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"When one thinks of what half a billion pounds could have been spent on in the NHS, let alone around the world, one has to be pretty scathing about that decision."

The findings come at the end of a gruelling battle with the drug companies to see the actual data produced during all the trials, rather than the often ghostwritten and always company-funded scientific papers selectively published in medical journals. In a watershed development, they have put all the company data online, to allow anybody to interrogate the source material.

The Department of Health said it looked forward to receiving the report, but insisted that the stockpile was important.

Roche said it fundamentally disagreed with the review and maintained that the drugs were a vital treatment option for flu patients. Cochrane had got it wrong, the company said. "The report's methodology is often unclear and inappropriate, and their conclusions could potentially have serious public-health implications," said UK medical director Dr Daniel Thurley. "We'd absolutely defend [Tamiflu] for treatment and prevention." A recent study of 30,000 patients given Tamiflu in the swine-flu pandemic, published in the Lancet, found it saved lives.

Ruddiman, who was recruited to Oliver from South Africa 18 years ago, said the issue comes down to educating young doctors about rural areas while they are still in school, as well as marketing communities to get the right fit. When he was thinking of coming to B.C. in 1991, for instance, Ruddiman said he was warned not to go anywhere with a "prince, a fort, a port or a saint" in its name. "Your towns were generally considered more remote and isolated and less desirable to work in," he said.

Yet many health care specialists are keen to work in communities with a population of 7,000 or more, especially if they are close to a ski hill, he added. Others touted their small communities as being safe and friendly for young families. "Our rural communities have great attributes to offer. You should work with health authorities to spread the word," Ruddiman said. "Port McNeill should be fully stocked with health practitioners, and it's not." Lake acknowledged the problem is rife across B.C., even in mid-sized cities like his riding of Kamloops, which could use another 30 family doctors. He said the province is working on boosting medical residencies to keep B.C. graduates in the province or lure them back from overseas. ksinoski@vancouversun.com Twitter:@ksinoski

There are more than 500 family medicine residents set to graduate in June. Most are burdened with debt and have to set up practice as soon as possible. The shortage of family doctors is hurting people. Men and women with legitimate pain needs are being forced to go to hospital emergency rooms in search of prescriptions. This imposes an additional burden on already overcrowded emergency services. Mayor Al McDonald has revealed that attempts are being made to have all of northeastern Ontario declared an under-serviced area. Presumably this might help to solve the problem.

Public health services are supposed to be one of the great Canadian assets that distinguish this country from the United States. As it is, wealthy Canadians are escaping their national system in favour of getting private care in the U.S. There seems to be no end to this government's penchant for meddling. It meddled with the Ontario Northland Railway with disastrous results. North Bay is still suffering.

In recent days, the Ontario government has decided to meddle with Hydro One and sell off 60% on the stock market. It is going to invite dividend-hungry private investors and promise the public that prices will not rise. This meddlesome government has decided to put beer into grocery stores which, by itself, may be a good idea. But there also will be an extra beer tax to enrich the government and hurt moderate topers.

A critical shortage of family doctors, private investors in the hydro system and beer in the grocery stores at a higher cost --will this government ever return to common sense?

P3s help manage a project's scope, schedule, and budget, and shifts much of the risk to the private sector. In return the public benefits from facilities that are built on time and on budget, but the value of the P3 model goes far beyond the construction of a building, it lives on for decades in the operation and maintenance of the facility. "In the past, we've seen infrastructure deficits with a lot of our facilities, because of deferred maintenance" says Farrell. "But with a P3, a standard of performance quality in maintaining the asset continues for the life of the agreement, which typically is 30 years."

P3s well-suited to health care environment While Farrell concedes that P3s suit some projects better than others, such as new hospital builds, she has seen a lot of innovation with health care P3s because of the collaboration between industry and clinical stake-

holders during the development of bid proposals. Clinical planners work with the design and construction team to optimize clinical flow and function, which means the best possible outcome for patients and clinicians. "Industry is bringing world class expertise to these projects," says Farrell, "they have embraced the model, which has led to a lot of success, and we are seeing broad industry participation, with lots of local contractors involved."

