com/Aaron_Derfel

The median wait time in hospital for a magnetic resonance imaging (MRI) scan in Quebec jumped to 12 weeks this year from eight in 2014, a survey has revealed. Wait times also increased slightly for other medical imaging. ALLEN McINNIS-MONTREAL GAZETTE FILES • MONTREAL GAZETTE / Source: Fraser Institute

The procedures are publicly funded and patients come from Island Health's standard wait lists. The B.C. NDP said Island Health's call for contracts entrenches stop-gap measures in which the use of private clinics to reduce wait times drains funding, doctors and nurses from the public to the private system. On Vancouver Island, there are 1,265 people waiting (for an average of 39 weeks) for all types of colonoscopies, including screening colonoscopies, at Victoria General and Royal Jubilee hospitals. There are 352 people facing an average wait time of 26 weeks for hip replacements, and 566 people facing an average wait time of 28.7 weeks for knee replacements.

There are 404 people waiting for a hernia repair (an average wait time of 22.4 weeks) and 445 people waiting for varicose veins to be treated (an average wait time of 99.2 weeks). Canadian Institute for Health Information executive Kathleen Morris said working through a list of people who had waited longer than the recommended limit might have temporarily made wait times look worse than they typically are. "The question, I guess, is if the strategy is successful and it's a one-time strategy, you'll have one year with funny results and then things will kind of - hopefully - go back to a better spot," said Morris, the institute's director of health-system analysis and emerging issues. Meanwhile on the East Coast, Nova Scotia posted the worst numbers for joint replacement surgeries. The province has high obesity rates and an older population, which increase demand for these procedures.

But so do several other provinces that performed better. "Nova Scotia, particularly on joint replacements, has historically had a difficult time getting all of the patients done within a timely fashion," Morris said. The battle to improve wait times for key surgeries began in 2004, with provinces setting targets for hip and knee replacements, hip-fracture repairs, cataract surgeries and radiation therapy. The goal is to ensure that 90 per cent of patients wait no longer than 48 hours for a hipfracture repair, 182 days for joint-replacement procedures, 112 days for cataract surgery and 28 days for radiation.

The Alliance, a coalition of medical specialists, is calling on provincial and federal leaders to help fashion a "new national vision for health care," one that sets national benchmarks that go beyond the 2004 initiative that targeted five procedures: hip and knee replacements, cataract surgery, heart operations, diagnostic imaging and cancer radiotherapy.

We still don't measure nearly enough," said Dr. Chris Simpson, chair of the alliance and a former president of the Canadian Medical Association. "You can't fix what you can't measure."

At a time when more care is moving out of the hospital, Dr. Simpson said wait times for home care and long-term care beds should be monitored by all provinces, as should the number of patients in hospital because they cannot access these services.

When health ministers meet in January in Vancouver, Dr. Simpson said he hopes a partnership to establish such standards will be part of the discussion, rather than just the level of federal funding. "If we have made a collective mistake in the past, it is to say to the federal government, 'It's all up to you,' " he said.

The annual report card provides a snapshot of wait times across a range of measures gathered from provincially available information this summer. In doing so, it highlights the variation in the information available among provinces, and this year also notes that the federal government - responsible for delivering health care to First Nations, refugees, veterans, Canadian Forces and inmates in federal prisons - provides only limited data on its own performance.

The study, which gives a grade to provinces across a range of procedures, finds those provinces that got high marks last year - Saskatchewan, Ontario and Newfoundland and Labrador - continue to do well.

Both studies point to the success of Saskatchewan in cutting wait times as evidence of what can be done with a focused effort and both note that the improvement came from more than increased funding.

In five years, the number of patients in Saskatchewan waiting more than six months for surgery dropped by 96 per cent, the Alliance report card finds, thanks to a $176-million investment over four years and also because of innovative practices. Bacchus Barua, a senior economist at the Fraser Institute and author of its wait-time study, said measures such as a pooled referral system helped give Saskatchewan the shortest wait times in the survey.

