AN INFORMATION FEATURE FOR THE CANADIAN MEDICAL ASSOCIATION

T H U R S DAY, D E C E M B E R 1 , 2 0 1 1

Special

SECTION CMA

2014 Health Accord

1. ENHANCE THE HEALTH CARE EXPERIENCE 2. IMPROVE POPULATION HEALTH 3. IMPROVE VALUE FOR MONEY
With Canadas current health care accord set to expire in 2014, leading health care professionals and other experts are bringing their ideas to Ottawa in a bid to help shape a better future for all Canadians.
CMA president John Haggie is among the chorus of experts calling for an overhaul of Canadian health care. In anticipation of the 2014 Health Accord, the CMA and the Canadian Nurses Association have tabled a set of principles to help inform a new health accord that will result in Canada having the best health and health care by 2025. PHOTO: MARK HOLLERAN/HOLLERONPHOTOGRAPHY.COM

A vision for high-quality health care

Poll results show public support for principles to inform new health accord
ith a goal of ensuring Canadians will have the best health and the best health care in the world by 2025, the Canadian Medical Association (CMA) and the Canadian Nurses Association (CNA) are spearheading a drive to transform health care for the better when the current health accord expires in 2014. Armed with the results of a new Canada-wide public opinion poll that shows overwhelming support for the key aspects of a set of jointly agreed principles as the basis for a new health accord, the two organizations are calling for a high-quality health care system that is universal, equitable, sustainable and truly centred on the needs of patients. CMA president John Haggie says while the 2004 Health Accord resolved the issue of stable and predictable funding; the system now needs a major overhaul. Anything you do now without a systematic transformational approach will just be tinkering, says Dr. Haggie. The system evolved from a different era with a different paradigm of health care focused mainly on acute care. But now 80 per cent of the disease burden in Canada is chronic disease management and the system of acute care management, does not t any longer. CNA president Judith Shamian agrees. The 2004 health accord made some progress on some of the issues, but we are nowhere near achieving the transformation of health care in Canada that we need to make sure that Canadians are healthier tomorrow than they are today, says Dr. Shamian. Right now, she says, Canada is heading in the wrong direction;

KEY FINDINGS*

#1
Health care is seen as the most important priority for the Government of Canada.

85%
of Canadians feel it is important that the CMA/CNA principles be adopted as part of the 2014 Health Accord discussions.

77%
support a national strategy to address the needs of our aging population (e.g., through increased home care and long-term care), even if this increases our taxes or increases our debt/decit levels.

46%
of Canadians feel quality of the health care services remains the most important aspect of the system.

28%
of Canadians feel the quality of the health care system has deteriorated over the past two years.

health care outcomes are worse in 2011 than they were 20 years ago compared to some other countries. For example, Dr. Shamian points out that Canada ranked 10th among OECD countries for infant mortality in 1982. In 2008, the country was ranked 27th out of 34 OECD member states. Former Quebec Minister of Health and Social Services Philippe Couillard says Canada needs to create an environment that better supports people and organizations operating in the health care sector to provide better service, safety, quality, access and patient experience. I believe there is a political will to make these changes; they are not revolutionary, they are patientcentred and aimed at bringing quality back into the system, says Dr. Couillard. Dr. Haggie believes that how Canadas health care dollars are spent is more important than the size of the budget. He points out that Canada spends close to $200 billion a year on health care, which puts the countrys health care spending fth among OECD countries as a percentage of GDP. However, Canada ranks only 27th in the OECD when it comes to the efcient use of its health care budget. Thats a huge gap, so it may not be a question of spending more, but just not letting costs rise by gaining efciencies and doing things better, getting better value by spending health care money closer to the patient and focusing on patient-centred care, he says. The CMA-CNA principles call for an equitable and accountable patient-centred health care system focused on quality and incorporating health promotion and illness prevention.

For Dr. Shamian, that means a system that measures outcomes rather than outputs and one that brings teams of practitioners together to meet the needs of patients. It also means looking beyond just the health care system to ensure a healthy population. We need to see health care as part of a larger system, she says. We can have the best health care in the world, but if we dont deal with the challenges that lead to health issues such as homelessness and poverty, we will not achieve the outcomes we are looking for. Dr. Haggie says the latest poll results underscore support for health care transformation. For example, more than three-quarters of respondents said improving the health care system should be the federal governments top priority. Nothing scored higher. And 85 per cent said our six principles should be adopted as part of the discussions on a new health accord between the federal government and the provinces, says Dr. Haggie. The acid test, he adds, is how policy-makers will respond to calls for health care transformation. The broadly endorsed principles on health care transformation are the standards that Canadians can use to determine if our elected ofcials have developed a new health accord that will create a patientcentred health care system, says Dr. Haggie. Canadians have told us clearly that is what they want. It is now up to our politicians to respond.

