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One big problem with the proposed summit: it could lead to increased tensions if the feds try to attach strings to how the provinces should spend any new money. The provinces have reason to worry: In the 1980s and nineties, as the federal fiscal situation deteriorated, Ottawa contributed less and less to the public health-care system, while prohibiting provinces from pursuing private-sector alternatives.

In the first years of the last decade, as the fiscal situation improved, the Liberal federal government was prepared to offer more robust funding, but insisted on new national standards for health-care delivery in exchange. Provincial governments resisted that federal intrusion in their jurisdiction. The struggle culminated in that 2004 first-ministers meeting in which the premiers browbeat the new Martin government into those massive increases in spending.

If Mr. Trudeau attaches conditions to increases in federal health care transfers, expect Quebec to demand that it be allowed to opt out of any program, but still get all the money. Expect Alberta to demand the same. It's called asymmetrical federalism, and it can quickly get ugly. Another major problem is that, given other Liberal spending commitments in infrastructure, fighting global warming, postsecondary education and so much else, the finance minister, whoever he or she may be, might not be able to balance the federal budget by the end of the mandate, as Mr. Trudeau has promised.

The Liberals have also promised to work with the provinces on a pharmacare strategy, which would inevitably involve funding for subsidized prescription drugs for low-income seniors.

If increased health-care commitments - along with everything else in the Liberal platform - cause federal finances to deteriorate to the point that Ottawa is running an entrenched structural deficit, the national debt will increase. At the same time, Canada's credit rating will start to decay, interest payments on the debt will consume more of the budget, and people will start saying, "Like father, like son."

To avoid that, Mr. Trudeau will have to rein in provincial expectations. But there is a political price to be paid for convening first-ministers conferences and then failing to meet the premiers' demands. It's why Stephen Harper avoided them.

It was also a trauma his family would face again, a coroner’s inquest into the 45 suicides in Nunavut in 2013 was told when the inquest began Sept. 14. Three months after Rex’s death, yet another brother — 15-year-old Peter — killed himself. Rex was living with as many as 23 family members in his grandmother’s four-bedroom house in Naujaat, a community of about 1000 people. The family shared eight beds and one bathroom while they waited for subsidized housing.

The evening before he died, Rex played with his cousins and stayed overnight at their home. His aunt and uncle found him and tried to revive him. His family reported not knowing the immediate triggers for Rex’s decision to hang himself. “I don’t know what was wrong with him,” Martha Uttak, Rex’s mother, testified. “He was my baby and he hugged me all the time.”

Five years ago, four partner organizations came together and released a suicide prevention strategy that was visionary and evidence-based in its design. The Government of Nunavut, the Embrace Life Council, the Royal Canadian Mounted Police and Nunavut Tunngavik Inc.’s goal was to reduce the territory’s suicide rate to one commensurate with, or lower than, the rest of the country.

Nunavut coroner Padma Suramala, a registered nurse who presides over death investigations in Canada’s newest territory, called the inquest to examine the rate of suicide that has seemingly left no one here untouched. “Nunavummiut are soaked in unresolved grief,” testified Jack Hicks, an expert witness at the inquiry and Nunavut’s former suicide prevention advisor. Hicks helped with a landmark follow-back study interviewing the families and friends of 120 people who committed suicide in Nunavut from 2003–2006 and 120 control subjects.

The widespread unresolved grief surfaced again when testimony from Shuvinai Mike, a senior government official who was called to talk about her department’s involvement in cultural activities, devolved into a description of the impact of her own daughter’s suicide. When someone kills oneself, the news spreads rapidly, often via social media, throughout this vast territory of only 36 000 people. Parents live with the constant fear that one of their children will be next

The inquest, which ran Sept. 14 to 25 and included testimony from about 30 witnesses, touched on many underlying issues: poverty, high rates of child sexual and physical abuse, housing shortages, unemployment, educational deficiencies, food insecurity and historical trauma that are the reality for too many Inuit families. It is also exposed the deep divisions among the territorial government and organizations coping with the population-wide damage that suicide inflicts.