The report from the Fraser Institute is based on a survey of specialists and tracks the time between the initial referral and the appointment with a specialist as well as the time between seeing a specialist and treatment. At the national level, it found the median wait time from referral to treatment was 18.3 weeks, almost the same as the 18.2 weeks recorded in 2014, but almost double the 9.3 weeks recorded in 1993 when the survey began.

Across Canada, wait times have stabilized, but they have stabilized at a very high level," Mr. Barua said

Saskatchewan had the shortest total wait at 13.6 weeks and Prince Edward Island had the longest at 43.1 weeks, although the small sample size in PEI makes that result less reliable. Among specialties, the longest waits were for orthopedic surgery at 35.7 weeks and the shortest were for patients in line for radiation oncology at 4.1 weeks, the study said.

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."

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

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

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

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

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

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

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

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

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

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

the Canada Health Act

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

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

John Abbott, Chief Executive Officer, Health Council of Canada

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

That is right.

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

We want to share best practices.

it is not likely to happen without strong direction from above

Excellent Care for All Act

quality plans

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

Canadian Hospital Reporting Project

by March of next year we hope to make it public

performance, outcomes, quality and financials

With respect to physicians, it is a different story

We do not collect data on outcomes associated with treatments.

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

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

Senator Eaton

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

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

universal screening

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

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

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

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

colorectal screening

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

adverse drug effects

over-prescribing

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

catastrophic drug coverage

a patchwork across the country

with respect to wait times

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

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

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

Have we made progress?

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

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

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

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

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

send him or her to the States

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

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

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

Dr. Kitts: We are without a leader.

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

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

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

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

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

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

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

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

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

the national pharmaceutical strategy

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

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

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

Data show that for hip replacements, B.C. has the second longest wait times in Canada, with a median value of 70 weeks. But that is a median value, which means about half of all patients wait longer. That is twice the wait time in Ontario, which is actually the third best province in Canada, according to recent Canadian Institute for Health Information (CIHI) statistics. So, I waited and the hip deteriorated until painkillers seemed useless.

Finally, just short of a year, I got a call on June 10 to say that my hip surgery was scheduled for July 15, or week 51. I fought back tears of relief. It almost made me forget the absence of a vital life during the weeks I had waited. What happened next knocked the wind out of my sails. One week before my scheduled operation, I was told that I had been bumped for a situation that presented a "higher level of urgency." They had just added almost eight weeks to my wait time for reasons that were opaque, at best, and without logic to me. Why did this happen? In the end, I got no real answers.

So, beyond my personal experience, the real question is: "Are Canadian wait times for hip replacement justified or could they be shortened?" Turns out, the variability within Canada's health-care system is wide, and does not just exist across provincial borders. In most provinces, wait times vary significantly from city to city, region to region, hospital to hospital and doctor to doctor. The evidence tells us that having a "private" alternative actually makes wait times in publicly funded health care facilities worse. So that is not the solution.

One of the problems in answering this question is a lack of provincewide databases in many jurisdictions. Such databases would help minimize wait times because patients from a busy facility in one region within a province could be transferred to other facilities (or surgeons) with shorter waiting lists. Today, in most provinces, doctors and specialists work in silos and there is no real overarching management of the system. Health care decision-making in Canada is largely decentralized, with few standardized measures of "success." One doctor can have wait times measurably better or worse than the next, and the system cannot be expected to respond well by moving individual patients. The only real leverage many provincial ministries impose is to incent desired behaviour through macrobudgets.

We need more integrated management and measurement in the system - if not countrywide, then at least provincewide. Alberta is a good model. Most recent data show that providing incentives tied to provincial benchmarks based on a standardized care path has created savings of almost 12,600 hospital bed days (and $13 million) annually. The incentive? The non-monetary savings in resources are pumped back into hip and knee replacement services, where the medical teams see the impact of their success first-hand, rather than disappearing back into the system as a whole. Alberta now meets CIHI benchmarks for hip replacements 87 per cent of the time, versus a 67 per cent success rate in B.C. In fact, for 90 per cent of its hip replacement patients, Alberta now meets the maximum wait-time limit criterion of 14 weeks. Note that providing financial compensation is not necessarily the primary motivating factor.

