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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.

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.

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

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.

The average number of people on wait lists as of May, 2015, is 611. Some regions have shorter wait lists, such as Toronto Central, which currently has zero. Others are in the four digits, such as the Central East CCAC, which stretches east from Victoria Park Avenue in Scarborough and north to Algonquin Park, and has 1,516 children waiting for speech therapy. Waiting that long can have a large impact on a child's ability to do well in school, according to Anila Punnoose, a director of Speech-Language and Audiology Canada. During the months or years children are waiting to get speech services, they can quickly fall behind in school, she said. A 1996 study found children with language deficits are more likely to experience social difficulties including interacting with their peers, which impacts their behaviour. Other studies have shown that children who don't get speech therapy early are at a greater risk of problems in their academic performance and mental health.

A lot of speech problems carry over to literacy, because a knowledge of speech sounds is crucial when learning to read, Punnoose said. "It's all about what you hear in those sounds. ... Do you know the beginning sounds in that word? A child who doesn't have good phonological awareness doesn't understand any of that," she said. When looking at school performance, Punnoose said early struggles carry through to later years. A child with speech problems who has difficulties learning in the early years won't be able to build on those lessons in later years as effectively as their peers, she said. Early intervention can mitigate and prevent those problems, she said. "If children are having severe difficulties with speech in kindergarten, it's a predictor that there's going to be academic difficulties, and especially reading and writing difficulties, by Grade 3," she said.

Jocelyn Fedyczko, Eddie's speech pathologist, has worked in a range that includes children from preschool all the way to teenagers. She said early intervention is crucial with young children such as Eddie. "The earlier you can help a child out, the more progress you see," she said. When a child gets to the top of the wait list, they get assessed again, and receive a block of treatment, usually around 10 or 12 sessions, says Peggy Allen, president of the Ontario Association of Speech-Language Pathologists and Audiologists (OSLA). That's often not enough to treat even minor to moderate issues such as Eddie's. Fedyczko said she can get through two to three sounds in that time, depending on the child. Many children have problems with more sounds than that, she said. But when a child finishes their block of treatment and needs more, because they haven't worked through all the sounds, for example, they go back to the bottom of the wait list, Allen said.

A spokesperson for the Toronto Central CCAC said they do not have an upper limit to the number of sessions per block assigned by a speech-language pathologist. The pathologist determines three goals for a child to achieve and assigns the number of sessions according to that. If after these sessions more goals are identified, the child is re-referred to the program, the spokesperson said. Parents who are worried about the impact waiting can have on their child can go to private clinics, if they have coverage or can afford the sessions out of pocket. Trish Bentley, Eddie's mother, decided to go for private therapy with Eddie's older brother Oliver. He was put on a six-month wait list for speech problems slightly more acute than Eddie's.

B.C.: Children's speech therapy is organized through the Ministry of Health, Ministry of Children and Family Development (MCFD) and through the Ministry of Education by way of school districts. Children are divided between preschool and school age. Preschool children go through regional health authorities. School-age children go through the school boards, but the pathologists there will often offer consultative services, rather than oneon-one speech therapy. B.C. also has a "no-wait-list" policy for children with autism, which translates to parents getting around $22,000 a year for therapy until the age of six, and $6,000 a year after that. Alberta: Health Services is in charge of speech therapy in that province. It offers both a preschool and a school program. The school program, unlike Ontario's, is done completely through the schools, with no CCAC-type system to refer out to. Saskatchewan: The school districts are responsible for speech therapy. Each school district divides up services slightly differently, though they all differentiate between children under three years, from three to five years, and from six to 18 years.

Rather than wait those six months, Bentley took him to Canoe. "As time went on, we said enough of this, he's going to be past the point of catching the problem," she said. For families who don't have coverage and who can't afford private services, though, the only option is to wait. Finding the cause of the long waits is hard, but one thing is certain: It's not due to a lack of speech pathologists, according to Shanda Hunter-Trottier, the owner of S.L. Hunter Speechworks, another private clinic in Toronto. She used to have problems finding qualified speech pathologists, but now she's facing the opposite problem. "I've been practising for 26 years. ... In the last five years, [I] have more resumes than I can keep track of," she said. Rather, she says, it's a large web of problems that slows down the system. First among these is a lack of public funding. "There's a lot of speech pathologists that don't have jobs, but these places aren't hiring. The cutbacks have been atrocious," she said.

