the country's premiers warned in a recent report that the new federal health accord will gut nearly $36 billion in funding from the provinces over the 10-year deal

Simpson repeatedly refers to the consequences of poverty and social inequity on the health of the population and their impact on health-care costs, but he does not include this fundamental issue in his remedies for our current problems.

"social insurance for drugs"

Alan Katz is a Winnipeg family physician and health-policy research scientist.

Despite this increased attachment, the chance of being seen in a timely way did not improve. Ontario's primary care models require evening and weekend clinics and on-call duties, and penalize practices for out-of-group primary care visits; therefore, these findings are unexpected. While many factors are likely involved, Ontario's auditor general noted two major faults: not establishing mechanisms for ongoing monitoring and evaluation, and not enforcing practices' contractual obligations, especially for after-hours care

The access bonus is reduced by outside primary care use but not by emergency department visits. Physicians responding rationally to such a financial incentive would logically direct their patients away from walk-in clinics and toward emergency departments. The access bonus also strongly discourages healthcare groups from working together to provide late evening and night coverage because all parties would lose financially. An incentive that costs more than $50 million annually should be structured to align better with health system needs.

A recent systematic review found insufficient evidence to support or not support the use of financial incentives to improve the quality of care (Scott et al. 2011).

Ontario's reforms occurred in the absence of routine measurement of primary care within practices, groups or communities and with limited accountability for how funds were spent.

Ontario adjusts capitation for only age and sex, whereas most other jurisdictions further adjust for expected healthcare needs, patient complexity and/or socioeconomic disparities (e.g., the Johns Hopkins Adjusted Clinical Groups http://www.acg.jhsph.org/). That may be why Ontario's primary care capitation models have attracted healthier and wealthier practices (Glazier et al. 2012).

Community health centres care for disadvantaged populations with superior outcomes (Glazier et al. 2012; Russell et al. 2009) and could play a larger role in Ontario's health system.

Unlike some other jurisdictions (National Health Service Information Centre for Health and Social Care 2012), Ontario has no routine measurement of primary care at the practice, group or community levels. It has no organized structures, such as the Divisions of General Practice in Australia (Australian Department of Health and Ageing 2012) or the Divisions of Family Practice in British Columbia (2010), that can help practices come together to improve care. It has also failed to hold practices accountable for their contractual obligations, including after-hours clinics.

In Ontario, there was little relationship between incentive payments and changes in diabetes care (Kiran et al. 2012), nor were there substantial improvements in most aspects of preventive care despite substantial incentives (Hurley et al. 2011). Similar cautionary tales about pay-for-performance can be found elsewhere in the health system (Jha et al. 2012).

Access to primary care has proven to be challenging in Canada, leaving it behind many developed countries in timely access and after-hours care, and more dependent than most on the use of emergency departments (Schoen et al. 2007).

A strong primary care system is consistently associated with better and more equitable health outcomes, higher patient satisfaction and lower costs (Starfield et al. 2005).

Recently, Centric has been buying up market share across Canada, acquiring surgical centres, diagnostic clinics, medical equipment companies, and Lifemark, the largest rehabilitation company in the country. It’s a vertically integrated company that looks to rival our public health-care system with its array of services and products.

could expose Canadian governments to sanctions under the investment provisions of NAFTA

claim damages should the province of Ontario regulate the services provided by Centric in a manner that diminishes the profitability of its investments

there is a lack of transparency and accountability

Just ask Dr. Wayne Hildahl of the Pan Am clinic in Winnipeg, a clinic that was previously for-profit but now operates publicly through the Winnipeg Health Authority. Hildahl has publicly said that when the clinic was for-profit, he had the advantage over government officials negotiating contracts to provide medical services because he knew his costs and they didn’t. And under its investor-based ownership, the Pan Am clinic cut corners, with outdated medical equipment — including dull scalpel blades! — to increase profit margins. His clinic now charges the government $700 for a cataract procedure instead of the $1,000 it charged when Pan Am was a for-profit facility.

Centric is also pushing for physicians to invest in the company

Researchers in Arizona found that those doctors with a financial interest in their facilities treated more patients whose conditions were least severe and would bring in the most money.

These conflict-of-interest problems led the U.S. Congress to deny medicare reimbursements to doctors for procedures done in hospitals in which they are shareholders.

Britain is following suit, reactivating a hospital food program the former government discontinued in 2006

Janice Gillan, the head of the Hospital Caterers Association in the U.K., who told CBC Radio, "Food is the simplest form of medicine."

The Sun, is campaigning for minimum dietary standards in hospitals

Ontario probably leads efforts for better hospital food, thanks to the provincial government making grants available to hospitals to purchase local food through its Broader Public Sector Investment Fund

Canadian Coalition for Green Health Care

Before 2005, nearly all the patient meals at St. Joseph's were pre-made and outsourced. Now, the hospital prepares about 75 per cent of them from scratch.

Retherm was the trend 10 to 15 years ago and is being put back into service

It has been estimated that about 30 per cent of hospital food ends up in the garbage.

Carson says that at St. Joseph's plate waste is about half that amount.

they avoid packaged meals

grain-fed beef they get from a local supplier

20 per cent of the food it serves is grown locally, contributing at least $140,000 per year to the local economy

$7.60 per patient per day, not including the cost of labour

The province does not stipulate an amount for patients in acute hospital care but the average is about $8 a day.

The move to home-style meals has not only seen patient satisfaction increase to 87 per cent but it's also had "a huge positive impact on morale," Leslie Carson, the manager of food and nutrition services

Over at St. Joseph's they also had to figure out how to make the changes to fresh and nutritious without a proper kitchen.