Canadians consistently show strong support for their health-care system. However, wait times continue to drag the outcomes down. We can shorten wait times, but it will take political courage. Let's hope that courage can be found. Robert Brown is an expert adviser with EvidenceNetwork. ca, a retired professor of actuarial science at the University of Waterloo and immediate past president of the International Actuarial Association. He lives in Victoria, B.C.

Legal precedent: Whatever way the case is decided at trial, it is likely to be appealed and eventually reviewed by the Supreme Court of Canada. A decision from this level will mean all provincial and territorial governments will have to revisit equivalent laws. The foundational pillars of Canadian medicare - equitable access and preventing twotier care - could well be vanquished in the process. Wait times: Day will likely argue that Canada performs poorly on wait times compared to other countries, and that other countries allow two-tier care; thus, if Canada is allowed two-tier care, our wait times would improve. But this approach is too simplistic. Comparisons to the British health system, fail to recall that, despite having two-tiers, it has in the past suffered horrendously long-wait times. Recent efforts to tackle wait times have come from within the public system, with initiatives like wait time guarantees and tying payment for public officials to wait times targets.

By looking to Britain, we are comparing apples to oranges. British doctors are generally full-time salaried employees while most Canadian physicians bill medicare on a fee-forservice basis. Consequently, the repercussions of permitting extra billing in Canada could eviscerate our publiclyfunded system, whereas this is not the case in Britain. Imagine if most doctors in Canada could bill, as those at the Cambie clinic have done, whatever they want in addition to what they are paid by governments?

Conflict-of-interest incentives: Evidence suggests there is a danger in providing a perverse incentive for physicians who are permitted to work in both public and private health systems at the same time. Wait times may grow for patients left in the public system as specialists drive traffic to their more lucrative private practice. Sound improbable? Academic studies have noted this trend in specific clinics that permit simultaneous private-public practice. And recent U.K. news reports have profiled a case where a surgeon bumped a public patient in need of a transplant for his private-pay patient.

Competition: Proponents of privatized health services often claim it would add a healthy dose of competition, jolting the "monopoly" of public health care from its apathy. But free markets don't work well in health care. Why? Because public providers and private providers won't truly compete if the laws Day challenges are struck down. Instead, those with means and/or private insurance will buy their way to the front of queues. Public coverage for the poor will likely suffer, as is clearly evident in the U.S., with doctors refusing to provide care to low-income patients in preference for those covered by higher-paying private insurance.

Of course, this is all based on an outcome that is not yet known. It may be that the charter challenge in B.C. will be unsuccessful, but clearly the stakes for ordinary Canadians are high. Sadly Dr. Day is not bringing a challenge for all Canadians. Isn't it past time our governments and doctors work to ensure all Canadians - and not just those who can afford to pay - receive timely care? Colleen Flood is Professor and University Research Chair in Health Law Policy at the University of Ottawa. Kathleen O'Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University and Managing Editor of EvidenceNetwork. ca

The member of the scheduling team responsible for that work unit would receive the request along with a list of employees that have the skill-sets and availability to work in that vacationing staffer's place. "They assign that work according to the various union collective agreements," he said. However, if the matter is unfolding in a shorter period of time, such as if someone was calling in sick for a shift scheduled to start later today, there's a different protocol. "Obviously that needs more immediate attention. There's an actual telephone call from a manager or a supervisor at (the unit) to a dedicated line in the scheduling centre," he said. Together, the employee's manager would work with the scheduling team to sort out the appropriate person to be offered the shift. Why is Horizon making this change? The goal is to lighten the administrative load on health-care managers across the province so they can focus on the day-to-day delivery of care.

