It’s Time to Test a Basic Income

March 1, 2016 9:50 am
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Recently I tabled a motion in the Senate calling on the government to create a pilot project that would test a basic income in Canada, also known as a guaranteed annual income. Canadians face immense challenges. Many families struggle to pay the rent, and some can’t afford their children’s school supplies or school trips. Many rely on donations at the food bank just to feed their families.

In numbers, one in seven Canadians lives in poverty. That equals to over five million people — including over one million children. And, there are an estimated 150,000 – 300,000 people homeless. Last year close to 900,000 Canadians used food banks every month, with over one third of those being children.

We also have increasing income and wealth inequality that is changing the core of our society. The Conference Board of Canada gave Canada a “C” grade for inequality, ranking us 12th out of 17 countries studied.

But why a basic income?

What we have done for far too long is simply not working. Even with all the social supports in place, the resulting income is often only enough to maintain a family in poverty. At their worst, existing policies and programs actually entrap people in poverty.

This is why we need a new way.

A basic income would work as a tax credit administered through the taxation system similar to the Guaranteed Income Supplement for seniors. If someone earns less or has less than the poverty line, they would simply be topped up to a point above the poverty line.

It would ensure that all Canadians would have an income that covers the basic necessities: clothing, food and decent shelter. It would provide a foundation that low-income people could then build upon for a better life.

A 2013 Environics poll found that this idea is supported by a majority of Canadians.

Interestingly, this support does not fall along party lines or political philosophy. People across the political spectrum support a basic income.

Conservative economist Milton Friedman was a proponent of basic income, as is former Conservative Senator Hugh Segal. On the other end, Green Party Leader Elizabeth May, Alberta NDP Finance Minister Joe Ceci and Quebec Liberal Minister of Employment and Social Solidarity, François Blais support the idea.

We also see communities across the country are on board. There are many other provincial, territorial and municipal leaders that have publically supported the adoption of a basic income or the adoption of pilot projects to that end. We also have organizations like the Canadian Medical Association that are calling for action on inequality.

Canadians have come to realize that there may be a lot of positives to this approach. A basic income is a simpler and more transparent approach to fighting poverty than our current patchwork of social programs. It would extend benefits to those who are currently not covered by social assistance programs, such as the working poor. And introducing a basic income could have a ‘stimulus’ effect by quickly injecting money into the economy.

In the 1970s, Canada piloted a basic income program known as ‘Mincome,’ in Manitoba, primarily in the town of Dauphin. Research done by Evelyn Forget from the University of Manitoba found that as a result “hospital visits dropped 8.5 per cent. Fewer people went to the hospital with work-related injuries and there were fewer emergency room visits from car accidents and domestic abuse. There were also far fewer mental health visits.”

What about employment? Research shows that only new mothers and teenagers worked less with a basic income. Mothers stayed home with their babies longer. Youth worked less but spent more time in school and graduated in higher numbers. Overall, labour force attachment remained strong.

Looking at these results, and other similar examples from around the world, Canada could see not only a great upsurge in the living conditions for our most vulnerable if a basic income were employed, but we could also realize a decrease in costs.

Poverty is costing us all (as much as $30 billion a year by one estimate) by slowing the economy, forcing up our tax bills, increasing health care costs and crime.

On the other hand, the now closed National Council of Welfare put the poverty gap in Canada at $12 billion in 2011.

If these numbers are correct, it’s obvious which one makes more economic sense.

But, let’s take this step-by-step. We need a pilot project that can provide new and robust Canadian data, that can determine how such a system would function in this day and age and that would make clear the benefits and costs.

A basic income is a different approach — a new path that has shown great potential. Let’s get the evidence. Let’s study this approach. If proven, we not only end poverty but we spend smarter, more efficiently and effectively.

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Art Eggleton is a Canadian Senator and former Mayor of Toronto and Member of Parliament.

Keeping Science Safe

February 25, 2016 11:46 am
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It’s time to close the gaps governing human participation in scientific research in Canada

The disturbing announcement recently that a man died and four others were seriously harmed in Rennes, France as a result of participation in a research study is a timely reminder of the importance of protecting those who volunteer to be subjects of research.  The drug being tested was thought to show promise in treating a variety of disorders including mood, anxiety and pain.  It was the first time this drug was given to people.

In 2014, we learned of the Facebook “Emotional Contagion” study in which, without their knowledge or consent, 690,000 subscribers’ newsfeeds, likely including the newsfeeds of youth and other vulnerable persons, were manipulated to see if their emotions, happy or sad, could be altered as a result.  They found out they indeed could manipulate subscribers’ emotions in this way.

The lesson we need to learn from these two seemingly disparate examples is that rules guiding the use of human subjects in science matter profoundly.  The Facebook study had no prior ethics review and the manipulation and lack of knowledge or consent by those enrolled violated ethical standards.  The Rennes study did have prior review by a French ethics committee, yet things still went very wrong.

The history of research, including research in Canada, shows that very serious harms may be suffered by persons taking part in research.  The rules are not perfect, and they continue to be refined when tragedies do occur, but prior review and oversight has proved a powerful corrective to make research safer for human subjects.

The problem is that these research protections don’t apply to everyone doing research on people in Canada — and they should.

In Canada, and most of the rest of the developed world, a consensus emerged during the 1970s through to the 90s, that a framework of binding rules was needed to protect research subjects.  This has led to the development of internationally recognized principles requiring that people in research trials be treated ethically – that is safely, and with protections for privacy, informed consent and vulnerable persons such as children.  These ethical standards also require prior review by an independent expert board – in Canada usually called a Research Ethics Board (REB) – to ensure that these vital protections are adhered to.

So what’s the concern?

In our country, key research regulations and guidelines have two sources.  First – the Tri-Council Policy Statement (TCPS) prescribes rules for research conducted at universities and large hospitals funded by the federal Granting Councils; and second – Health Canada and US FDA Regulations prescribe rules for new drug and medical device testing carried out primarily by pharmaceutical and biotechnology companies.

Remarkably, aside from these two categories of research, there is no legal requirement in Canada that any other human research undergo this or any other scrutiny.  Such a critical gap in Canada’s research rules for human subjects must be addressed.

For example, there is no requirement that research undertaken by federal or provincial governments undergo such review and oversight to protect human subjects.  A few individual federal government agencies have acted voluntarily to have their research reviewed according to the TCPS: Health Canada, the Department of National Defense, and the National Research Council (I am its REB Chair).  These agencies do this job cheaply and with generally good results.

But all other federal government departments and agencies, provincial governments and commercial and industrial companies (aside from those doing new drug and device research) have no rules requiring prior review to ensure they meet ethical standards.

This means that plenty of research with human subjects takes place every year in Canada without having to show that it is reasonably safe, that privacy is protected or that human subjects are treated fairly.

Doing high quality research on significant medical, scientific and social questions is of surpassing importance.  But research, particularly that involving human subjects, must be done ethically.

The Prime Minister and the Liberal Party made vigorous commitments to the twinned themes of science and integrity during the election campaign, and this priority has been echoed by many interests inside and outside the federal government.   As a start, the new government should act promptly to ensure that all federal government research takes place with mandatory ethics oversight to protect human subjects and urge others to follow.

Should we not provide ethical protections to everyone who gives of themselves to promote research for the good of us all – particularly when directed and funded by our own elected governments?  Let’s learn from past tragedies and help make sure they don’t keep happening.

Gordon DuVal is a Part-Time Professor at the Gordon DuvalUniversity of Ottawa Faculty of Law and a member of its Centre for Health Law, Policy and Ethics.