Dividing services by language issues and other issues doesn't make sense when treating a child, she said. "You shouldn't be splitting up the kid," she said. Punnoose said she wants to see speech therapy come together under one roof. It would mean co-operation from all three ministries, as well as a major reorganization of the funding, but she believes it would be a better model for children. "Students are in schools the better waking part of their lives. Why wouldn't we have the services right there in an authentic environment where it's totally accessible," she said. There are changes coming.

Last December, the Ontario government announced more funding for preschool speech and language programs, as well as efforts to integrate speech services better, through its Special Needs Strategy. Punnoose says it's a good step. "The government recognizes that the system was broken," she said. For now, the choice for parents in many CCACs will be between long wait lists and paying for private service. Hunter-Trottier said many parents, even those with coverage, don't know about the latter option. "We sometimes get parents here in tears, saying, 'Oh my goodness, the services here, I wish I had known about that a year ago,' " she said. Bentley said she won't be looking at public services for Eddie, as she's happy with the service she gets at Canoe. "I'd be open to it, but I'm not going to actively seek that out," she said.

For Eddie, what matters is the progress he makes. Within 10 minutes of his trouble saying "lipstick," he was opening up a treasure chest, with a key. With little prompting, he used the same technique as before, separating the sounds of the word. "Kuh-ey," he said. Could he try it all together? He pauses for a second. "Key," he says, almost flawlessly, beaming at his success. SPEECH THERAPY IN EACH PROVINCE

Speech therapy, like all healthcare matters, is regulated differently in each province and territory in Canada. Information on how each system works is difficult to come by. But generally, most provinces have very similar systems - and challenges - according to Joanne Charlebois, CEO of Speech-Language and Audiology Canada. Charlebois said Ontario's wait times are probably worse than those in other provinces, but she's spoken to people across Canada who tell her similar stories. Here's a breakdown of how it works across the country. Ontario: Speech therapy for children falls under the responsibility of three ministries: the Ministry of Long-Term Care, the Ministry of Education and the Ministry of Community and Social Services. Children in Ontario are divided by age and by the nature of their speech problem. Children under school age qualify for Ontario's preschool speech and language program. Once in school, those children with language problems - major problems speaking or understanding words or sentences - go to a school speech pathologist, while any other problems, such as pronunciation, stuttering, voice and articulation are referred to the Community Care Access Centres, which employ contract speech pathologists.

But the problems go deeper than a lack of funding, according to Allen. She said many of the issues in Ontario stem back to a series of agreements in the 1980s between the provincial Ministry of Long-Term Care, the Ministry of Education and the Ministry of Community and Social Services. These agreements divided up who is in charge of different treatments, between the school boards and the CCACs. At the time of their creation, these agreements made sense, but times and needs have changed, she said. "It's difficult when ministries make agreements that are frozen in time. It's very difficult to provide the kind of services that we all expect and want Ontarians to receive," she said. Dividing up the services is necessary when trying to manage resources, but the fragmentation is hurting children more than it's helping, Punnoose said.

Manitoba: School districts are also in charge here. The inschool speech-language pathologists offer services from classroom-based programming to individual therapy. Quebec: The system here is more like Ontario's. Speechtherapy services are offered through the local community service centres (CLSC), similar to Ontario's CCACs. The CLSCs are not obliged to provide speech therapy in English, though some, especially in areas with a large anglophone population, usually do. Nova Scotia: The province has 28 speech and hearing centres, with 35 pathologists in total. They assess and provide treatment for children and adults. School boards in the province also have speech-language pathologists who also have a teacher's certificate.