"We're taking that sort of task or transaction work out of the nursing units. Typically, it's done by ward clerks or, in many cases, the managers themselves. It consumes a lot of their time. But that's only part of their job. They have responsibilities for other operational requirements in their various units," he said. Doull said the health authority also sees value in managing schedules in a consistent way across the province. "What we want to do for all of the areas is standardize the processes and the application of the collective agreement rules. So instead of having (more than) 200 people in Horizon who have as some small part of their job (tried) to get by in doing scheduling work as best they can with no formal software support or training, we're going to bring that into a purpose-built department," he said. "And there are efficiency payoffs for that, both financial and operational, for us as an organization." He did acknowledge that there will still be room for personal interventions by managers, particularly if a quick conversation at the office door can resolve a pressing matter easily and effectively.

If a matter is of an urgent nature, the employee can contact their manager or appointed supervisor directly and have a conversation about the request for time off and the manager can figure out a specific way to handle the situation. "All the manager is going to do is simply call the centre in Saint John, or email the staffing team that they work with, and say, 'An employee has talked to me. This is what we're going to do and here's how I want you to deal with the shift on Saturday,'" he said. "The manager always has that direct-line option to deal with things that are of a more timely nature." Although, too much of that can be a problem, said Doull, explaining that in some units across the province managers can fall into routines where the easiest employee to reach, or the most willing employee to work, receives most of the overtime or sick-time shift offers. "Later on, one of the four or five people (ahead of the preferred employee) may very well come back and say, 'I have a grievance because I should have been offered that shift. What are you going to do for me?' And we may be in a situation of having to, in effect, pay twice for time that needs to be worked," he said.

"I wouldn't characterize it that it happens often, but it certainly happens often enough that we know about it and it's one of the problems that we're specifically trying to solve." Members of the scheduling team are working to determine which site will be the next to adopt this new staffing system. Ultimately, when the scheduling team is fully operational and slotting shifts for units across Horizon, a team of 21 staff members will be working at the Saint John centre between the hours of 5 a.m. and 11 p.m. "That's roughly 70 full-time equivalent (positions for our team)," he said.

Doull said he knows many employees are likely worried about this change, but the move is expected to create significant savings for Horizon. "What we're looking to do is return time to managers and clinical staff," he said. "We know patients have a better experience if they know who the manager is in their area and they're able to interact with them regularly ... We know staff are more satisfied at work if they're able to have access to their manager." There are also savings expected through reductions in payroll errors.

"If someone puts in the wrong code for a specific number of hours and an employee gets paid the wrong thing, we know how often we're going back and correcting these. What this system will do is take a lot of the manual data entry of our pay processes away," he said. "It'll be automated and driven by what the employee is scheduled to work." It should also help to highlight problems in specific units, he said. "If we have an area, for example, that is using a lot of overtime, we'll know who is not there, why they're not there, which positions are not actually filled because there's nobody to work them, and we'll be better able as an organization to identify where our recruiting issues are," he said.

Ralph McBride, CUPE Local 1252's provincial co-ordinator, said he's concerned about the economic impacts the move could have on communities across the province. "We're not overly impressed with centralizing services. We see this as taking away important jobs in rural New Brunswick and moving them to urban centres," he said. "We think there are economic hard times happening currently in the Miramichi. This won't help." There are no plans to integrate this system with scheduling protocols used by the Vitalité Health Network. The Daily Gleaner requested information from the Vitalité Health Network on how the province's other regional health authority schedules its staff and the paper is still waiting for a response.