Albertans Must Get Inventive in Healthcare as Price of Oil Slides Further

February 9, 2016 10:45 am
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As world oil prices and the Canadian dollar slide perilously, Albertans must become more inventive and rigorous in managing our costs – and our expectations – especially in high-cost areas like infrastructure, education and health care.

Health care is the biggest challenge. We cannot turn off the population’s health care needs simply because provincial revenues are declining. Illness is oblivious to low commodity prices and market share.

Unless we become inventive, health service declines are inevitable. The temptation to reduce surgeries such as hip and knee replacements and cataract removal will be irresistible. The general public will notice these changes as increased wait times. In fact, we’ve already seen increases in wait times for hip and knee replacements in Alberta – one of the leading indicators of our health care system’s performance.

Yet hip and knee replacement is actually an area where we have inventive opportunities waiting to be tapped. “Gain sharing” is one such innovative approach.

Health care teams in hospitals around Alberta, supported by Alberta Bone and Joint Health Institute (ABJHI) and Alberta Health Services’ Bone and Joint Strategic Clinical Network, have for the past five years led efforts to improve the quality and efficiency of orthopaedic care. As a result, patients undergoing hip or knee replacement require fewer blood transfusions, are up and mobile sooner after surgery, have less pain and better physical outcomes, and are home from hospital sooner.

The savings in hospital beds freed up by patients returning home sooner and from blood transfusions have exceeded $40 million to date.

Allowing these health care teams to share in the gains they make by reallocating resources to more operating room time and more dedicated hospital beds to enable more surgeries would create a virtuous circle of improved performance and decreased wait times. It might also add an element of competitiveness as health care teams look to out-gain each other to the benefit of patients and the health system.

Alberta could further put some of the savings from this success into smart investments like an orthopaedic registry that would serve as a valuable storehouse of rich and current data on health care performance in critical areas of quality, such as recovery of joint function, pain reduction and implant safety.

Related: Can wait times for hip replacements in Canada be shortened? 

Alberta has made strides in collecting wait time data but there is no single registry in the province or anywhere else in Canada that collects the range of performance data needed to guide modern medical practice and service planning in orthopaedics. A storehouse of reliable information across a broad range of quality indicators would have positive effects on clinical decision-making and resource planning. The value to both patients and the health system would be enormous and the investment very modest.

One area of clinical decision-making that would have broad implications for patient satisfaction, economic savings and wait times is patient appropriateness for surgery. Patient feedback analyzed by ABJHI suggests that almost two in 10 knee replacement patients in Alberta derive little to no benefit from their surgery. A research team working in Alberta is now developing criteria to help surgeons and their patients assess the likelihood of benefit from knee replacement.

Applying such criteria could reduce wait times for those who need – and are likely to benefit from – the surgery with some of the savings produced used to enhance non-surgical treatments known to produce excellent outcomes.

There are silver linings in those dark economic clouds over Alberta. If we are resourceful and make evidence-based, intelligent decisions now, there is no doubt the province will be much better off when the sun shines again.

Ferguson-pell_MartinMartin Ferguson-Pell, Ph.D., is Executive Director of Alberta Bone and Joint Health Institute and a contributor to EvidenceNetwork.ca.

From Grievance to Growth

February 8, 2016 2:19 pm
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James Wilson argues that the Maori in New Zealand have created a system we should aspire to emulate.

How Indigenous-led business partnerships can lead the way.

Moving Manitoba’s Indigenous peoples from the liability to asset column was a topic that consumed some of Manitoba’s most innovative First Nations and mainstream business minds during recent a two-day ‘design-thinking boot camp.’

It was facilitated by Karl Wixon and Trevor Moeke, two Maori business leaders from New Zealand who, as part of a broad Indigenous-led partnership, have helped create and stoke a movement in their homeland that has transformed the role their people play in the island’s economy.

As directors of a treaty settlement trust, they have been part of a wealth creation plan that saw their initial settlement of $176 million in 1996 grow to an asset value of $1.3 Billion today.

More broadly speaking, the Maori are now responsible for 40 percent of the fishing industry; 36 percent of forestry; 30 percent of lamb production; 12 percent of sheep and beef, and 10 percent in each of the dairy and kiwi fruit sectors.  By any measure, it’s an astounding story of growth and success from an Indigenous group that represents just 10 percent of the New Zealand population.

It is the wide open, collaborative “design thinking” process that has guided them through to the creation of industry-led strategies, not strategy-led industries in New Zealand.   At its heart, is the cumulative work that has been done to transform the country’s story, from one of conflict and discrimination, to one that celebrates and relies on its Indigenous character to help it build business opportunities abroad.

Fundamental to the shift towards wealth creation to support culture, language and environment was a shift from grievance to growth thinking.  From dispute and protest that pitted Maori vs. Government to mindset that allowed Maori to work with government.  In this move from grievance to growth, tradition and a strong connection to the land were not lost, they were enhanced.

In fact, Maori leaders are now creating 75 and 100 year business plans for sustainable fishing and forestry sectors. Managing valuable commodities like rock lobster (called crayfish in NZ) which are harvested by open water deep divers then shipped straight to Shanghai that night for consumption, requires a deft hand to protect the resource for future generations.

As Wixon says, “We still have our dust-ups with government, but that’s no longer what we are solely about.”

“Initially, we sent our youth out to become lawyers. A generation of hundreds of lawyers and they got in dust-ups. Some still do that,” he said.  “Now we send our youth out to get commerce degrees, and environmental management degrees. We have moved beyond the dust-ups by having our communities invest in their own futures.”

Some of this shift was predated by settlements attached to Waitangi Tribunal.  “Once assets change hands, the ‘biff biff’ approach changes to become about how we transmit wealth inter-generationally, said Moeke.

In the midst of this transition, the Maori have discovered that they have a value added effect on New Zealand business. They could help the country create a differentiating factor that would allow them to increase the value of products.

Related: Before the National Inquiry.

Honey is a perfect example.  The Miere honey coalition takes ‘a genuine path to market that is supported by provenance and storytelling, that is traceable and safe, and is able to command a premium.’ Premium meaning $40 per kg vs. regular honey selling for $4 per kg (and expected to grow upwards to $100 per kg).  Again, the power of allowing indigenous-led development increased value.

We have a lot to learn from the Maori in how to sell our Indigeniety as something that can attract investment (both monetary and social) from the rest of the world.  Luckily, we can add to this learning as we already have a model that helped shape Manitoba’s business future internationally, many, many decades ago.

It was the Hudson’s Bay Company that first made formal business partnerships with First Nations in Manitoba. They used ‘chiefs’ to act as their agents, taking advantage of millennial old Indigenous trade routes to bring goods to York Factory.  First Nations were not pawns of the fur trade, but active agents who largely controlled its markets for a 200 year period.  The trade protocols they used (both HBC and First Nations) were based on Treaty protocols, which, in many senses, were our earliest economic agreements.

Whether we look to our past or our present, one thing seems certain.  While conflict may still be necessary, now may be the perfect time for Manitobans to stop investing in dust-ups and, instead, invest in relationships that bear the fruit originally intended in our earliest Treaties together.

Wilson_Jamie_Learning to walkJames Wilson is an advisor with EvidenceNetwork.ca and commissioner of the Treaty Relations Commission of Manitoba, a neutral body mandated to encourage discussion, facilitate public understanding, and enhance mutual respect between all peoples in Manitoba. @jamesbwilson_

OLM Editorial: The LeBreton Flats Fiasco and Why Melanie Joly Must Reform the NCC

February 3, 2016 1:55 pm
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A concept image for Rendevous LeBreton. 

For years the National Capital Commission (NCC) has been the most inept, closed, secretive, elitist and incompetent organization in the federal government. Their tagline should be “The NCC- We Never Miss an Opportunity to Miss an Opportunity.”