Kim Johnson, Chief Strategy Officer and Senior VP Commercial and Shared Services at Graham Group credits a supportive political environment and growing public acceptance of private sector involvement for the success of these large projects. "People understand that P3s provide a huge public benefit," he says, "and there is an extensive track record with these types of projects, especially in health care, where there is a critical mass of knowledge and expertise."

Collaboration and continual learning lead to successes Canadian jurisdictions looked at what was happening in the UK and Australia in the 1990s with P3s, and refined that knowledge for use domestically. "We've learned from those mature markets, and made it even better, and become a leader globally," Johnson adds. Experience with large projects is that they can often run into problems with design, construction and maintenance, but under a P3 model there is a single production team that is performance based, drives innovation, manages costs, and delivers the project quicker.

Two new Ontario health facilities have benefited from the P3 model, most notably the New Oakville and Humber River Hospitals, the prior set to open in the new few months.

P3s show positive results Despite the wealth of P3 experience in Canada, there are still some naysayers who say these projects end up costing the public more, and contend that government should just build these facilities on their own.

"We think it's simplistic to say that a P3 costs more in the long run than if government just built the projects on their own, because they are not taking into account the risk factor that is passed on to the private sector and the long-term cost of operating and maintaining facilities, which is built into the P3 agreement," says Farrell. "Under the right circumstances, P3s have been proven to deliver value for money."

Johnson echoes those comments and adds that government could build these projects on their own but they will end up costing more. He adds, "with a P3, you can deliver the same project in less time and at less cost."

Paul Brunet, president of the Conseil pour la protection des malades, expressed concern about the potential unintended consequences of the government's costcutting measures. "Oh yeah, certainly patient care will suffer," Brunet said. "Longterm care facilities are going to take most of the hit. We know that." Some institutions, however, have signalled to the government that they won't cut the number of medical tests. "At this stage, it's out of the question to re-evaluate the pertinence of medical tests for patients," said Joëlle Lachapelle, a spokesperson for the Centre hospitalier de l'université de Montreal.

(A standard complete blood count test, for example, costs a hospital $5.77, while a private clinic will charge more than $60 for it. Private insurance would cover most, if not all, of the latter fee.) The CHUM must cut $15.4 million in its 2015-2016 budget, and of that sum, $11.3 million is supposed to come from an optimization measure called "pertinence of care and physical health services." Lachapelle said the CHUM will focus on reducing overtime rather than cutting the number of tests and procedures. Joanne Beauvais, Barrette's press attaché, denied that the government is pressuring hospitals to cut patient care.

"We are not cutting funding for care, but implementing measures to help clinical professionals provide better care by foregoing tests and procedures that are expensive and shown not to result in either improved recovery or better diagnostics," Beauvais responded in an email. "We expect the progress we will be making over the next year to yield recurrent savings of $150 million." The $583 million in "optimization" savings breaks down as follows Cutting $220 million in payroll costs by abolishing 1,300 management positions. Avoiding "unnecessary" (Beauvais's word) tests and procedures, saving $150 million. Not funding leap year day: $64 million.

Persuading hospitals to team up in buying goods and services to save $35 million. Additional "compressions" that are unspecified: $114 million. The CHUM will have to cut through attrition 15 managers out of 337. The MUHC, in contrast, will have to cut more than 100 managers out of 459. A cloud of fear and anxiety has descended over the managerial ranks at both the CHUM and MUHC. Ian Popple, a spokesperson for the MUHC, said the reduction in the number of managers will be carried out over three years. "Part of the reduction will be done by attrition as managers leave or retire," he explained. "Other reductions will have to occur by transforming some manager positions into professional-level positions (that pay less) in order to meet the ministry target. We are looking at every option, but there remains a shortfall that is requiring ongoing work to address."