As a policy under the workers' compensation insurance system, expedited fees were effective in reducing wait time to surgery. While a difference of only two weeks may not improve longer-term clinical outcomes post-surgery, it represents a reduction in the total disability duration (i.e., pain, suffering, quality of life) for the injured worker and increases the worker's likelihood of successfully returning to work; the reduced disability duration also represents a cost saving to the workers' compensation system for time-loss benefits and to employers who pay compensation premiums based on the frequency and duration of their claims experience.

the provision of surgeries "after hours" or within private clinics may result in a redistribution of finite resources (e.g., surgeons, surgeon time, surgical staff) from one insurance provider to another, favouring those associated with higher fees, thus creating inequities. An evaluation of the effect of workers' compensation policies on inequity in the provincial healthcare system was not part of this study and warrants future investigation.

the time leading up to surgery may be confounded by co-morbidities and that individuals with complications may be directed to the public system

A difference of approximately two weeks in surgery wait time associated with the expedited fee policy may have meaningful clinical and quality-of-life implications for injured workers, in addition to being cost-effective policy for workers' compensation insurance systems, but did not affect the return-to-work time post-surgery as part of total disability duration. Minimal (and not statistically significant) differences in disability duration were observed for surgeries performed in private clinics versus public hospitals.

full-time employment during each recession was, in many ways, permanent," Tal wrote in the report. The findings come as no surprise to professors who study Canada's labour market. "There's been this idea that now that oil prices are low and the dollar is low and now we'll see these big plants come back to Canada. I think that's overly optimistic," said Mike Moffatt, assistant professor at the Richard Ivey School of Business at the University of Western Ontario. "The big takeaway from this is that the issues that we have in Canada and Ontario, in particular, aren't just recession-based. Policy-makers need to figure out other ways of economic growth and job growth that don't just assume those manufacturing jobs are coming back." The number of self-employed workers rose four times faster than the number of paid employees during the year-ended January 2015, CIBC noted in the report.

While self-employment can provide flexibility and other advantages, it is considered to be of lower quality because on average it pays less than salaried positions. The number of low-paying jobs has risen faster than the number of mid-paying jobs, which in turn has risen faster than the number of high-paying jobs. In the last year, the number of low-paying full-time positions rose twice as fast as the number of high-paying positions, CIBC said. Over the past decade, wages in high-paying sectors rose almost twice as fast as wages in low-paying sectors. "In other words, the fastest-growing segment of the labour market is also the one with the weakest bargaining power," Tal wrote. Unemployment insurance, the Canada Pension Plan, as well as health care, education, and child care, were built to suit the labour market from the 1960s and 1970s, when a single breadwinner had a good-paying job with steady income, hours, and benefits that could support an entire family, said Wayne Lewchuk, a professor at McMaster University who has researched precarious employment.

"I think we're coming to terms with the fact that we have the wrong institutions for a modern labour market," Lewchuk said. "If we get the institutions right, then these people who are precarious, they become flexible employees. That's not necessarily a bad thing, and the supports are around them make this a viable way of operating." Lewchuk points to the public discourse around the perils of precarious employment, as well as the proposed Ontario pension plan, the Canadian Skills Training and Employment Coalition, and worker protection legislation passed last year, as evidence of change, Lewchuk said. "It has taken 20 or 30 years for us to get here. It will take that kind of time to move away. But I think the momentum has shifted," Lewchuk said. "There are all kinds of reasons to be optimistic but it's going to take time and it's going to be through struggle."

MacKinnon also challenged two frequent criticisms of private clinics: that they’d cream off the easiest surgeries and steal the best staff. Instead, she says surgeries were assigned by health regions and clinics hired retired nurses and nurse practitioners who liked the better hours and low-hassle atmosphere. She noted that surgeries — which covered only an array of specialties, not a complete list of surgeries — came in 26 per cent cheaper than in hospitals. “I think it was extremely well done.” Only in Canada, she said, would there be any fuss over who owns the clinics providing service in a single-payer system, MacKinnon said.

"You don't have enough time to sit and talk with them. It's always a rush. Everything has time constraints. You have to be in the dining room by 8:30; you have to be out by whenever; you have to have a shower today - I mean, that's their home. And you actually want to sit with them and talk with them, but you just don't have the time. You can't even get to know your residents. You know them by seeing them every day but you don't really get to know their background, or their history, you know, what they did before. You try to get to know them but you don't have the time to spend with them." If Bill 188 passes, all long-term care homes in the province will be required to stafftheir facilities adequately enough to provide a minimum four-hour standard of care for each resident each day.