The NCC board of directors has 15 members, including the chairperson and the chief executive officer (CEO). Thirteen members represent the regions across Canada. Five are from the Capital Region. They are appointed by the minister responsible for the National Capital Commission (now the Hon. Melanie Joly), with the approval of the Governor-in-Council. Their role is to oversee the corporation, ensure that the corporation’s resources are used effectively and efficiently; to monitor, evaluate and report on performance; and to foster relationships between the NCC and other levels of government and the public. In all cases they get an F.

The NCC’s continuous incompetence over decades is mind boggling. Where to start? They botched the memorial to Victims of Communism project, interfered and tried to delay Ottawa’s $1 billion light rail, against the wishes of the democratically elected Ottawa City Council. In 2011, they spent 5.2 million taxpayers’ dollars to install seven new ice chalets at a cost of $750,00 each (shacks) along the Rideau Canal which is double the value of most families homes in Canada. They messed up the so called Metcalfe Grand Boulevard plan, the King Edward Avenue redevelopment plan in the 1980s, spent decades fighting with Public Works Canada and the City of Ottawa over the development of Sparks Street, embarrassed the entire country by making a complete mess of the Millennium Celebrations in 2000, tried to unilaterally expand the Champlain Bridge against the wishes of every local city council in the region, destroyed the town of Hull in the late 1960s with the horrible development of federal buildings on the Quebec side of the Ottawa River. In 1998, Rhys Phillips, in his book Great Gaffes of the National Capital Commission said of the NCC and Hull: “what emerged from the rubble was a textbook example of the twin horrors of postwar urban renewal and late-modernist architecture. Brutalist concrete buildings encase a soulless mall that spans a bleak, six-lane street; they cruelly mock the former humanely scaled cityscape. Four thousand people were displaced. The new ‘city centre’ turns a cold shoulder to the river and the parliamentary precinct across the water.”

IllumiNATION LeBreton

IllumiNATION LeBreton

The NCC board members are largely unknown. One is a forest industry person, another in general management and marketing, a philosopher and the rest are all either government administrative or education management bureaucrat types. There is not one serious entrepreneur or businesses corporate executive like a Terry Matthews or Jim Balsillie. This explains the insanity of the current LeBreton Flats redevelopment proposal. NCC conditions for applying were so ridiculously secretive and onerous that only two bidders stepped up. Of these, only the Rendezvous LeBreton, 100 per cent private money proposal led by Ottawa Senators owner Eugene Melnyk is credible. The other, the LeBreton Re-Imagined by Devcore, Canderel and DLS Group (DCDLS) is not a serious bid. Their plan is built around an NHL arena and reliance on existing government incentives (whatever that means!). DCDLS does not own an NHL team and will not own one. This should disqualify them immediately from consideration. If the NCC board is dimwitted enough to proceed with the DCDLS LeBreton Re-Imagined proposal (and we know from their track record that they are foolish enough to do this) it will create the biggest white elephant in the region’s history. DCDLS is jesting in the media that they can build and then sell their rink to the competition. This is unprofessional and disrespectful to what should be a serious process. Their glib remarks about Mr. Melnyk are in poor taste to the Ottawa Senators organization who has put hundreds of millions of dollars into our economy over the past quarter century, including millions to local charities. The Rendezvous LeBreton proposal should be approved and given the fast track to proceed as soon as possible. Heritage Minister, Melanie Joly should introduce a bill to disband the NCC and set up a new agency that can better serve Canada’s capital region, of which the Mayors of Ottawa and of Gatineau should be permanent ex-officio members. The incompetence of the NCC does not serve the public interest and continues to destroy the soul of our great city.

What We Need to Learn from the Death of Sammy Yatim

February 1, 2016 1:57 pm
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As long as there is something we can learn from the shooting death of Sammy Yatim by a Toronto Police Officer, than the 18-year-old’s passing will not have been in vain.  If you follow the innumerable examples of wrongdoing by police, not just in this province but across Canada, one thing is clear, and that is that there is something seriously wrong with the way law enforcement are policing our communities.  While Yatim’s murder has set off a maelstrom of public outrage for many of us who work in the justice system, or have concerns about how we are being policed, the topic is not a new one.

Two years ago Dan Donovan, the founder and Publisher of Ottawa Life Magazine, and I launched a Kickstarter Campaign hoping to raise funds to establish a police centre that would collect and post all cases of police incidents in Canada online. The purpose for creating the site was to track the investigation of these cases by oversight bodies and the courts and to post consequences to the offending officer(s) on the site.  We felt the establishment of such a site was needed because we were very familiar with the widespread frequency with which police officers were committing offences and then receiving penalties that amounted to nothing more than a temporary demotion or suspension of pay for a few months.  In short, we were appalled at the conduct being exhibited by police officers and the fact that no one, including our elected politicians, were saying or doing anything to correct the problem.  To our dismay the site garnered less than $2,000 in contributions from the public, far short of our goal of $75,000.

However, once criminal charges were filed against Toronto Police Constable James Forcillo for the shooting death of Sammy Yatim, the public suddenly woke up to the fact that policing in this province and across the country is in a state of crisis.  Forcillo’s conviction suddenly galvanized the public mind in a way that it never has before about problem policing.  People now recognize that there are serious issues with policing and they are looking for answers to the problem.  As a criminologist who has worked in the criminal justice system for over 25 years, I would like to put forward some remedies that would vastly improve the current state of policing.

First, we have to address the inadequacies of the current training system, which in my view is 50 years out of date.  Training should reflect what police officers actually do on the job as opposed to what the general public thinks they do.  Research shows that less than 20 per cent of a police officer’s work relates to law enforcement.  Police spend over 80 per cent of their time on order maintenance functions such as directing traffic, responding to noisy parties, writing reports and responding to neighborhood disputes.  Contrast this with the fact that the training is just the opposite.  Eighty per cent of the training for recruits focuses on firearms competency, use of force scenarios, tactical training and crowd control and less than 20 per cent involves mediation, communications, race relations, and mental health issues.  It should come as no surprise to learn therefore that 80 per cent of complaints filed against police from members of the public relate to order maintenance functions of which they are poorly trained and unequipped to deal with

Second, the current training program for police (outside of the RCMP) lasts for no more than eight to 10 weeks.  It’s unrealistic to think that in such a short space of time a recruit could be even remotely prepared for the challenges that they are going to face on the street once they graduate.  Police training should last a minimum of one year and the program should teach them the skill set they will need when they graduate. These officers need to understand the Canadian Charter of Rights and Freedoms, verbal judo, important rulings from the Supreme Court of Canada and de-escalation techniques.

Third, once recruits leave police college they should be subject to a two year probationary period under the supervision of a certified training supervisor.  They should not be allowed to take the oath of office to become a police officer until such time as their training has been validated in the field.  Certified training supervisors should be required to have a minimum of at least five years experience in street policing.

Fourth, although recruits receive a battery of psychological tests to gain admission to a career in policing, they are never evaluated on the job.  There should be mandatory psychological tests administered to every street cop who has policed for at least five years.  Such tests would help weed out officers who are suffering from psychological issues or who have a propensity to be aggressive or violent towards members of the public.

Related: Why Police Fear Evidence-Based Research

Fifth, we know from research that the police subculture plays a major role in changing the behaviour and attitude of young recruits more so than training.  To address this issue, police recruits should be reminded that their loyalty must be to the rule of law and the public they serve. Police officers should be required to renew their oath of office every year to ensure that this point is driven home.