ABOUT THE CANADIAN MEDICAL ASSOCIATION (CMA) The CMA is the national voice of Canadian physicians. Founded in 1867, the CMAs mission is to serve and unite the physicians of Canada and be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. On behalf of its more than 75,000 members and the Canadian public, the CMA performs a wide variety of functions. Key functions include advocating for health promotion and disease/injury prevention policies and strategies, advocating for access to quality health care, facilitating change within the medical profession, and providing leadership and guidance to physicians to help them inuence, manage and adapt to changes in health care delivery.

INSIDE
Smarter investments are needed for better health, writes Canadian Nurses Association President Judith Shamian.
CMA 2

Wellness model emphasizes illness prevention.

CMA 4

ONLINE?
For more information, visit healthcaretransformation.ca.

Overcoming social inequities among keys to better health.

CMA 5

*Statistics are drawn from a recent, nationally representative telephone survey commissioned by the Canadian Medical Association and Canadian Nurses Association that asked 1,001 Canadians, 18 years of age and older their views on health and health care.

Will my aging parents get the health care they need?

www.healthcaretransformation.ca
CANADAS DOCTORS ARE LISTENING.

CMA 2 AN INFORMATION FEATURE FOR THE CMA

t h e g l o b e a n d m a i l t h u r s daY, d e c e m b e r 1 , 2 0 1 1

2014 HEALTH ACCORD

View the principles in full at globeandmail.com/healthcaretransformation

PRINCIPLE

Enhance the health care experience

Patient-centred: The patient must be at the centre of health care. Patient-centred care is seamless access to the continuum of care in a timely manner, based on need and not the ability to pay,

that takes into consideration the individual needs and preferences of the patient and his/her family, and treats the patient with respect and dignity. Improving the patient experience and the health

EVOLUTION

Focus on patient-centred care highlights need for reforms

iven todays overtaxed health care system, it can be difcult to see whats at its centre: patients. Patient-centred care is increasingly the focus of reforms and initiatives across the health care spectrum, from improving patient access and delivering more timely care to helping family physicians cope with exponential demand. When you have an over-loaded, over-stressed system, constantly running at 100 per cent capacity, it becomes increasingly difcult to maintain a patient focus, says Dr. Linda Slocombe, president of the Alberta Medical Association and a family physician in Calgary specializing in low-risk maternity cases. Its a different world for doctors out there now, and patients need more support. Alberta has responded by creating Primary Care Networks (PCNs), multidisciplinary teams, led by family physicians and organized under formal arrangements with Alberta Health Services, that co-ordinate primary care services for patients. There are currently 40 PCNs in Alberta, involving 80 per cent of family physicians and looking after more than 2.5 million Albertans. PCNs are tailored to needs and are the connective tissue allowing for better integration of care, while fostering innovation and increasing capacity and access, says Dr. Slocombe, whos been practising for 28 years. She is a member of the Calgary Foothills Primary Care Network, which includes 350 practitioners, while some PCNs have just a handful of doctors, she says. Its a co-ordinated approach to care for that group of patients and that group of doctors. Barry Stein, a corporate lawyer and businessman in Quebec who is president of the Colorectal Cancer Association of Canada, says that patient-focused initiatives need

BRIEF
Toward a strategy for patient-centred care The CMA has called for implementation of a strategy for Patient-centred care within a national framework to ensure: the rights and expectations of patients as to the quality and timeliness of health care; the responsibilities of patients for their health and health care; a mechanism to register patient concerns and complaints about the quality and timeliness of health care; a mechanism to provide redress of patient complaints. The Strategy for PatientCentred Care is built on a foundation of reasonableness and fairness. The essential principle is that health care services are provided in the manner that works best for patients. Health care providers partner with patients and their families to identify and satisfy their range of needs and preferences. Notwithstanding resource constraints, governments have the duty to ensure availability of the resources required to provide high-quality care. To read more on the PatientCentred Strategy, go to healthcaretransformation.ca.

Colorectal Cancer Association of Canada president Barry Stein is among the health advocates who want to see improvements to services that would put patients in the drivers seat. PHOTO: CHRISTINNE MUSCHI to put the patient in the drivers seat, while incorporating business models to improve how services are delivered. Weve become accustomed to being at the will of a very outdated system, says Mr. Stein, a survivor of metastatic colorectal cancer who sought health care outside of Canada to ght his disease and was reimbursed by the province following a judgement in the Superior Court of Quebec. Today hes an advocate for cancer awareness and educational and support programs for patients and their families. Nurse-navigators, who help cancer patients co-ordinate their treatments, are a step in the right direction, but they are rare and only come into the picture once patients are in specialist care, Mr. Stein says. Solutions such as communities of practice that focus on certain types of patients and creative models and systems for delivering health care services are critical, he adds. This is a huge challenge. Dr. Slocombe says that as well as focusing on patients and better co-ordinating their care, its been important to offer support to family physicians, who are dealing with more signicant cases, often in isolation The solutions are complex, she explains. Weve got a ways to go,

whoever you are wherever you live

we are registered and nurse

but we are seeing real benets. The development of the PCN model in Alberta is a start, Dr. Slocombe adds. Its brought family doctors together, and its given them extra support to provide patient-centred care.