Despite this being a newly introduced bill, Laronde said front-line care workers at long-term care facilities in Ontario have been fighting to have this for years. "This campaign (to legislate more time for individual long-term care residents) has been going on for many years and it's finally got a bill," said Laronde. MPP Gilles Bisson (NDP - Timmins-James Bay), explained, "It's a bill that has yet to be debated. It's been introduced. We're waiting for it to be debated." The fact the bill was introduced by a the health critic of the NDP doesn't mean the Liberals will automatically shoot it down as an act of partisan politics, said Bisson.

"There are a number of bills put forward, quite frankly, by members of the opposition that wind up becoming law," he said. "In fact, France Gélinas has been very successful in putting forward a number of private member's bills that the government adopted as their own bill." The Extendicare Timmins workers intend to hold information pickets again on Thursday and Friday. © 2016 Postmedia Network Inc. All rights reserved. Illustration: • Ron Grech, The Daily Press / Front-line care staffat Extendicare Timmins held an information picket Wednesday afternoon to express their support for Bill 188 which is currently going through the Ontario legislature. The NDPinitiated bill, referred to the Time To Care Act, would make a minimum four-hour daily care a legal standard for long-term care residents.

How timely will the service be? Do wait times threaten the health of those waiting? Wait times are obviously a form of rationing within the system, but at what point does a person's "right to life," a phrase from the Charter of Rights and Freedoms, become threatened by this rationing? These questions were central to the Supreme Court's Chaoulli decision in 2005. If, as is almost certain, the B.C. case winds up back in Ottawa, will the court stand by its earlier decision? The 4-3 Chaoulli judgment found that the ban on private insurance violated the Quebec Charter of Human Rights and Freedoms.

Three judges said it also violated the Canadian Charter; three judges disagreed and one expressed no opinion. In other words, the court was conflicted 10 years ago. Its membership has changed hugely in a decade. Who knows what all the new judges appointed since 2005 might decide? And, as we have just seen in its recent assisted suicide ruling, the court is not above reversing itself by overturning previous decisions.

These B.C. and Quebec healthcare cases illustrate the legalization of politics that has become such a feature of Canadian public life under the Charter of Rights and Freedoms. No issue has been more debated in Canada, and no public program has absorbed more public money (and attention) than health care. Judges might be unhappy with the results of the debates and decisions, but no one can deny that the issue has been central in Canada's politics. And yet in the Chaoulli case, a majority dismissed the decisions of elected officials and barged into the health-care field, despite an obvious lack of expertise.

Health care - its provision, organization and financing - is an essentially political issue in the broadest sense of the term, but in the age of the Charter, judges can make just about anything into a legal issue. So they did in Chaoulli, and might again when confronted with the B.C. case. Madame Justice Marie Deschamps, writing for the majority in Chaoulli, declared about the situation in Quebec: "For many years, the government has failed to act; the situation continues to deteriorate." Much has been done since those words were written. More than $40-billion in extra funds has been spent on health care, courtesy of a federalprovincial agreement. The share of the national economy taken by health care has risen since 2005 (although it has dropped in the last two years).

Wait times in some provinces have come down. But have they come down enough to satisfy the Supreme Court, which set itself up as the arbiter of such answers in the Chaoulli case? Many more hip and knee replacements have been done, but wait times have not come down, owing to increased demand. How long is reasonable? Should a person in distress have the right to spend his or her money to relieve pain, or must they be triaged by the state? It shouldn't be this way, but the courts will decide.

Fraser Institute

Both reports are about wait times in health care.

response rate is only 21%.