Sixth, there should be a quarterly performance and evaluation review of every officer in order to identify problem issues relating to behaviour and their performance on the job.  At the present time this is not the case and what this means is that problem behaviour can go undetected for years before it explodes with violence in the public domain.  It has been widely reported in the media that Constable James Forcillo had a tendency to frequently draw his weapon on the job even when it was neither necessary nor justified under the circumstances.

The measures set out above will go a long way to correct deficiencies in our police system.  If we couple them with dramatic changes to our oversight process for policing in Ontario than perhaps we will stand a chance at turning around the tidal wave of bad policing that is infecting our society and blighting our justice system.  Whether it would have prevented Sammy Yatim’s death no one can say for certain.  However, what it will mean is that Sammy’s death will not have been in vain, and in my opinion that is no small matter.

The views expressed are those of the author in his personal capacity.

Darryl T Davies is an Instructor in criminology and criminal justice with the Department of Sociology and Anthropology at Carleton University.

The New Health Accord could be Trudeau’s Most Significant Achievement

January 27, 2016 10:00 am
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Photo by Jean-Marc Carisse.

Health Ministers Must Spend Smarter and Negotiate Wiser.

This week the country’s 14 health ministers have been gathering in Vancouver for a pan-Canadian summit to begin negotiating a new Health Accord. The previous accord saw $41 billion transferred to the provinces over the last decade. This next one may be even bigger.

The challenge facing our health ministers is to set clear priorities for how federal health dollars should be used. If we learned anything from the previous Health Accord, it is that wide-ranging agreements get diluted and that diluted agreements do not achieve their intended results – even when they boost provincial coffers.

The rationale for a Health Accord lies in the lackluster performance of our health systems when compared to other industrialized countries and the catalytic role that federal government leadership can play. Canadians currently pay more, receive less, wait longer and live shorter than citizens of most other industrialized countries. We only look good in international rankings when compared to the United States.

We can do better, and this Health Accord is our best opportunity for doing so. But health ministers will only succeed if they commit to spending smarter and negotiating wiser.

To start, spending smarter means channeling any new health dollars strategically towards those services that will achieve the greatest health impact. We do not need to invest in more of the same. This means ending what amounts to unlimited budgets for costly curative health care at the expense of other health-promoting initiatives like home care, public health, rehabilitation and social services.

In particular, the vast majority of government health dollars currently go towards hospitals and physicians, both always shamelessly crying poverty no matter how comparatively well-funded they may be. This leaves fewer dollars for new ways of delivering care and for population health strategies that keep us well in the first place.

The best principle for channeling new health dollars is value-for-money. This means gathering all available evidence on the benefits and costs of each service and prioritizing accordingly. Measuring cost-effectiveness can be difficult.  We do not always have complete information and it takes expertise to pool results from different studies. This can be overcome by centralizing these assessments nationally and linking federal funding recommendations to which provinces can respond.

More difficult are the politics of implementing value-for-money policies. No politician will win votes by funding even the most cost-effective services like public health if the people who benefit don’t know it. They are also not helped by the Canada Health Act which petrified priority for hospital and physician services instead of creating an automatic process for updating priorities as needs change, values evolve, evidence develops and cost-effectiveness becomes clear. As a result, the hospital and physician winners of today’s underperforming system have also understandably created the most powerful lobbies.

All health ministers and Canadians would benefit from institutionalizing in the Health Accord a binding commitment to spending smarter. Status-quo champions would find their influence diminished when health ministers can argue that unpopular value-for-money decisions are about spending tax dollars wisely.

Related: Toward a True Health Accord.

To get there, health ministers also need to negotiate wiser. Next week’s meeting need only have three results. First, a commitment to spending new federal health dollars on the most cost-effective initiatives. Second, a mandate for officials to begin work on a mechanism for identifying, constantly updating and adapting those initiatives for the unique context faced by each government. And third, a detailed plan for delivering a final Health Accord including a target date for a First Ministers conference.

In this way, the new Health Accord will not only commit governments to principles and processes worthy of celebration, but also to a plan for kick-starting a more sophisticated partnership that reflects our federation in which all fourteen governments share constitutional jurisdiction over health.

The political conditions are right for getting such an ambitious agreement and setting this new collaborative tone. Canadians overwhelmingly support health reform, provinces have an appetite for change, federal politicians are willing leaders and the risk of silly partisan disagreements is low. There is also growing understanding that the status quo is unacceptable and that we can do better.

Negotiating this new Health Accord could end up being the most significant achievement of the recently elected federal government. It could be Trudeau’s Obamacare. But all governments will collectively be judged for the Accord’s success or failure.

Steven HoffmanSteven J. Hoffman (@shoffmania) is a member of the University of Ottawa’s Centre for Health Law, Policy and Ethics and an Associate Professor of Law and Director of the Global Strategy Lab at the University of Ottawa and an Adjunct Associate Professor of Global Health & Population at Harvard University.

 

 

 

Patrick FafardPatrick Fafard (@pcfafard) is a member of the University of Ottawa’s Centre for Health Law, Policy and Ethics and a former senior government executive and Associate Professor of Public & International Affairs at the University of Ottawa.

Toward a True Health Accord

January 25, 2016 10:46 am
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This week Canada’s Minister of Health, Dr. Jane Philpott, will meet with her provincial and territorial counterparts in Vancouver. This is no ordinary get-together. In his letter to the Minister, Prime Minister Trudeau tasked Philpott with “engaging provinces and territories in the development of a new, multi-year Health Accord with long-term funding agreement.” This is a distinct change in tone; the previous federal government had refused to meet with provinces to negotiate a new agreement after the accord ran out in 2014.

The top-down approach by the Harper government was greeted with two distinct reactions. There were those that saw the cancellation of the Health Accord as a step backward that would further reduce the federal portion of funding for health care, offloading costs to the provinces.  Others criticized the past accord, billed as “a fix for a generation,” because it didn’t buy the intended change. While progress was made on wait times for certain services, other innovations in home care, primary care, prevention and health promotion, and the development of a national pharmaceutical strategy were not achieved in any meaningful way, with most of the increased funding getting absorbed into regular health budgets.

Both of these perspectives hold merit.

There is a strong case to be made for a return to the original 50/50 funding arrangement, which is one of the key reasons the provinces signed on to Medicare in the first place and has steadily been eroded in the decades since. There is also a fair criticism that increased funding should have been used more deliberately to attempt to achieve the intended change. An increase in private and public health spending in Canada from $124 billion in 2003 to $207 billion in 2012 bought little in the way of meaningful change in system performance or health outcomes for Canadians.

So as the health ministers meet in Vancouver, how can they bend the curve toward a less costly and more effective health care system? How can they ensure the funds invested this time around will buy real improvements in health?

Some of the directions for this can be found in the Prime Minister’s mandate letter to the Minister of Health, which included an exhortation to “support the delivery of more and better home care services.” Investment in quality home care has been shown to improve patient experience while easing pressure on acute and long-term facilities.

The letter also encouraged Minister Philpott to “encourage the adoption of new digital health technology.”  If done right, electronic medical and health records can greatly expand our ability to effectively treat individuals and the population.

A third major element described in the mandate letter was a call to “improve access to necessary prescription medications” by “joining with provincial and territorial governments to buy drugs in bulk,” and “exploring the need for a national formulary.” This falls short of a national pharmacare program, but does not close the door to the possibility.

Related: A New Health Accord Needs to Include Better Planning

Canada is the only nation with a universal health care system that doesn’t include drug coverage; one in five Canadians reports being unable to afford to take necessary medications as prescribed. A national pharmacare program would eliminate that problem while saving Canadians approximately $6 billion per year in excess costs. Half measures in this area will not achieve the desired savings or accessibility.