Beauvais dismissed the notion that the government is actually making cuts: "These are not cuts. Quebec cannot afford the kind of growth rate in health-care spending we experienced over the past decades, and the system is clearly able to do more with less. The best-performing teams in the network prove it. Since the health-care budget keeps growing, those measures are not cuts. They are a strong inducement to everyone in the system to improve their game." Quebec has budgeted $32.8 billion this fiscal year on health care, an increase of 1.4 per cent, but less than the 5-per-cent annual hikes of previous years. aderfel@montrealgazette.com twitter.com/Aaron_Derfel

The McGill University Health Centre has not yet figured out where it will have to cut to make up the $2.5-million leap-year day shortfall. • VINCENZO D'ALTO, MONTREAL GAZETTE FILES / Of all the "optimization measures" that Quebec is imposing, the most controversial is compelling doctors to stop ordering tests that the government is now considering "unnecessary."

"Whether you're in a healthcare facility, a manufacturing facility, driving a vehicle - if you're tired, the risks of mistakes are going to go up." Two studies comparing eightand 12-hour schedules during day and night shifts found that 12hour night shifts were associated with more physical fatigue, smoking or alcohol use, according to a 2004 report from the U.S. Centers for Disease Control and Prevention. "It's the law of diminishing returns," said Liane Davey, vicepresident of team solutions with Lee Hecht Harrison Knightsbridge, which specializes in talent recruitment and development.

"We think that we're staying and doing more and being more productive; but the negative outcome of doing that actually means our core quality suffers." Irregular schedules - such as switching from a block of night shifts to day shifts - can result in sleep disturbance which can become chronic, Mustard noted. "If you build up a period of disturbed sleep ... this is somewhat different from fatigue, although in a sense the consequence is kind of the same. "If we can't rest, we're not renewing our cognitive and physical capacities."

German-born Moritz Erhardt was a week from completing a work placement at Bank of America Merrill Lynch in London when he died in 2013. A British coroner said the 21-year-old intern died of an epileptic seizure that may have been triggered by fatigue. Erhardt's case sparked widespread speculation that the notorious long working hours and competitive environment at top investment banks were to blame for his death. Matt Ferguson said his 22-yearold brother, Andy, died in a headon collision in 2011 after logging excessive hours as an unpaid intern at an Edmonton radio station.

When Jeff and Andrea Archibald launched their design agency, the couple initially worked from home and logged significant extra time to establish their business. "We definitely hit 60-hour work weeks mainly because when there's two of you, you have to do all the billable work," recalled Jeff Archibald. "When you're starting out, your rate's a little lower, and then you have to balance out with all the business side of things, like invoicing. You don't have anybody on staff that can do those kinds of things, so you're basically wearing all of the hats," he said. "What ends up happening is you have all your meetings and your phone calls ... during the day and you do your production work at night - and that's not just us. A lot of our friends are in similar situations."

The Archibalds are now part of a team of seven at their Edmonton custom Web and branding firm, Paper Leaf. Weekly meetings help assess key tasks to accomplish within a given day and week - and avoid overbooking. "One of the singularly biggest concerns I think we all have is balancing the amount of workload so that we can have a profitable company - but also not overwork people," Jeff Archibald said.

"When you overwork, you're staring down the barrel of burnout. It's a real short-term gain." Mustard said employees logging overtime should be aware of the pace of their work and ensure they are taking breaks. "Being thoughtful about nutrition, making sure that you're not missing meals is very important. And then rest. Not shortening your chance to have sleep."

She said her investigation was prompted by "a number of complaints" detailing concerns about the way psychological problems such as anxiety, depression, alcohol and drug dependence and post-traumatic stress disorder are triggered by paramedic job duties. Among their responsibilities are providing services to people in dire need of medical attention - some well past help - and entering harrowing crime scenes like Savoia encountered with Conter.

"I cannot tell you how many times I have responded to a call for a child that was physically abused," Savoia said. "Those types of calls crawl under your skin." The calls can be hard to forget and to talk about, he said. Plus, not everyone is willing to discuss gruesome experiences with staff psychologists or peer-support teams.