Prince Edward Island: The province provides free speech services for children until they enter school. Northwest Territories: Speech therapists are only able to visit some remote communities once or twice a year. Instead, the province offers a service called Telespeech, where pathologists can help people without having to be physically present. Nunavut: The territory had no speech pathologists in 2013, according to Statistics Canada.

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."

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.

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

Wait times Currently, MRI wait time trends are hard to figure out. Because there has been no consistent record-keeping, requests for data are met with several caveats. Looking at raw numbers, waits in 2014 were anywhere from within 24 hours for a Level 1 priority patient, to 287 days for a Level 4 patient. Current wait times also differ markedly between health regions - bad news if you're in Saskatoon, where for the past few years, average waits for all but Level 1 patients have been longer than in Regina. In 2014, for example, patients waited 10 days for a Level 2 scan in the Regina Qu'Appelle Health Region, compared with 19 days in the Saskatoon Health Region. Level 3 waits were 58 days in Regina and 86 in Saskatoon, and Level 4 waits were 96 and 120 days respectively. Duncan admits part of that might come down to overuse of diagnostic imaging - something the Saskatchewan Medical Association and government are working on.

That's backed up by the fact that in the past eight years, the number of publicly funded scans in Saskatchewan has more than doubled and there are more MRI machines, but it hasn't made a dent in wait times. Health policy analyst Steven Lewis can't see the new approach reducing waits, because the only way you do so "is if demand stays constant while you're increasing capacity - and that never happens." Duncan is convinced the new approach "will help toward wait times," but Dr. Ryan Meili, a family physician in Saskatoon and vicechair of Canadian Doctors for Medicare, disagrees. As evidence, Meili points to Alberta. It has private MRIs, he says, yet it "has the longest wait times for MRIs in the country." Erosion of public health?

You would expect Meili to be ideologically opposed to the privatization of MRIs - after all, he ran for NDP leadership and is a vocal opponent of privatizing any aspect of health care - but he also has "evidence-based" objections. "It starts to just further reinforce this idea that we need to privatize care, piece by piece, and it erodes confidence in the system," he says. Duncan argues that paying out of pocket for MRIs already "happens in Saskatchewan today" when people head to Alberta or the U.S. for a scan. The provincial health system doesn't stop them, he says, but "we don't get any benefit from people doing that." Duncan says at least this way, "the public system will get a scan for each one paid for out of pocket."

Because MRIs are generally a diagnostic tool, Lewis says the biggest risk in the change is that people who need a scan and pay out of pocket will end up getting treatment sooner than those who don't pony up the cash. "It's troublesome on so many levels," he says. egraney@leaderpost.com Twitter/LP_EmmaGraney

The announcement comes as the provincial government prepares to defend itself in a lawsuit filed by Brian Day, an orthopedic surgeon, co-owner of the Cambie Surgery Centre and 2016 presidential candidate for Doctors of B.C. Day contends in his suit that patients should have the constitutional right to pay for care in private clinics if waits in the public system are too long.

"I think this is a good initiative. I think it's, in a way, brave of the government to do this when it's involved in a lawsuit," said Day. He said the province's announcement did not put it in an awkward position going into the court case, given that "contracting out has been going on for years," but it showed that the public sector is stressed to the point that it cannot handle the workload. "Obviously I support what the government's doing here, but I think there's a touch of hypocrisy going on when they're involved in a lawsuit where they claim that wait lists are not the fault of the hospitals or themselves but the fault of the doctors," Day said. "There are two wait lists.

There are the patients waiting for surgery. Then there are the surgeons waiting to be able to do the surgery. ... The surgeons are waiting because they can't get operating time." Day's lawsuit is expected to last seven months and is tentatively scheduled in the B.C. Supreme Court at the end of the year. Under current laws, private clinics are not supposed to collect money from patients if the treatment is an insured service in the public system. Lake said B.C. remains fully against a two-tier health system, but the government has used private clinics in the past and considers many of its physicians to be private health care contractors.