The directives from Trudeau to Philpott are helpful, but there are two key ingredients missing. The first is that the flow of health care funds needs to be connected to clearly articulated goals. Indiscriminately increasing fund transfers with no accountability for how they will be used is a recipe for continually increasing costs without improving the quality and accessibility of care.

The second is that all levels of government need to move toward a Health in All Policies approach that understands all areas of government – policies affecting income, education, housing, food security, for example – impact health outcomes. Health care is the greatest cost driver in provincial governments, but it isn’t the area in which spending has the greatest impact on health – and it’s not where those costs can best be controlled.

The decisions emerging from this upcoming summit could change the landscape of health care policy in Canada. We can only hope that Dr. Philpott will be practicing “medicine on a larger scale,” looking first and foremost to improve the health and well-being of Canadians.

Meili_Ryan_high resRyan Meili is a family physician in Saskatoon, vice-chair of Canadian Doctors for Medicare, an expert with EvidenceNetwork.ca and founder of Upstream: Institute for A Healthy Society.

Ottawa Expertise on Display In Kazakhstan/Central Asia

January 21, 2016 2:59 pm
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Downtown Astana, photo by Ken and Nyetta.

Kazakhstan is a country on the move.

Kazaks are the ancestors of the great Genghis Khan. Today, their diverse multicultural society, with its historical tribes, numerous languages and religions and their international outlook in global affairs has made it one of the most compelling countries to watch in Central Asia.

Economic growth in Kazakhstan is led almost exclusively by the coal, iron, gold and copper sectors. It is the world’s largest supplier of uranium. It has the second largest uranium,  chromium, lead, and zinc reserves, the third largest manganese deposits and one of the world’s largest copper reserves. It is a significant diamonds exporter and has one of the world’s largest reserves of petroleum and natural gas. The giant Kashagan field in the Caspian Sea has made Kazakhstan one of the world’s top oil exporters. The past decade has also seen exponential growth in its banking and financial services sector. The country is on a roll but none of this came easy. After the dissolution of the USSR in 1991, Kazakhstan experienced a difficult transition from a planned to a market economy. One of the key problems was dealing with the consequences of the fallout of 456 Soviet nuclear weapons tests held in northern Kazakhstan between the 1950’s and late 1980’s covering a geographic area larger than France. Over 1.5 million Kazakhs still suffer radiation-related illness from those tests today. Under the leadership of its first (and only) President, Nursultan Nazarbayev, Kazakhstan voluntarily rid itself of all nuclear weapons and signed the Nuclear Non-Proliferation and the Comprehensive Test Ban treaties. Nazarbayev then launched Project ATOM (Abolish Testing is our Mission) to promote nuclear disarmament and end nuclear testing resulting in the passing of the Declaration on a Nuclear-Weapon-Free World at the UN General Assembly. These efforts were supported by Canada.

Nazarbayev also devised an economic plan for the newly emerged country. A slow but gradual recovery began in the early 2000s, followed by a rise in Kazakhstan’s total trade in the second half of that decade, when it became one of the world’s top grain exporters and its mining economy started moving into overdrive. As a result, the Kazak people have seen their standard of living, incomes and quality of life improve dramatically. Nazarbayev’s free market economic reforms have made Kazakhstan Central Asia’s strongest and wealthiest economy and its capital, Astana, has become one of the most important financial centres in Central Asia.

In his sunset years, Nazarbayev is now working to secure the future for Kazakhstan and protect his legacy with Constitutional changes that embrace democratic governance models and the rule of law, all overseen by the country’s freely elected bicameral Parliament.

Some of the wealth and profits generated from Kazakhstan’s diverse economy have gone to underwrite the wonderfully extravagant capital of Astana. This city is like Dubai on steroids. To see it is to believe it. Astana has an energetic vibe and boasts an impressive skyline of buildings, ministries, museums, malls and boulevards that scream 21st century. Kazak citizens are young, educated, professional, multi- ethnic and busy. Very busy. They are true internationalists and whether it’s in the private or public sector they look to other countries to gain knowledge about how to best develop their own governance and business models. Canadian diplomats and NGO institutions from the Ottawa area are playing an important and active role in this effort.

On December 9th the Canadian Centre for International Governance Innovation (CIGI) organized the inaugural Central Asia Security Innovation in Astana in cooperation with the Kazakhstan Ministry of Foreign Affairs and the five Central Asian states (Kazakhstan, Kyrgyzstan Republic, Uzbekistan, Turkmenistan and Tajikistan) to discuss security governance challenges in five major key areas: anti-terrorism, border management, human and drug trafficking, energy and nuclear security, and transboundary water management. CIGI policy experts were on hand to provide a Canadian perspective these matters.

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Participants from CIGI, Canadian Embassy and Central Asian States at the Central Asia Security Innovation Conference in Astana Dec. 9.

The tone was set at the outset of the conference by Shawn Steil, Canada’s Ambassador to Kazakhstan, the Kyrgyz Republic and Tajikistan and Ottawa based Margaret Skok, Senior Fellow, CIGI and a former Canadian Ambassador who both observed that there was an absence of region-wide cooperation between Kazakhstan and its smaller neighbouring countries. Skok suggested these five countries work on setting aside their various enmities and try to work on a multilateral relationship that could provide them with a collective influence as a Central Asian bloc. Steil said it was his experience that “lots of dialogue, conversation and programs are the key things that build trust between states.” He also said this was easier said than done, noting that “Kazakhstan must balance the competing interests between its geographical neighbours, Russia and China, against its determination to maintain its own hard won independent foreign policy and economic relationships with the European Union, the United States and Canada.” Steil and Skok suggested Kazakhstan and the other Central Asian republics – Turkmenistan, Tajikistan, Uzbekistan and Kyrgyzstan – have a vested interest in closer regional co-operation.

Stockwell Day, Canada’s former Minister of International Trade and former Minister of Public Safety, said that the Central Asian states should work together and share information wherever possible on mutual security matters, on technical matters and on health issues. Day noted that the United States-Canada relationship was “a friendship based on respect and the ability to link arms and work together on issues and share information in areas of mutual concern in security, trade technical matters, health issues and even military.” He said that cooperation and preparation are the things that can get countries “through moments that could otherwise be disastrous” and noted that “Canada had learned from disasters within its borders and among its neighbours.”

A common theme raised by the five central Asian countries was the issue of how to prevent Central Asian citizens from joining international terrorist groups like ISIL and then returning home to cause havoc. Former Canadian Deputy Minister of Foreign Affairs and former CSIS Director Reid Morden responded to these security issues with a recommendation that Central Asian governments consider coordinating their intelligence efforts. Reid said that “intelligence today comes from across all areas whether its transportation, health, immigration, export, trade or other areas, but intelligence gathering must be based in law through an act of Parliament.” When asked about the guidelines and rules related to the collection of intelligence, Reid said that “while intrusiveness is allowed, it must be governed by the proper oversight and that there must always be a balance between security needs and the inherent rights of citizens.”

Ambassador Steil said that better communication between Central Asian states was the first step in moving forward to form a “Central Asian bloc” and that region-wide cooperation in a variety of areas including trade, border controls and the harmonization of customs regulations were good starting points. CIGI invitee and Former Ambassador of the United States to Kazakhstan (2009–2011) and Tajikistan (2003–2006) Richard Hoagland said that the kind of cooperation that could drive Central Asian prosperity would be stunted unless there was an end to “endemic and sometimes government-sanctioned” corruption. He said that the Central Asian states themselves need to understand that it is in their interest to fight corruption for their own international reputation and credibility.