In response to news of the ombudsman's investigation, TPS chief Paul Raftis said in an email to the Star, that the TPS "welcomes" the investigation and is "actively supporting her office in this matter." The (www.tema.ca») Conter Memorial TrustEND, which Savoia founded as a way to provide mental health support for emergency workers, estimated that between 16 and 24 per cent of these workers will experience PTSD.

Many, including former president of the Paramedic Chiefs of Canada Michael Nolan, counted Toronto among the municipalities leading the way when it comes to mental health services for paramedics. Nolan pointed to Toronto's in-house psychologist and peer-support teams as innovative ways that the city is trying to curb operational stress. "There is a lot to be learned from Toronto," he said.

Still, Savoia welcomed Crean's investigation, saying, "even if they are doing things right, the investigation will help them learn how to do things better."

The auditor's findings come after a report to the government from a blue-ribbon panel in the spring that called on the province to make home-care services easier to navigate and more accountable. An investigation by The Globe and Mail also found a system plagued by uneven access to care, byzantine processes and a troubling lack of transparency for both patients and family caregivers.

"The time has come for the government to take a hard look at how CCACs deliver services to patients," Auditor-General Bonnie Lysyk said. "The solution is not simply to add new programs and make adjustments to existing services," she added. "This will only leave core problems and inconsistencies entrenched."

Catherine Brown, executive director of the group that represents the province's 14 CCACs, took issue with the audit's definition of direct-care spending, noting that time spent in consultations, case management and travelling to homes is a necessary part of delivering care and should not be considered part of overhead costs. "I don't think people understand the complexity of getting service to people in their homes," she said. Kevin Smith, the chief executive officer of St. Joseph's Health System in Hamilton and a member of the expert panel, said the audit provides valuable numbers on which to base future discussions.

Ontario's Minister for Health and Long-Term Care, Eric Hoskins, has vowed to repair the home-care system, laying out a 10-point plan in response to the expert panel report and setting up working groups with a threeyear time frame to make changes. He accepted all of the auditor's findings on Wednesday, saying he intends to "deepen" reform efforts and singling out the recommendation for a review of the way home care is delivered.

"This gives us the opportunity to be bold and be transformational," he said, but stopped short of saying what form such change would take. Dr. Hoskins said it is "premature" to say if the current system of access centres should be scrapped, as critics of the system have long suggested.

Getting it right is crucial for the Ontario government as it, like other provinces, looks to shift an ever-increasing share of health care out of expensive beds in hospitals and long-term care and into the home. The increasing emphasis on home care for the sick and the elderly is also what patients are demanding, and comes as many, including the Canadian Medical Association, say it's a change that is needed as the country's population ages.

The experience in the province of cutting wait times, he said, showed that "data, money and embarrassment" are a powerful combination to lead to change. NDP health critic France Gelinas, a member of the committee that asked for the report in the spring of 2014, said the audit confirms the system is broken.

"The structure has failed us and it is costing us a pile of money," she said. Among the audit's findings:

The province's 14 CCACs manage 264 separate contracts with 160 different agencies, and there is no standard rate for the same services among those contracts. The cost of an hour of care varies even among contracts involving the same CCAC and service provider.

In a sample of three CCACs, the nursing costs ranged from $49 to $73 an hour and personal support costs from $26 to $49 an hour. Pay for top executives jumped by 27 per cent between 2009 and 2013, to an average of $249,000.

Compensation for other senior executives increased 16 per cent during that time. Rapid-response nursing teams, created in 2011 and employed directly by the CCACs, failed to see patients within 24 hours about half the time, with some teams not available on weekends.

CCACs report 92 per cent of expenses are for direct patient care. That drops to 81 per cent when overhead and profit for service providers are taken out, the auditor finds, and to 72 per cent when documentation, travel time and training are not included. When case co-ordination is removed, it falls to 61 per cent.

The report is the first of two on home care by the AuditorGeneral. The second part, to be included in her annual report later this year, will focus on personal support workers. An examination of Ontario's 14 Local Health Integration Networks is also expected at that time.