ONLINE
See this entire 2014 Health Accord report plus webexclusive stories online.

A MESSAGE FROM CANADAS NURSES

Smarter investments needed for better health

and productivity, chronic diseases such as diabetes one of many examples could be managed better if the system provided the appropriate structure and support. Targeting investments for primary care options, such as nurse practitioners and community health centres, will make Canadians healthier. Better primary care will open access points to the system and enhance the teamwork of health care professionals like nurses, doctors and other health professionals who educate patients about their health and how to prevent and manage chronic illnesses. We need to get a better return on our health care investments. Refocusing our approach must be based on improving health outcomes and the performance of the system. Funding needs to be tied with national health indicators linked to expected outcomes, such as reducing diabetes and improving management of high blood pressure, rather than the number of patients seen or prescriptions written in a given day. To assure Canadians access to an equitable, patient-centred and high-performing health system, the federal government must fulll its leadership role by setting meaningful and measurable goals for regions across the country. Canada has outstanding health care professionals, world-class research and the investments to match. Only when we have goals and collaboration between health care interest groups, governments and the public can we achieve a healthy, productive Canada. Moreover, we want our leaders to recognize and appreciate that because registered nurses and nurse practitioners are so connected to the delivery of care from coast to coast, they are integral to the future of health care in Canada and have solutions to offer.

practitioners

globeandmail.com/healthcaretransformation

nurses

By Judith Shamian,
RN, PhD, LLD (hon), D.Sci. (hon) FAAN

President, Canadian Nurses Association

he Canadian Nurses Association (CNA) believes our countrys health care system is one that Canadians can be proud of and grateful for. However, changes are critical now more than ever if Canadians are to become healthier. Despite an ongoing increase in spending, Canadas health care system is lagging. In 1982, Canada was ranked 10th among Organisation for Economic Co-operation and Development (OECD) countries in infant mortality rates, the overall best indicator of a societys health. By 2008, Canada slipped to 27 out of 34 OECD nations. Considerable strides in improving our populations health could be made if the federal and provincial/territorial governments worked together to uphold Canadas not-for-prot, publicly funded system, while shifting investments from the current illness treatment model to one that is patient-centred and emphasizes health promotion and prevention and management of chronic diseases. Currently, millions of Canadians are forced to turn to hospital emergency departments one of the most costly forms of care for health problems that could be managed more effectively in the community. According to the Public Health Agency of Canada, chronic diseases represent 67 per cent of all direct health care expenditures. Costly to budgets

invested in your health committed to your care

cna-aiic.ca
THE VOICE OF 143,843 REGISTERED NURSES

This report was produced by RandallAnthony Communications Inc. (www.randallanthony.com) in conjunction with the advertising department of The Globe and Mail. Richard Deacon, National Business Development Manager, rdeacon@globeandmail.com.

t h e g l o b e a n d m a i l t h u r s daY, d e c e m b e r 1 , 2 0 1 1

AN INFORMATION FEATURE FOR THE CMA CMA 3

2014 HEALTH ACCORD

of Canadians must be at the heart of any reforms. vidual choice and are delivered in a manner that is timely, safe, effective and according to the most currently available scientic knowledge. Services should also be provided in a manner that ensures continuity of care. Quality must encompass both the processes and the outcomes of care. More attention needs to be given to ensuring a system-wide approach to quality.