Colin Robertson, a trade expert, former Canadian diplomat, CIGI fellow and Vice President of the Canadian Global Affairs Institute stressed the importance of these Central Asian nations to develop a professional civil service. He said that those involved in the military, policing and border security should be “well educated, well trained and have a high esprit de corps because these are traits that help protect countries from corruption practices.” He added that “border enforcement is important but so is trade, and it is important to expedite goods at the border and keep them moving.” Robertson said that the Central Asian countries should not see cooperating and the sharing of information as something that weakens their country, but as a strength. He noted “that sharing info builds trust and that the Central Asian countries should share info on infrastructure, roads, and pipelines.” Robertson provided numerous examples of cooperation between the American and Canadian governments in trade, commerce and border issues. He said that Canada and the United States understand the importance of dialogue and communication on many issues but they also understand that on other issues “good fences make good neighbours.” Attendees to the conference  included representatives from key ministries in Kazakhstan and the four other Central Asian governments and a large group of Central Asian university students. Two graduate students told Ottawa Life Magazine that they were impressed with the views of the Canadian participants. One said he was very impressed by the way Reid Morton explained the requirement in democracies to balance security needs with citizens’ rights and a female student said she thought Ottawa’s Margaret Skok was an outstanding moderator who “got Kazakhstan” and really seemed to understand Central Asian issues.

Moving Forward on Health Care Reform

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Why more money for health care is not the answer

In the Speech from the Throne and since, the new Liberal government has clearly said it is ready to re-engage with the provinces and territories on health care. This is a welcome development. For most of the past decade, the Harper government was distinctly unwilling to provide any leadership or even play a secondary role in health care reform.

The fact that the new Trudeau Liberal government is ready to work with the provinces and do so quickly is a big step forward.  But the prospect has likely raised many expectations of what new arrangements might emerge.

First, many players will be looking for more money to flow from Ottawa to the provinces. But the Harper government, even as it withdrew from active participation, committed to adequate transfers to the provinces until 2024. There may be legitimate debates about the distribution of those transfers across the provinces, and there may be some new funding called for to support new initiatives in areas such as pharmacare or mental health, but the federal money now on the table in support of the range of health care services is more or less adequate.

The health care problems we face are not the result of insufficient spending. In fact, more money may be counterproductive.

The primary focus of any new accord needs to be on the structure of the federal-provincial arrangements. The most commonly visualized instrument seems to be a return to something like the Health Accords of 2003 and 2004. Indeed, the Minister of Health referred to a promised re-engagement in these terms. What these Accords did was to identify a number of problem areas — most notably, wait times — where provinces pledged remedial actions to remedy them and Ottawa committed to increasing cash transfers to be used at the discretion of provincial governments.  

The expression at the time was that the cash transfers would “buy change” necessary in the health care system. But the link between the provincial actions and the federal money was tenuous at best in 2003 — and all but absent in 2004.

So while the Accords did initiate significant flows of new money to the provinces and territories, they were not successful in spurring necessary health system reforms. They were not sufficiently specific to generate sustained efforts or sustainable change.

In fact, the extra money Ottawa provided probably did more to hinder health reform across the country than promote it. Rather than “buying change,” the extra money bought peace and serenity (at least temporarily).  Throwing additional money at problems was a lot easier than tackling structural change.

The Accords were weak because to some extent the provinces and territories have different needs and priorities.  To reach consensus on a single agreement it was necessary to be vague and general in terms of what each province and territory would do by way of reform.

A better alternative going forward might be to more directly address particular regional concerns with a distinct contract between Ottawa and each province rather than a single accord.

For a model for this we could look to the Paul Martin Liberal government’s arrangement for funding in two other areas. The first was the transfer of gas tax revenue to municipalities via the provinces for infrastructure investments. Ottawa signed one-to-one agreements with every province and territory. While the broad goals and structures were the same across all provinces, the individual contracts included variations that permitted some provinces to pursue regional goals within the national framework. A significant amount of much needed municipal infrastructure investment resulted from these agreements, and continues today.

The same general model was used by the Martin government to conclude childcare agreements with the provinces, but before they could be implemented the Harper government was elected and chose not to proceed.

This model of federal-provincial fiscal arrangements can more effectively promote health care renewal and should be considered by Minister Philpott going forward.

A set of pharmacare agreements might be concluded that would create nationally universal and portable coverage while recognizing that provinces are starting from different positions and may have different specific needs and administrative arrangements in mind. Other issues such as home care and long-term care facilities might be addressed at the same time or in a separate set of contracts.

The federal government would retain the capacity to represent national goals and interests, and the provincial governments would have flexibility to pursue their respective regional objectives within the national framework.

A stronger link between national objectives and each province’s priorities offers a better chance of sustainable health care reform.  

Maslove_alanAllan M. Maslove is an expert advisor with EvidenceNetwork.ca and a Distinguished Research Professor, School of Public Policy & Administration, Carleton University.

Why it’s time for a National Autism Strategy

January 20, 2016 11:55 am
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Over a year ago, I was invited to celebrate World Autism Awareness Day on Parliament Hill.  It was attended by a dozen or more Senators from both major parties, political staffers and invited guests mostly from autism non-profit organizations.  I expected a predictable ‘feel good’ event about how far we’ve come and how far we have still to go.

But an hour later there weren’t many dry eyes in the chamber.  

It turns out, many of the politicians who decided to join the event that day had personal experiences with autism.  One Senator spoke at length of his daughter who struggles to get adequate services for his grandchild with autism, and how challenging it has been – economically, physically and emotionally — for the whole family.  He cried openly.

Another Senator spoke of a family she knows that is struggling with long wait times for essential services, such as speech or behavioural therapy.  More than one participant spoke of the difficult choice families have made to uproot and move across the country to Alberta or British Columbia where autism services are often more readily available and flexible, particularly if a family happens to have more than one child on the autism spectrum.  

Others spoke of the economic burden of pursuing private therapies – funded out of pocket (my own experience), often in the tens of thousands of dollars per year.  Many have to refinance homes or sell them altogether just to get their child with autism the basic supports they need to learn and thrive.

What became clear that day is something I’ve heard autism champion, Senator Jim Munson say before: autism doesn’t affect Liberals or Conservatives or NDPers. It’s an equal opportunity neurodevelopmental disorder that affects Canadians across the political spectrum and clear across the country.  

What was also clear that day – and from a number of reports since — is that autism families in Canada are struggling, diagnosed cases of autism are on the rise, and most provinces are not able to keep up with necessary services.

According to a recent survey from the Canadian Autism Spectrum Disorders Alliance (CASDA), almost three quarters of parents of preschoolers in Canada with autism wanted, but did not receive, early intensive behavioural intervention (IBI) for their child — one of few interventions for autism with solid peer reviewed evidence.  

A similarly troubling report, released last month from the Ontario Auditor General, reveals that in some jurisdictions in the province, there are more children waiting for autism services than receiving them, with more than 16,000 children on wait lists that continue to balloon.  

It’s not an exaggeration to say we have an autism services crisis in Canada.  So what can be done?  Plenty.  

Evidence shows proper health and educational supports for those affected by autism pay off.  Early intervention heads off more expensive and extensive supports that are needed later in life if it is not provided.  It makes economic sense, in other words, to provide autism services early.

Kids with autism are not lost causes, they are full of potential.  We are failing them.

The last federal government made a good start establishing an Autism Spectrum Disorder Working Group to bring together those working on the issues across the country to discuss key concerns and share best practices.  But much more federal support is required to make things better – now — for Canadian families.

For starters, the new Liberal government could dust off the excellent cross-party Senate report – aptly titled – Pay Now or Pay Later: Autism Families in Crisis from 2007 and get to work.  It’s number one recommendation? A comprehensive national autism strategy.  

We’ve waited almost a decade.  Now is the time for the federal government to bring together the brightest minds in the country on the issue and enact a federal strategy to give our kids with autism the services they need to survive and thrive in communities across the country.
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Kathleen O’Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University, Managing Editor of EvidenceNetwork.ca and mother of two sons, one with autism.