Sadly, the offerings in our health system are driven as much by tradition as they are by evidence. We needn't be prisoners of our outmoded structures. In the fifties and sixties, we created a system to provide care in hospitals and in physicians' offices and it's almost impossible to break that mould and innovate - for example, by putting psychological care on an even footing with psychiatric/medicinal treatment. What we really need to do is provide care where people bring their mental-health problems - in primary care. As most provinces try to transition from a solo, fee-for-service model to multidisciplinary teams, it provides a perfect opportunity to bolster mental-health care by integrating psychologists onto teams. Other countries have done so, notably Britain and Australia, and the early evidence is that it's paying off. The fear, of course, is that providing public funding of psychological care will cost more. Of course it will. Estimates range from $950-million to $2.8-billion a year.

But the offering of psychological care doesn't have to be an open buffet like other aspects of health care, and some of the hundreds of millions now paid for (not always trained) doctors to provide psychotherapy can be spent more smartly. If done right, the investment should pay off down the road, in lower health costs, disability-insurance payouts and absenteeism. Because the greatest costs of mental illness arise when it is left untreated, and festers. Mental illness is common: 10 per cent to 25 per cent of women and 5 per cent to 12 per cent of men experience a major depression; 4 per cent to 7 per cent of Canadians suffer from anxiety disorder; 7 per cent to 12 per cent experience posttraumatic stress disorder; 10 per cent suffer from phobias; 5 per cent experience panic disorders; 2 per cent to 4 per cent suffer from obsessive compulsive disorder or eating disorders; 1 per cent to 2 per cent suffer from bipolar disorder or schizophrenia. For years, we have been focusing efforts on combatting the stigma, urging Canadians with mental-health disorders to come forward. But the care is not available for those who need it; waits stretch from months to years, and an estimated one in three adults and one in four children don't get care at all.

Psychotherapy can help fill the gap. There are 8,000 psychologists in Canada. About three-quarters are in private practice, charging $100 to $200 an hour, and roughly one-third work exclusively in the public system, where there is no charge to patients. Canadians spend about $950million on psychological care, most of it covered by private insurance and workers compensation; but a good chunk, about one-third, is paid out of pocket. We have a mixed health-funding model in this country, but when it comes to mental-health care, we don't have the mix right. Too many people are being denied care because they can't afford it, or because their workbased insurance provides paltry benefits for psychological care. As it stands, mental-health care remains an orphan. We can take another big step toward correcting this by adopting a more rational approach to the use and funding of psychological care.

I am writing to let you know that over the next few weeks the CUPE Saskatchewan Health Care Council will be conducting a survey on scope of practice for Licensed Practical Nurses.

And if any of this gets especially heated and you're feeling especially cheeky, just whip out your smartphone and play Canadian doctor Danielle Martin's excellent deposition on medicare to the U.S. Senate.

In Canada, the top six determinants of health include income, social status, education, working conditions and physical and social environments. We don't need diet tips. We need guaranteed incomes and safe housing. We need social infrastructure that values people as people.

A team of doctors at St. Michael's hospital in Toronto have launched a project that approaches health this way. The team is finding that supporting people through concrete initiatives aimed at improving incomes and job security improves the health of their patients. And, I would argue, it does so far more effectively than the traditional methods employed by doctors who lecture us about lifestyle choices.

Julie Devaney is a health, patient and disability activist based in Toronto.

More and more clinics are achieving same- and next-day access. According to the The Commonwealth Fund 2015 International Health Policy Survey of Primary Care Physicians, released this morning, 53% of physicians say most of their patients can get a same- or next-day appointment if they request one. That’s up from 39% in 2009, but it still places us second-last of the 10 countries surveyed. In Switzerland, which did the best, 85% of doctors said their patients had access to same- or next-day appointments; in the U.S., 74% of doctors said they did. There’s also significant variation among provinces, with 66% of Ontario’s doctors answering yes – the best of all the provinces – and 53% of physicians in Alberta saying so.

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.