Quality: Canadians deserve quality services that

are appropriate for patient needs, respect indi-

TECHNOLOGY

Electronic Medical Records provide a new platform for efficient, quality care
he promised benets of electronic medical records are no longer a futuristic vision. They are here, and health experts say the full potential of EMRs and EHRs are just beginning to be explored. With the PS Suite EMR system developed by MD Physician Services, for example, many physicians now have ready access to their patients health information, wherever they are. In Ontario, critical mass has been achieved in the provinces primary care system, reports Dr. Darren Larsen, Ontario MDs senior peer physician. In two to three years, as physicians collect data, we will be able to make some powerful improvements to population-based health delivery and service. EMR adoption has already improved efciencies and quality of care. When a medication is prescribed, for example, the EMR system ags potential interactions with other medications, as well as side-effects and risks associated with co-existing conditions. Physicians also have mobile access to EMR, enabling them to connect to patient records wherever they are. If Im on a house call, at the hospital, or at home and on-call, I have all the information I need at my ngertips, all the time. That leads to better decisionmaking and more effective patient advice, says Dr. Larsen, a PS Suite EMR client. PS Suite EMR has the potential to improve patient education and compliance. I use my computer to show my patients graphs of where theyve been and where theyre likely going, he notes. For example, I can point out that someone has had a high number of urinary infections over a period of time, to show that we need to investigate the cause. For the millions of Canadians living with chronic health conditions, EMRs enable more proactive health management. If a patient with diabetes has not had an eye examination in the past year, the system will alert the physician, so the patient can be notied. Much of chronic care for diabetes, asthma, cancer, thyroid disease, COPD and scores of other disorders requires looking forward, using the data from the past. EMR allows that. Once you build a system of reminders, a lot of the process becomes almost automatic, Dr. Larsen says. In Peterborough, Ontario, Dr. Nick Vanderkamp has used PS Suite EMR in his practice for about four years. Its helpful in measuring the benet of lifestyle interventions and medication. On a macro level, he says, search capability makes it possible to measure quality of care. As a community, were working to improve overall health outcomes, particularly for chronic disease management. With EMR, we can search records to see how many people in our practice are meeting the outcome measures were looking for. Its an exciting new direction. In multi-physician clinics, legibility of records, lost records and record retrieval were formerly challenging issues, says Dr. Neeraj Sanjeev Bector of Edmonton. With PS Suite EMR, nothing falls through the cracks. Whether its our staff or a physician dealing with an issue or patient request, everything is dealt with in the system electronically and can be reviewed after, if necessary, in the audit log. Visual representation of lab results are much more powerful in motivating patients than having a bunch of numbers thrown at them, he says. They can actually see the effect that medications or other interventions are making on their care in a simplied graphic. In Alberta, NetCare is a provincial repository for lab information, diagnostic imaging, hospital discharge summaries and emergency records. It provides timely access, and I can retrieve data that other physicians have generated, says Dr. Bector. Were not duplicating lab tests or imaging, potentially re-exposing patients to radiation or generating extra cost. For patients, EMR can mean better care and greater peace of mind. Mary Jane McQueen, who is the primary caregiver for her 86-yearold mother, says, When my mom has serious health issues, Im able to stay in contact with Dr. Larsen by e-mail. As he has access to her electronic health records wherever he is at the time, weve been able to get ahead of the game in terms of treatment, rather than get to the point where wed have to go to emergency. While Ms. McQueens mother has had a number of long stints in the hospital, thanks in part to EMRs and her daughters ongoing communication with Dr. Larsen, she is still able to live at home most of the time with her daughter and son-in-law. Being in regular contact with the family practitioner also made a big difference when her mother was in the hospital receiving acute care, says Ms. McQueen. It made me feel like we had a support team. All physicians quoted in this article use PS Suite EMR and are clients of MD Physician Services Software. PS Suite EMR is a leading EMR solution, which also offers a fully integrated mydoctor.ca Health Portal, developed exclusively for Canadian physicians. For more information, please call the Hotline at 1-800-361-9151, e-mail practice.hotline@cma.ca, or visit md.cma.ca/EMR.

With PS Suite EMR, nothing falls through the cracks. Whether its our staff or a physician dealing with an issue or patient request, everything is dealt with in the system electronically and can be reviewed after, if necessary, in the audit log.
Dr. Neeraj Sanjeev Bector, Edmonton

By the numbers
Canadas evolving health needs

Life span
B.C. Medical Association president Dr. Nasir Jetha says while managing change can be difficult, we cant throw our hands up in the air when we see there are ways by which we can deliver better care and better quality.
PHOTO: RAYMOND LUM