Five Ways We Can Reduce Suicides in Canada

January 19, 2016 11:51 am
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Why a suicide prevention strategy needs to include injury prevention

Despite recent headlines, Canadian rates of suicide and attempted suicide have remained largely unchanged over the last several decades (11 per 100,000).  What has changed is that we’ve seen increasing rates of suicide in the Canadian military recently, after stable rates for decades.

With over 40,000 Canadian soldiers deployed to the mission in Afghanistan, there has been an understandable concern about mental health problems and suicides among military personnel and veterans. Both the Minister of Defense and Minister of Veterans Affairs have rightly made suicide prevention a top priority.  

The problem of suicide is not limited to the military in Canada; indigenous populations, especially in northern remote communities, have high rates of suicide.  

We need a unified approach across provincial and federal sectors to reduce suicides in the military, among veterans and civilians.  Here are five promising evidence-based strategies for suicide prevention.

1) Implement a National Deliberate Self-Harm Registry

The single most important predictor of future suicide attempts is a history of previous self-harm behavior.  It is important to develop a confidential, administrative national registry of people with self-harm behavior, similar to the national registry created in Ireland, in order to record accurate data and to target and measure our evidence-based approaches to reduce the risk of future attempts.

2) Invest in anti-suicidal psychological treatment

For patients presenting with suicide attempts, current practices and programs focus on treating the underlying mental health problem and/or addiction. Recent work is challenging this practice by showing that there is also a need for psychological interventions that directly address suicidal behavior. Two such treatments have shown to reduce suicide attempts among people with a history of self-harm behavior – cognitive behavior therapy and dialectical behavior therapy.

Both types of therapy focus on understanding the causes of suicidal thoughts, improving coping skills in managing distressing emotions and developing careful plans to reduce future attempts.  Strong investments nationally are required to increase the availability of these therapies for people with a history of self-harm behavior.

3) Reducing access to lethal means

This approach has the greatest evidence for suicide prevention worldwide. Suicide can often be an impulsive act. Access to firearms is a risk factor for suicide and is a factor in half of the completed suicides in the United States.

In the Swiss military, when access to guns was reduced, almost 80 percent of people were deterred from suicide. Although firearm related deaths are less common in Canada, 20 percent of male suicides in Canada are related to firearms.

In the UK, limiting pack sizes of Tylenol per bottle was also shown to reduce suicide.  In Canada, prescription medications, especially opioids, anti-anxiety and anti-depressant medications are common causes of both intentional and unintentional deaths.  Limiting access to large quantities of prescription and over-the-counter medications for people with a history of self-harm may reduce suicides and accidental deaths.

4) Accidental deaths and undetermined deaths need to be tracked with suicide deaths

Accidental or undetermined deaths look like suicides. We know that suicide rates around the world are widely underestimated, perhaps by as much as 30 per cent or more. This is because it is often difficult to determine the nature of the death, and specifically whether it is definitively a suicide or an accident. Often, the case can be unclear, and the coroner classifies the death as undetermined.

There is evidence to indicate that some mechanisms of suicide are more likely to lead to the undetermined classification. In fact, in the UK, injury deaths of undetermined intent are routinely included in their suicide statistics for this reason.

5) Suicide prevention strategy should include injury prevention

We have learned that individuals dying by either suicide or by accident share many similar risk factors including male sex, younger age, being unmarried, lower education and income, impulsivity, mental health problems and addictions.

Generally speaking, prevention efforts for accidental injuries and suicide are distinct. But given the shared vulnerability of these populations along with the finding that many of the accidental or undetermined deaths may in fact be misclassified suicide deaths, a more broad approach to suicide prevention must include injury prevention.

If we really want to change the rates of suicide in Canada, we need to look at areas of medicine that have been successful in reducing mortality.  For example, HIV disease prevention and cancer prevention have created national registries and invested heavily in innovative prevention programs that specifically target these deadly diseases.  We need a concerted national effort that uses evidence-based strategies to specifically target suicidal behavior.

Sareen_Jitender_High resJitender Sareen is an expert advisor with EvidenceNetwork.ca, professor of psychiatry at the University of Manitoba and team leader of the Manitoba Population Mental Health Research Group.

 

 

 

KATZ_Cara high res photoCara Katz is a junior researcher with the Manitoba Population Mental Health Research Group and a Psychiatry resident at the University of Manitoba

What Should be Covered by our Publicly Funded Healthcare System?

January 15, 2016 9:44 am
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Patients and doctors need to learn the difference between ‘need’ and ‘want.’

All across Canada provincial governments are grappling with ever growing healthcare demands in the face of shrinking resources.  Our enviable publicly funded health system is now well into a downward spiral of unenviable disrepair.  As patients are becoming more knowledgeable about their own care, and as doctors develop a wider array of options available to treat diseases, the costs are increasing.

The truth is, we can’t have it all.  Both the physicians who deliver care and the patients who receive it need to start considering the concept of limited resources in our publicly funded healthcare system.    

One of the main tenets of the Canada Health Act is that medically necessary care should be insured by public funds and that all related hospital or physician care should be paid for by the public system.  This is the soul of the cherished notion of “free” healthcare that most Canadians hold so dearly.  

But the tricky thing is that the Canada Health Act does not actually define what constitutes “medically necessary care.”  This is left up to the individual health providers to determine, on a case-by-case basis.  

At first glance it might seem easy to distinguish “medically necessary” care from optional care.  If a patient is sick, then the treatment needed to fix the problem is intuitively considered necessary – the idea being that medical needs dictate what will be provided by the public system.

And in some circumstances, determining what is “medically necessary” is easy.  Both patients and doctors could likely agree that if you have cancer, it needs medical treatment.  If you have fractures from a car accident, they need to be fixed.  

Likewise there are many other examples that most of us could agree fall into ‘optional’ care, such as laser eye surgery to remove the need for glasses or cosmetic facial surgery – wants, not needs, that don’t merit public funding.  

In between these examples, though, is a wide gray area where distinguishing need from want is not nearly so clear.  Is fixing an annoying nasal blockage a need or a want?  Is getting arthroscopy for a sore knee a need or a want?  How about a patient who wants blood tests that aren’t medically indicated, but they are just curious?

Non-essential care is by no means limited to patient demand.  There also exists a vast array of low-quality or low-impact health interventions initiated by doctors – and publicly funded.  Many of these interventions are not supported by evidence. That blood test or chest x-ray your physician ordered for you before your elective operation?  Very possibly unnecessary.  The CT scan you had for pain in your lower back? The evidence says it will not improve your outcomes.  The antibiotics you were prescribed for a persistent virus? Unnecessary and they won’t work anyway.  

Tests and treatments like these examples, and others, are not medically necessary and they are also costly to the struggling healthcare system.  In fact, unnecessary tests can expose patients to harm because of false-positive rates.  The “Choosing Wisely Canada” initiative spearheaded by the Canadian Medical Association is just beginning to explore the massive scope of unnecessary care and the impact it has on patients and the health system.

Are doctors too often offering to use public funds to investigate or treat problems that are wants versus needs and not actually medically necessary?  Are patients losing sight of the fact that no province has the funds to provide all care for all people all the time?

Our contemporary free-for-all style of healthcare, a challenge on both sides of the medical consultation room, is totally unsustainable on the public purse.

Doctors need to start openly and directly considering the concept of medical necessity when talking with patients about tests or procedures.  Patients, in turn, need to keep in mind that their healthcare is not “free,” and that many of their health-related complaints likely represent wants, rather than needs.  