Though the report does not say this, many of these waits are due to a severe shortage of hospital beds. (Ontario has cut more beds than anywhere in Canada.)

public hospital system including better wait list management and pooled referrals, additional operating room nurses and health professionals have improved wait times in Saskatchewan.

Ontario has one of the most robust reporting systems in the country,

On the negative side, most provinces do not report their wait times on most procedures, so the report is based on limited information and only from those provinces that do report.

So, focusing on the report that is worth looking at – The Wait Times Alliance report is a thought-provoking addition to the body of research on access to care and timeliness of care.

Long waits in hospital emergency departments were cited in Ontario. Waits are up to 26 hours for Ontario patients with complex conditions that require additional diagnostic tests or admission into a hospital bed.

These are good recommendations that we should support.

There is only really one item with which we would take issue in the report: there is considerable confusion about Alternate Level of Care (ALC) patients.T

one type of hospital bed waiting for another type of hospital bed (not waiting for discharge to long-term care or home care).

Unfortunately, this misinformation is driving dangerous levels of hospital cuts.

There is also a gratuitous positive mention of the LEAN methods in the report, without any real analysis. We receive endless complaints about this Toyota management system that is now being used in public hospitals.

askatchewan Premier Brad Wahl,

Instead the evidence is that patients in those provinces are being charged fees ranging from hundreds to tens of thousands of dollars for medically-needed care.

On top of these user fees, private clinics are billing the public system — for the same procedures. I

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.

Ontario Health Minister Eric Hoskins predicted that the reduction in the annual "escalator" to three per cent would result in a "declining partnership." Yet considering Ottawa contributes only 23 per cent of the average provincial health budget, the three per cent difference in the annual "escalator" translates into a reduced rate of increase of only 0.69 per cent! Much of this is mere political bluster! Is it not finally time to revisit the Canada Health Act and fine-tune it?

As Konrad Yakabuski has stated (Globe and Mail, Oct. 19), "As long as the provinces remain bound by the Canada Health Act, which constrains their ability to dramatically alter the way health care is paid for and delivered, any new conditions on the use of federal transfers are only likely to further weigh down an already overly bureaucratic system."

When it was passed in 1984, it was understood that the federal government would pay half of health costs. Now it covers less than a quarter. Thanks to Ottawa's admission of refugees and migrants, overall growth of an aging, sicker population, new diseases, and new technologies, the provinces must shoulder an increasing burden.

Yet as Bacchus Barua (Ottawa Sun, Oct. 21) has stressed, more efficient health care systems in Europe allow a greater role for the private sector, use co-payments and user fees (with exemptions for the poor and elderly) and fund hospitals according to activity, not by global budgets, which have been frozen in many provinces.

MDs could be required to work - perhaps 25 to 30 hours per week - in the public system in order to receive government reimbursement for malpractice insurance. Most MDs would confine their practice to the public system. They deserve fair treatment. Thus Philpott should amend the CHA to mandate binding arbitration when provincial negotiations fail.

For those not a member of a "special group," the main option for timely care may be to go to the United States. This provides employment to American doctors and nurses and profits to U.S. hospitals. Would it not make more sense to allow all Canadians to spend their after-tax discretionary income on their own health in their own province?

Frozen hospital global budgets have caused excessive wait times for knee and hip replacements as operating rooms are often not functioning at full capacity. According to a 2013 survey, 15 per cent of Canadian surgeons considered themselves underemployed and 64 per cent cited poor access to ORs. Hence if orthopedic surgeons had access to additional "private" OR time, wait times could be shortened. If hospitals were permitted to operate electively on Americans and other foreign patients, this would bring in extra revenue for hospitals and relieve the strain on provincial health ministries.

Philpott has vowed to do more than just "open the federal wallet." She admits that "innovation" is required. Yet governments are being constrained by blindly adhering to certain parts of the CHA. Despite denials by politicians, a "two-tier" system has always existed. Federal prisoners, WSIB patients, members of the military and RCMP, politicians and professional athletes usually obtain more timely care - often at private facilities.