1961:
71 years

IMPROVEMENTS

2011:
81.4 years

Initiatives aim to improve care and better manage health care costs
n an age of health care cutbacks and harried practitioners, a sign in Dr. Davidicus Wongs medical ofce in Burnaby, B.C., sends an unusual message. The sign asks patients to reveal their complete lists of medical problems at the start of each visit, so that each can be addressed thoroughly by the family physician and his staff. Its a philosophy of quality that Dr. Wong both practices and teaches as the Family Practice Champion of the provinces Practice Support Program. Set up by the British Columbia Medical Association (BCMA) and the B.C. Ministry of Health under the General Practice Services Committee (GPSC), the program helps family doctors and their ofces enhance both their efciency and the level of care they provide. It includes nancial incentives, strategies and training modules in areas ranging from chronic disease management to better scheduling, sessions that Dr. Wong helps to deliver. I tell my colleagues to embrace the list, he says, explaining that some doctors limit patients to one medical problem per visit, to keep appointments short. But it can actually be more efcient for the doctor to know all aspects of their conditions, because it can help uncover related issues and plan overall care, says Dr. Wong, who has been practising for 20 years. Its a new way of listening. Such quality initiatives are intended to improve the health of the population, enhance the patient experience and reduce or at least control the cost of health care. We are on the right track, says Dr. Nasir Jetha, the president of the BCMA, adding that the GPSC is having a benecial effect on processes and outcomes in the province. The patient is getting the best care possible, the physicians have the right tools, and its a benet to the health care system in terms of savings. Dr. Jetha, who has been practising as a pediatrician in Vancouver for 27 years, says that managing change can be challenging for doctors. But we cant throw our hands up in the air when we see there are ways by which we can deliver better care and better quality. There are more to come in B.C., Dr. Wong says, such as additional training modules focused on areas such as palliative care and youth mental health. Theres many, many layers to improving quality, he explains. For example, he is the Medical Lead and Chair of the Burnaby Division of Family Practice, set up under the GPSC, sort of a new doctors lounge where a communitys family physicians have a voice to improve the health of their patients, he says. Were no longer working in isolation. The divisions, as well as the training modules and other strategies, spell the renaissance of family practice, he says. Were closing the care gap between what patients need and what they get.

2025: ?

CMA 4 AN INFORMATION FEATURE FOR THE CMA

t h e g l o b e a n d m a i l t h u r s daY, d e c e m b e r 1 , 2 0 1 1

2014 HEALTH ACCORD

View the principles in full at globeandmail.com/healthcaretransformation

Improve population health

Health promotion/illness prevention: The health system must support Canadians in the prevention of illness and the enhancement of their well-being. The broader social determinants of health (e.g., income, education level, housing, employment status) affect the ability of individuals to assume personal responsibility for adopting

and maintaining healthy lifestyles and minimizing exposure to avoidable health risks. Co-ordinated investments in health promotion and disease prevention, including attention to the role of the social determinants of health, are critical to the future health and wellness of Canadians and to the viability of the health care system.

CHRONIC DISEASE

Wellness model emphasizes illness prevention

r. John Haggie is a strong proponent of the adage an ounce of prevention is worth a pound of cure. As a surgeon practising in Gander, Nd., he has rst-hand experience with serious medical conditions that could be prevented with early intervention. Among his examples, Dr. Haggie points to a patient who is about to lose her leg due to complications of type 2 diabetes. This outcome could have been avoided at any number of points, he says. Better childhood nutrition and tness could have prevented the obesity that led to the development of this womans diabetes. Better drug coverage could have improved her blood glucose management. Even something as simple as having her feet checked by a nurse, which costs about $20, could have saved this womans leg and tens of thousands of dollars to the health care system. Canadian Diabetes Association president and CEO Michael Cloutier says public investments in primary and secondary As president of the Canadian prevention initiatives are money well spent. The evidence shows that an upfront investment more than pays for Medical Association, Dr. Haggie is promoting a transformation of the itself down the road. PHOTO: SUPPLIED health care system that will focus and secondary prevention initiatheir prescribed therapy to effecon illness prevention and health Our goal is to ensure tives. The evidence shows that an tively manage their disease. A promotion. The current acute that by the end of the upfront investment more than lot of people have to choose bedisease model of health care is 20 end of the next Health pays for itself down the road, tween paying for their rent or for years out of date. Today, the bigsays Michael Cloutier, president their medications. Many more gest burden on the system comes Care Accord, Canadians and chief executive ofcer of the especially those in remote and from largely preventable chronic will have the best health Canadian Diabetes Association. lower income communities diseases and their complications, in the world. He notes that just a two per cent cannot afford healthy food. The he says, noting part of the chalreduction in diabetes prevalence result is more diabetes-related lenge in promoting health is that John Haggie, rates would result in a nine per complications, poorer quality of many highly effective intervencent reduction in direct health life for these individuals and an tions are based in the community, President, Canadian Medical Association care costs. increasing strain on our health not in hospital or doctors ofces Unfortunately, the tools and care system, says Mr. Cloutier. (for example, programs to encourmedications that promote health We need to create a standard of age youth tness and smoking are not accessible to all Canadicare for chronic disease managecessation initiatives). As a result, ans. Almost two-thirds of people ment across Canada. they are not funded by medicare. with diabetes report that they The Canadian Medical AsWe have to convince the cannot afford to comply with sociation is advocating for cogovernment to invest in primary ordinated investments in health promotion and disease prevention that will eliminate these gaps. Our goal is to ensure that By the by the end of the end of the next numbers Health Care Accord, Canadians will have the best health in the Canadas world, says Dr. Haggie. There is evolving no reason why we cant do that. By emphasizing health promohealth needs tion now, we will see results by 2020.