But as the inquest heard, Rex was living with many of the risk factors for suicide that researchers have identified, including repeated exposure to the suicide of others. From 1999 until 2014, Nunavummiut took their lives at a rate of 111.4/100 000 population — nearly 10 times the rate of other Canadians, which stands at 11.4/100 000 according to the most recent Statistics Canada data (2000–2011).

A year later, in 2011, the territory released and began to implement an action plan with specific goals, assigned responsibilities and time frames in eight different areas. Those areas, including early childhood education and school curriculum programs, gatekeeper prevention training, and mental health and addiction supports, are intended to address the root causes or risk factors that trigger suicide. The need for a strategy is undeniable. Between 1999 and 2014, 436 Inuit completed suicide. Like Rex, 22 of them were children between the ages of 10 and 14.

Before the implementation plan was tabled in the legislature, however, the territorial government stripped out the column stipulating the financial resources required to implement each item, Hicks testified at the inquiry. None of the other partners was consulted. Not only did the Government of Nunavut never allocate a specific pocket of resources, it never asked the federal government for money to tackle this critical public health issue. As a result, “we’ve had to cobble together funding from various sources,” Natan Obed, Nunavut Tunngavik’s director of social and cultural development, testified.

Nunavut has made progress on implementing pieces of the strategy, according to an independent evaluation. The government’s lack of capacity, poor communication with the other partners and inadequate resources have retarded success, the evaluation states. Nunavut has not yet achieved its overall vision for decreasing suicide rates, denormalizing suicide and keeping children — like Rex — safe.

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

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

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

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

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

Justice Slatter clearly had issues with the majority judgment in Chaoulli. He highlighted that section 7 is a notoriously unsettled and controversial Charter provision, and the “drafters of the Charter never intended it to be applied to the review of social and economic policies” (para 33).

Lisa Levin, chair, Ontario Caregiver Coalition The HQO report on caregiver distress backs up what we see every day: caring for someone with dementia plus other health conditions causes extraordinary caregiver distress, anger and depression. The report says that distress has doubled in the last four years.

Alzheimer Societies in Ontario are deeply immersed in this issue. Through our First Link program, which has reached 60,000 new clients over the past five years, as well as our ongoing caregiver education, counselling and support groups, we hear every day the need for a responsive, co-ordinated home-care service with a workforce specially trained in dementia care.

The report underscores the importance of putting in place an Ontario dementia strategy, an initiative currently being led through the Ministry of Health and Long-term Care. We want to ensure that the strategy enables the voice of caregivers and people with dementia to be heard and to influence how programs can better serve them. Chris Dennis, CEO, Alzheimer Society of Ontario

But John Frank, a Canadian physician who is now chairman of public health research and policy at the University of Edinburgh, argues in his report that more private health care "would be expected to adversely affect Canadian society as a whole."

"Anything like a user fee is a barrier to people being able to receive medically necessary care and

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

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

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

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

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

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

Those changes included cutting wait times, improving home care, electronic records and telehealth, better access to care in the North, a national pharmaceuticals strategy, improvements in prevention in public health and accountability and better reporting to Canadians. Philpott's assessment Tuesday was the provinces had intended to live up to their commitments but that it hadn't happened. "The transformation to the system didn't follow," she said. Philpott said Canadians want to be able to measure where new money is going, such as the number of hours of therapy delivered in a mental health program or the number of additional home care visits added. Manitoba Health Minister Kelvin Goertzen said in a later conference call he agrees there needs to be more reform and innovation, particularly when it comes to accountability and meeting specific performance targets. "I would take exception that there hasn't been any innovation," he said. "Could there have been more? Sure."