"The use of private surgical clinics within the publiclypaid and publicly-administered health care system has always been an important part of the system," he said. Of the 541,885 publicly-funded surgeries in 2013, 14, 5,503 were done in private facilities using public money. The Vancouver Island Health Authority is seeking private clinics to conduct 55,000 day surgeries over five years to ease the pressure on hospital operating rooms.

A Health Ministry official said the "cost of doing procedures in a private surgical facility is generally comparable to what it would have cost to do them in a public health care facility" but could not offer a specific comparison. There were almost 72,000 adults waiting for surgery in B.C. at the end of April. Approximately 90 per cent of patients receive surgeries within 33 weeks, according to a government website.

The reality is we're still struggling with wait times despite a huge increase in the number of surgeries that we are performing each and every year," said Lake. NDP critic Judy Darcy chastised the government for turning to private clinics when underfunding has left some hospital surgical rooms empty. The government estimates 82 per cent of its 295 operating rooms are fully operational, with the rest unused due to financial or staffing shortages.

"It's a very small Band-Aid on a very big problem," said Darcy. "It's yet another short-term fix that shifts services to private clinics rather than addressing the serious problems in the public system." If the province properly funded the public operating rooms it could help retain staff and have a better long-term impact on waiting times than short-term contracts with the private sector, she said.

Darcy also accused government of "talking out of both sides of its mouth" by relying on public surgical suites to knock down waiting times while at the same time fighting against them in court. Lake said the $10 million will also be used to "optimize the booking system" for surgeries, which could mean sending a patient to a hospital outside their home city if it has extra capacity in an operating room.

He also suggested B.C. could move to a "first available surgeon model" where patients are referred to whoever can conduct the surgery quickest rather than to a preferred surgeon. The government will announce further ways it intends to increase surgical capacity later this year. rshaw@vancouversun.com mrobinson@vancouversun.com

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

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

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

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

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

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

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

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.

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

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.

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.

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.

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."

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.

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."

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.

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

In Quebec last year there were 3.4 million ER visits, including 2.3 million ambulatory and 1.1 million non-ambulatory patients. (Canada-wide, it's 14 million visits, with roughly the same two-thirds, one-third split.) According to Quebec's health and welfare commissioner, the ambulatory spend, on average, 4.6 hours in the ER. Almost all are discharged home, none the worse for wear (and waiting). The non-ambulatory are a different story. The true emergencies, the trauma cases that are a mainstay of prime-time TV, have an average wait time of fewer than 10 minutes from the time they hit the ambulance bay. Perhaps we should take some comfort in that, but these "code blue" cases make up fewer than 1 per cent of patients. Most people who come to a hospital emergency department by ambulance will be triaged and treated relatively quickly, but then they will wait. These non-ambulatory patients, most of them frail seniors with chronic conditions like COPD or heart disease, wait, on average, 18.4 hours in the ER. Remember, that's an average; waits of 24 to 48 hours are not uncommon. We stick them in hallways, behind curtains or in transformed broom closets.

The commissioner estimates that 60 per cent of patients who go to the emergency room should not be there at all. They should be treated in primary care, by physicians or nurse practitioners. But lots of people don't have a regular doctor and very few of those who do can get same-day appointments for urgent (but not emergency) problems. Healthy people wasting a few hours in the ER waiting room is not, in the grand scheme of things, a big deal, though it doesn't make for good continuity of care. The real worrisome situation is that of the non-ambulatory patients stuck in ER purgatory. Some of the gurney-bound are waiting for a hospital bed, but only about one-third are admitted to hospital. Beds are in short supply because there are many frail seniors already stuck living in hospital with nowhere to go for lack of home care or longterm care beds. The majority of elderly ER patients have the same dilemma: They're not sick enough to be hospitalized, but too sick to go home alone, or back to a nursing home where there is no medical care.

It's a perverse scenario that plays out daily and with increasing frequency. But we know the solution. We don't need bigger ERs. We need to shift resources from hospitals into primary care for the ambulatory and home care and community care for the non-ambulatory. Until we do, our parents and grandparents will continue to fill emergency departments and fester in hospital hallways, gasping for care.