PRINCIPLE

RISK MANAGEMENT
Poll shows Canadians need to wake up to chronic disease truths According to poll results reported in the 2011 Heart & Stroke Foundation Report on Canadians Health, nine out of 10 Canadians are jeopardizing the quality and length of their lives. The foundation found that many Canadians are in denial about their risk factors for heart disease such as being overweight and being physically inactive risk factors they can manage and control. While the poll results indicates 90% of Canadians rate themselves as healthy, the reality is:

9/10
Canadians have at least one risk factor for heart disease and stroke.

Approx.

50%

of Canadians dont meet the physical activity and healthy eating recommendations.

25%
of Canadian adults are obese. The foundations prescription for a healthy lifestyle and more quality years of life includes managing controllable risk factors by following a healthy diet, being physically active, knowing and controlling ones blood pressure and cholesterol levels, maintaining a healthy weight, being smoke-free, reducing stress, managing diabetes and limiting alcohol consumption.

Governments across Canada will soon decide the future of our healthcare.

Lets Put

Birth rate
1932:
22.4 births/ 1,000 population

EXPERT OPINIONS

People First!

Ideas for improved chronic disease management

CIHR: Better health care through patient-oriented research
esearch focused on patients is the cornerstone of world-class health care. Canadas Strategy for Patient-Oriented Research is a new national health research strategy that puts patients rst. It is focused on providing patients, health professionals and policy-makers with the best available information to make treatment and policy decisions that are appropriate, timely and effective. It aims to strengthen support for clinical trials and intervention studies as well as research that compares the effectiveness, benets and harms of existing treatment options. The strategy also endeavours to improve the translation of innovative preventative, diagnostic and therapeutic approaches into the health care setting. The strategy was created after extensive consultations led by the Canadian Institutes of Health Research (CIHR) with health charities, academic health care organizations, industries, universities and governments. The strategy, a rst for Canada, will bring together a coalition of researchers and stakeholders to work with the provinces and territories to meet the challenge of delivering high-quality and sustainable health care. Patients are at the centre of health care. Canadas Strategy for Patient-Oriented Research is about recognizing the patients perspective and ensuring that the care they receive meets their needs and is based on the best available information. If done right, the strategy can transform clinical practice in this country for the benet of Canadians. This will improve health outcomes as well as the patients satisfaction with their care, said Dr. Alain Beaudet, president of CIHR.

Knowledge for practice: Managing medical knowledge

n January 1911, when the post ofce began delivering the rst issue of the Canadian Medical Association Journal (CMAJ) to about 1,500 physicians spread across the country, CMAJ was the only form of continuing education available to most of those readers. Fast forward 100 years. Today, 71,000 doctors receive the paper version of CMAJ, but they are also joined online by thousands more readers spread around the world. But thats just the start other changes in physicians ongoing education have been even more staggering. At the Canadian Medical Association, this education explosion is called K4P Knowledge for Practice and its ripple effects are being felt across medicine. Physicians of 100 years ago even 25 years ago usually had access to a handful of journals and textbooks to help them provide up-to-date care. The CMAs K4P program takes the same concept upto-date information and delivers it instantly to the patients bedside or physicians examining room. Today, CMA members can instantly consult more than 100 online textbooks and marvellous diagnostic resources such as DynaMed and MD Consult just by clicking a few computer keys or touching an iPad. When patients visits are over, the doctor can provide them with take-away information by pressing a few more keys. Later, that same physician can update his or her skills by taking an accredited online course or webinar. That, in a nutshell, is the goal of the CMAs K4P project: to provide doctors with easy access to the best information so that patients can receive the best care. Theres no doubt that the editors of that rst edition of CMAJ would be pleased.

2011:
10.28 births/ 1,000 population

2025: ?

Together we can make the health of Canadians the centre of the debate.

cancer.ca

t h e g lo b e a n d m a i l t h u r s daY, d e c e m b e r 1 , 2 0 1 1

AN INFORMATION FEATURE FOR THE CMA CMA 5

2014 HEALTH ACCORD

Equitable: The health care system has a duty to Canadians to provide and advocate for equitable access to quality care and multi-sectoral policies to address the social determinants of health. In all societies, good health is directly related to the socio-economic gradient the lower a persons social position, the worse his or
ACCESS her health. The relationship is so strong that it is measurable within any single socio-economic group, even the most privileged. It is due to the sum of all parts of inequity in society material circumstances, the social environment, behaviour, biology and psychosocial factors, all of which are shaped by the social determinants of health. Some health inequities are preventable; failure to address them will result in poorer health and higher health care costs than necessary. Improved health literacy (dened as the ability to access, understand and act on information for health) would help to mitigate these inequalities.