Goertzen said Manitoba will be announcing more health-care targets shortly, with plans to better account for the dollars spent. He said additional funding for home care or mental health would be welcome but Ottawa needs to be a better partner on the day-to-day business of health-care delivery, and the three per cent increase isn't enough. The provinces have long complained Ottawa was to contribute half the cost of medicare but its contribution is now around one-fifth. They want the accord to move Ottawa to contributing 25 per cent. "We didn't get that commitment today," said Goertzen. The provinces want to discuss the health accord with Prime Minister Justin Trudeau when they all meet in Ottawa in December. Trudeau called that meeting to discuss climate change and the new carbon price he is requiring all provinces to impose. Health care is not currently on the agenda. mia.rabson@freepress.mb.ca

Ms. Banerji said Inuit may also have a genetic predisposition to these types of infections. But until those environmental conditions are addressed, a medicine called palivizumab is effective against such infections. In 2010, the Canadian Pediatric Society recommended that "consideration should be given" to administering a preventative drug to all fullterm Inuit infants younger than six months of age in areas with high rates of hospital admissions for respiratory infections. The territory currently gives palivizumab only to children born prematurely or who have chronic heart or lung conditions. The region of Nunavik has recently changed its policy and will administer the drug to all newborns. Palivizumab costs about $6,500 an infant. Ms. Banerji said the cost of treatment, including flying sick kids south, is so high that it would be cheaper to give it to all babies born in the worst areas. She says that policy would save $36,000 for each hospital admission avoided. It would also save wear and tear on families. "A mother has to either come with her two-month-old baby to the hospital in Ottawa and leave all the rest of the kids behind, or the baby's there all alone. It has a huge societal impact." The government of Nunavut has received a copy of the paper. The territory's chief medical officer of health was travelling Tuesday and not immediately available to react to its findings. © 2016 The Globe and Mail Inc. All Rights Reserved.

"That included Mount Sinai Hospital, the Hospital For Sick Children, Sunnybrook Hospital and McMaster University Centre," said MacDonald.

"All of which were either closed or restricted."

According to the Mount Sinai Hospital website 1,100 babies are admitted to that hospital's Newton Glassman NICU each year.

He pointed out that so far no babies have needed to be sent outside of the province.

Ontario Ministry of Health and Long Term Care officials confirmed that some NICUs are facing an unusual "surge," in critically ill babies, but emphasized the situation is temporary and that they are working with the Local Health Integration Networks and affected hospitals to take immediate action.

"This is a fluctuating situation and hospitals are working closely and in coordination to manage these pressures," said Mark Nesbitt, ministry spokesperson.

"The NICU situation continues to show improvement since last week, this is consistent with the fluctuating nature of patient flow."

Nesbitt says there is no single cause for the sudden increase in babies requiring highly specialized care.

"On Tuesday night of last week (Aug. 22) the possibilities were that the child would have to go to Ottawa or possibly out of province."

"The situation is stabilizing," said Nesbitt on Sept. 1.

"While we know there is always more work to do, investing in health care is a top priority of our government. That's why as part of the 2017 Budget, we are investing an additional $518 million in all public hospitals, a 3.1 per cent overall increase to the hospital sector, to improve patient access to care, reduce wait times, and improve the patient experience for all Ontarians at their local hospital."

He said the ministry is monitoring the situation and will increase NICU capacities as necessary.

While MacDonald said he is optimistic the right people are now listening he pointed out that on Aug. 28 there were still issues at McMaster University Centre because their transport team, which picks up the sick babies from other hospitals did not have enough nurses.

He argues that ultimately this is a government funding issue, which needs to be resolved to expand the capacity of the NICUs at these children's hospitals.

"They have pared down things so much and have gotten away with it in the past and have been able to send babies to other units within the metro area, but for this cycle this wasn't a possibility," said MacDonald.

"There is a need for government funding, not just for beds, but for nurses. Nurses are critical to the running of a NICU. They look after the patients. We of course have to make decisions about how to manage the patients, but the nurses are the ones that deal with the kids from minute to minute. They are with them all the time and if they don't have enough nurses to staff the units then the units will close or the transfer team will close down, like what happened on Monday."

MacDonald also pointed out that while the province is attributing this problem to a "surge" in critically ill babies, the NICU bed shortage has really been happening on a smaller scale for years.

"It is only getting worse with the government cutbacks."

He attributes this reaction to the reality that NICU bed shortages is not a local issue, but a national one with similar problems recently reported in the Maritimes, Alberta, Manitoba and British Columbia.