Then there's little Meghan Arnott, age 12, who's waiting for surgery in British Columbia to correct a complication brought on by Crohn's disease. Unfortunately for Meghan, she's been told her surgery may have to be postponed eight or nine months due to a severe shortage of nurses in B.C., caused by-you guessed it-chronic underfunding of our health-care system by the government. Meanwhile, this young girl waits in excruciating pain and discomfort, yet another invisible victim of Medicare.

Or how about 16-year-old Walid Khalfallah, who hails from Kelowna, British Columbia? Walid is now a paraplegic thanks to his encounter with our health-care system. All because those running the show felt it was a reasonable risk for a young boy of 13 to wait 27 months-that's right, folks, I said 27 months-for surgery on his spine. By the time Walid had the surgery in 2012, at Shriners Hospital in Spokane, Washington, it was too late.

Still think we have the best health-care system in the world? Not by a long shot. Despite statements by elected officials to the contrary, Canada's health-care system is no longer something we Canadians can-or should-be proud of. Stories like those of Laura, Meghan and Walid, while admittedly anecdotal, point to inadequacies in how Medicare is funded and how decisions are made when it comes to deciding on what programs receive funding and which don't.

It's sort of like winning the lottery. If you belong to a demographic that is older and more inclined to vote-baby boomers, for example, in need of cataract surgery or hip replacements-then you might very well be in luck. If you happen to be a child, however, or suffering from some less-than-"sexy" disease, then good luck, you're on your own.

No one's life should have to depend on the roll of the dice. That's crazy. Fortunately, after years of delays and legal maneuvering by the B.C. Government, Dr. Brian Day's charter challenge is finally about to get under way this coming September in Vancouver. The case, which will be argued before the Supreme Court of British Columbia, will include six other plaintiffs, including Walid Khalfallah, in addition to Dr. Day. Sadly, two of the six plaintiffs have died as a result of delayed access to care. The irony of that should be lost on no one.

In 2005, the Supreme Court of Canada ruled that those living in the province of Quebec should have the right to purchase private health-care insurance under the Quebec Charter. This was known as the Chaoulli case. Dr. Jacques Chaoulli successfully convinced all seven judges hearing the case that patients were suffering and, in some cases, dying while waiting to access care. Dr. Day and his fellow plaintiffs will be arguing that those living outside Quebec should have similar protection under the Canadian Charter of Rights and Freedoms.

Not surprisingly, the B.C. Government and Government of Canada will be arguing the opposite, as will a number of special interest groups, including representatives of the B.C. Health Coalition and Canadian Doctors for Medicare, who have applied for and been granted intervener status. While I have no doubt that Dr. Day will ultimately win his charter challenge-after all, Dr. Day and those representing the more than two million Canadians currently suffering on waiting lists, including Walid and the other five plaintiffs, are on the side of the angels. As for all those bureaucrats, lawyers and elected officials-armed with an endless supply of "lies, damn lies, and statistics," desperately trying to justify maintaining the status quo-I'm not really sure whose side they're on.

Certainly not yours or mine. Because if they were, they'd come clean and admit the truth. Canada's health-care system is not sustainable and on the verge of complete and total collapse. Spending millions of dollars to defend the indefensible is not only wrong, it's obscene. Just ask Laura, Meghan, Walid and the friends and relatives of the two plaintiffs who died after waiting for both care and justice. Access to a waiting list is not access to care, as the judges in the Chaoulli case so rightly pointed out 11 years ago. Hopefully, when the decision is handed down, once all the arguments have been heard this fall in British Columbia, we'll finally be able to have that "adult" conversation we've been avoiding for the past 20 years and actually do something to fix the mess we find ourselves in. One can only hope. Stephen Skyvington

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."

The Auditor General found wait times for long-term care that are extraordinary. Crisis clients are waiting more than three months for placement and wait times have tripled.

In Ontario’s privatized clinics (Independent Health Facilities) the Auditor found inadequate monitoring, poor inspections, a lack of financial oversight and inequitable access to care.