Overcoming social inequities key to improved wellness

n apple a day may keep the doctor away, but what if you cant afford to buy apples or other fresh fruits and vegetables? What if your home is overcrowded or has mould? What if you dont even have a home? Studies show that factors such as the availability of affordable healthy food, housing and employment have a direct impact on an individuals health. The United Nations recently declared that the right to health extends beyond health care to include the underlying social determinants of health, such as potable water, adequate sanitation and access to healthrelated information. The health care system is really just a small portion of health care, says Canadian Medical Association president Dr. John Haggie. We need to look beyond doctors and hospitals, and address the social inequities that are contributing to poor health. These inequities are particularly evident in remote and poorer communities. Consider the challenge of providing nutritious meals to a family when Coke is far cheaper than milk and the single local grocery stores shelves are bare of fresh produce, meat and sh. That is the reality YMCA

If you are living in an isolated community and are on a low income, the apple-a-day approach to health is not relevant.
Scott Haldane, President, YMCA Canada

SERVICE DELIVERY

Home can be where the health is

ow Canadians age and die has changed dramatically in recent decades, with the resulting shift emphasizing growing needs to rethink the ways and places care is delivered. Just a generation or two ago, death usually came suddenly, the result of an acute cardiac event or illness. Today, more people are living longer than ever with chronic diseases (80 per cent of seniors over the age of 65 have at least one chronic disease), yet our health care system still works on the old acute care model. We need to shift our philosophy about setting of care to think beyond acute care hospitals, says Sharon Baxter, executive director of Canadian Hospice and Palliative Care Association (CHPCA). Home care offers an alternative that not only benets patients, but is also more cost-effective than hospital-based care. Wellsupported home care enables people to be discharged from hospitals earlier, delays admission to long-term care facilities and allows individuals to live with dignity and independence, says Nadine Henningsen, executive director of Canadian Home Care Association (CHCA). For those with terminal illnesses, hospice palliative care helps patients die the way the majority of Canadians say they would prefer: at home. We believe that everyone has the right to die with dignity, free of pain, surrounded by their loved ones, in the setting of their choice, says Ms. Baxter. Funding for and availability of these services varies widely across the country, however. If you want to die at home, you need home care. But you may or not be able to get home care, and it may or may not be funded, depending on where you live, says Ms. Baxter. Even where services are available, terminally ill patients sometimes remain in hospital because they do not receive timely referral to palliative program. We need to train health care workers how to talk to patients about endof-life issues, she says. Availability of home care and hospice palliative care services are also being strained by increasing demand and limited resources. CHCA estimates that more than 800,000 seniors with chronic conditions will require home care services in 2017. The lack of qualied human resources is a signicant challenge all home care providers face. It is difcult to recruit and retain health professionals, and our current workforce is aging. The demand for home care services will soon outstrip our human resources, says Ms. Henningsen. The results are waitlists for services, an increasing burden on family caregivers and continuing reliance on hospitals. Both CHCA and CHPCA want to see the federal government commit increased nancial, human and technology resources to home and palliative care services. We want to guarantee a minimum standard of resources across the country so that you can spend the last years of your life at home if thats what you want, says Ms. Baxter.

Canada president Scott Haldane witnessed recently when he visited several First Nation communities as chair of a national panel on native education. If you are living in an isolated community and are on a low income, the apple-a-day approach to health is not relevant, he says. In addition to struggling with a lagging food security, First Nation families also contend with high unemployment, substandard housing and high dropout rates. The latter is particularly concerning, says Mr. Haldane, as youth who dont graduate high school are more likely to fall into substance abuse, be unemployed and live in poverty all factors that contribute to poor health. Lack of education also affects the ability to access, understand and act on health information. How can you educate yourself about wellness and develop the skills you need to care for yourself if you cant read? asks Dr. Haggie. The disparities in health status between First Nation populations and the rest of Canada are striking and disturbing. Compared to the national average, First Nations communities have double the infant mortality rate, three to ve times the prevalence of type 2 diabetes, 30 times the rate of tuberculosis infection and a life expectancy that is ve to seven years lower. Closing these gaps in health outcomes will require the development of innovative, culturally relevant community-based programs that address a wide range of social issues. We cannot talk about health in isolation, says Shawn Atleo, Assembly of First Nations (AFN) National Chief.

YMCA Canada president and CEO Scott Haldane says youth who dont graduate high school are more likely to fall into substance abuse, be unemployed and live in poverty all factors that contribute to poor health.
PHOTO: SUPPLIED

Towards that end, AFN recently held a national health forum that highlighted the need for First Nation control of First Nation health to achieve fair and sustainable health service delivery to their communities. Experts discussed the need for programs that tackle inequities in education, overcome barriers to economic development and improve infrastructure so that communities have access to clean water and safe housing. Funding is critical to implementing these plans. In 2010, First

Nation communities received less than half the funding given to non-First Nation communities to provide basic services for their citizens ($8,754 compared to $18,724). If services and programs do not receive sustained, equitable funding, health care and judicial costs in First Nation communities will reach close to $1 billion over the next 10 years. Collective action at this juncture in history is critical. If we dont act now, we risk the loss of an entire generation, says National Chief Atleo.

By the numbers
Canadas evolving health needs

Infant mortality
1911:
120 deaths/ 1,000 live births

2011:
4.92 deaths/ 1,000 live births

2025: ?

While they have proved to be cost efficient, demand for home care services is expected to soon outstrip the sectors human resources capacity.
PHOTO: ISTOCKPHOTO.COM

CMA 6 AN INFORMATION FEATURE FOR THE CMA

t h e g l o b e a n d m a i l t h u r s daY, d e c e m b e r 1 , 2 0 1 1

2014 HEALTH ACCORD

Sustainable health care: This requires universal access to quality health services that are adequately resourced and delivered along the full continuum in a timely and cost-effective manner. Canadas health care system must be sustainable in the following areas: resourcing, research, measuring and reporting, and public support. Accountable: The public, patients, families,

View the principles in full at globeandmail.com/healthcaretransformation

PRINCIPLE

Improve value for money

providers and funders all have a responsibility to ensure the system is effective and accountable. This includes: good governance, responsible use, strong public reporting, enforceability and redress, leadership/stewardship and a responsive/innovative approach to care.

ECONOMICS

Enhanced quality and safety among keys to sustainable health care

or Don Drummond, the question of whether Canadas health care system is sustainable is best answered with another question: why would one want to sustain the status quo? For the amount of money spent, the system should surely be delivering better results, says Mr. Drummond, the former chief economist for TD Bank and now chair of the Commission on the Reform of Ontario Public Services and Matthews Fellow in Global Public Policy at Queens University in Toronto. He says the health care system is often described as unsustainable because health care costs are increasing faster than government revenue growth. But he cautions that this approach ignores changes that could make the system more sustainable. For the health care system to become more sustainable, Mr. Drummond argues, it needs to shift from an acute-care model to a chronic-care model and also broaden its scope to health in general including prevention and socio-economic factors that lead to health issues. But that does not necessarily mean increased spending. In fact, says Mr. Drummond, economic realities mean that provincial governments will soon be compelled to rein in health care cost increases as part of their drive to return to balanced budgets, which means reform of the system is the most obvious solution to the growing challenge. The process for reform, in which stakeholders must take a leading role, will be as important

Don Drummond, a former senior federal finance official and TD Bank chief economist, says to become more sustainable, Canadas health care system needs to shift from an acute-care model to a chronic-care model and also broaden its scope to health in general including prevention and socio-economic factors that lead to health issues. PHOTO: MARK HOLLERAN/HOLLERONPHOTOGRAPHY.COM as the diagnosis, prognosis and perhaps even the medicine, says Mr. Drummond. Improving the efciency and sustainability of the system, he adds, will require a range of actions from organizational and informational improvements, to reforming service delivery incentives and sharpening the focus of health care. Mr. Drummond believes the necessary reforms can be accommodated under the current public administration or nancing model without modifying the general parameters of the Canada Health Act. Specically, he would like to see better integration of the system around the patient. For instance, better value for money could be achieved when high-needs patients, such as high-needs diabetes patients, are closely attached to a primary care practice. Cost reductions, in this instance, might be had from a substantial reduction in hospital costs the greater the attachment to one primary care group, the lower the overall costs on the health system, he says. Peter Barrett, a past president of the Canadian Medical Association, believes the health care system can move towards sustainability by focusing on quality and safety and reducing waste. There are still huge variations in what we do and how we do it. Variation is the breeding ground for error; most other organizations know that and try to standardize their activity. We need to do that too, says Dr. Barrett. He adds that a focus on evidence-based best practices improves outcomes and quality and saves money. Ultimately we will need policy changes to bring about some of these reforms, but a lot can be done without policy changes. If it is good for patients and the system, it seems to me to be a no brainer, says Dr. Barrett.

What kind of health care system will my grandchildren have?

www.healthcaretransformation.ca

patient care
By fostering the Physician/Physician Assistant Model, we can ensure superior care for Canadians and improve access to quality medical care.

Optimizing

Physician Assistants

CANADAS DOCTORS ARE LISTENING.

Adjoints au mdecin

soins aux patients

En favorisant le modle mdecin/ adjoint au mdecin, nous pouvons assurer des soins de qualit suprieure pour les Canadiens et les Canadiennes et damliorer laccs aux soins mdicaux de qualit.

Optimiser les

www.capa-acam.ca