Working together we can salvage what is left of public healthcare in this country, but only if both groups promptly adopt a more realistic attitude toward medical necessity.  
Rotenberg_Brian_headshotBrian Rotenberg is an expert advisor with EvidenceNetwork.ca and an Associate Professor in the Department of Otolaryngology – Head & Neck Surgery at Western University, London, Ontario.

Why Ontario Needs to do More About Doctors who Abuse Patients

January 14, 2016 11:12 am
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Reforms by Ontario College of Physicians and Surgeons are a step in the right direction, but not enough.

Ontario’s College of Physicians and Surgeons receives numerous deeply concerning reports of doctors sexually abusing their patients each year despite the adoption of a “zero tolerance” approach to such abuse 20 years ago. This persistent problem has eroded public trust in doctor self-regulation. But now both the College and the province are poised to make long-overdue improvements in this area. The College recently proposed several reforms, while the government has appointed a task force to examine patient abuse.  It’s a good start, but more needs to be done.

Under the current approach, doctors often continue treating patients (subject to restrictions) while the disciplinary process drags out over several years. For example, Dr. Tariq Iqbal, who was the subject of four unrelated complaints of inappropriate pelvic and rectal exams in 2011, did not receive practice restrictions until 2014 or his final penalty (which he is appealing) until October 2015.

These delays may put additional patients at risk, particularly if the College does not adequately monitor compliance with restrictions. For example, pediatrician Dr. Eleazar Noreiga’s license was restricted after he sexually abused a patient in 2003. He was then subject to additional discipline in 2013 for flagrantly breaching restrictions that he only treat female patients with a chaperone and that he post a notice to patients. Even after other abused patients came forward, the College Discipline Committee commented that their penalty was not a “professional death sentence,” citing Dr. Noreiga’s ability to apply for reinstatement of his license.

An important concern with the current regime is that the “zero tolerance” approach only applies to the most egregious conduct. When the behaviour falls short of the requirements for mandatory revocation of license, the College has the discretion to order various penalties including reprimand, restrictions, temporary suspension or revocation of license. The College is often criticized for its lax approach to penalties in these discretionary cases. For example, only eight months after putting his mouth on a female patient’s breast, family doctor, Dr. Sastri Maharajh was permitted to resume treating male patients.

The College recently proposed the mandatory revocation of a medical license for any “sexual contact” with a patient and the discretion to order immediate revocation after a finding of misconduct, without waiting months for a penalty hearing. This has been a long time coming, but even if the government amended legislation to adopt these important changes, several gaps would remain.

First, there would be concerns with the adequacy of penalties for conduct falling short of “sexual contact.” Second, doctors subject to practice restrictions may continue to put patients at risk if the College does not properly monitor these restrictions. It is also unclear whether doctors who have displayed the poor judgement necessary to engage in sexual contact with patients have the requisite judgement to carry on professional relationships with any patients, regardless of gender.

Another concern with the current model relates to the patient’s role in the disciplinary process. The College has proposed allowing victim impact statements and enhanced privacy of witness’ medical records during the disciplinary process. Again, a good start.  However, these piecemeal changes fall short of meaningfully empowering patients.

During the disciplinary process, doctors are backed by their formidable defense organization, the Canadian Medical Protective Association, which is notorious for zealously defending its members. Taxpayers controversially bear the bulk of the nearly $200 million per year in defence costs to defend doctors against malpractice, professional discipline and even criminal charges.

Conversely, patients receive no publicly-funded representation during the disciplinary process and are treated as witnesses rather than parties to these hearings.

Although the College’s proposals represent important progress, there is more to be done. Regulatory changes must come from government, including expanding the “zero tolerance” approach and empowering the College to revoke a license without waiting for a penalty hearing. By enshrining these changes in the Regulated Health Professions Act, patients would be protected not only from abuse by physicians but the myriad of other regulated health professions in Ontario.

Provinces must also push for greater accountability of the Canadian Medical Protective Association, given the share of physician defence costs borne by taxpayers.

More broadly, regulatory bodies and the medical profession as a whole must train young doctors to respect appropriate boundaries with patients and create an environment where doctors can speak out about the inappropriate conduct of colleagues.

Lorian HardcastleLorian Hardcastle is the Associate Director of the Centre for Health Law, Policy and Ethics and an Assistant Professor in the Faculty of Law at the University of Ottawa

Putting children’s health and resiliency on the national agenda

January 12, 2016 1:48 pm
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By Chris Harper

Last year, at a camp in southern New Brunswick, I met Evan. Before turning eight, he had bounced from foster home to foster home. He was sent to camp without a bathing suit or sufficient lunch. Regardless, Evan smiled constantly, excelled in school and had a striking sense of compassion. I still think about Evan all the time – what allowed him to thrive in spite of the cards he had been dealt?

Aaron Antonovsky was a medical sociologist with a similar curiosity. He worked with women who had undergone severe hardship in the past, many of whom survived the Holocaust. He found that some suffered more profoundly while others were more perseverant. He spent his life trying to figure out why. As a medical student, I learn plenty about complex management of disease once it’s started – but rarely do we learn about what keeps people well in the first place. What contributed to those women’s ability to overcome physical and psychological trauma? What keeps Evan so resilient?

Antonovsky’s research lead to what he called a “sense of coherence,” a concept just beginning to gain traction outside of academic circles in many countries. He theorizes that it is the most fundamental protective factor against disease. Based on three components, it also provides a valuable framework for how we should approach public policy making in the area of health and wellness in Canada.

First, Antonovsky found that whatever stresses you encounter must be comprehensible. Children, for example, must have the basic understanding that an action will often have a predictable, stable reaction. Imagine how difficult this must be when moving homes constantly or not having one at all. In 2010, 52 percent of single-mother households in Canada with children under six years of age were living in unstable housing. Just last year, by the age of seven, 7.5 per cent of children in Manitoba had been placed in some form of foster care. How can we expect children to comprehend stress when they don’t even have a home base in which to do it?

Secondly, children must have the basic tools to see challenges as inevitable yet manageable. For example, one in six Canadian children have vision problems interfering with their ability to read, yet despite our “universal” healthcare, just 14 per cent receive professional eye care before first grade. I would imagine it’s a lot easier to break the cycle of poverty when you’re able to see the blackboard.

Finally, children must be able to find things meaningful. To thrive, it’s pivotal that children have the opportunity to find satisfaction and a sense of purpose. Sadly, even that isn’t guaranteed.

Jordan River Anderson, a five-year-old aboriginal child with a rare muscular disorder, spent nearly his entire life in hospital while provincial and federal governments fought over who should pay for his at-home care, as responsibility for First Nations’ health services is often shared between jurisdictions. Jordan was denied the opportunity to make meaningful memories outside of his hospital room. This gave birth to Jordan’s Principle, which makes the reasonable request of the department first in touch with the child to cover services in the legal interim.

A strong sense of coherence – the cognitive capacity to see challenges as comprehensible, manageable and meaningful – isn’t just a fluffy sociological construct. It has been tied to evidence: better glycemic control in Type 1 diabetics and faster return-to-work following musculoskeletal injuries. In Scandinavian countries, it was found to predict the need for social assistance and unemployment benefits later in life.

Such findings present major opportunities for rethinking public policy from an “upstream” perspective – creating the foundation for good health in the first place – and pay off with a more effective use of public funding in the process. In other words, the “social determinants of health” – the multitude of non-medical factors like adequate income, stable employment and quality education that impact health – need critical attention.

So what do our policy makers and politicians need to do in real terms?

Build an effective national housing strategy so kids have a place to call home, institute comprehensive pre-school vision screening across the country so classrooms can have their full impact and cut red tape for First Nations children by committing to Jordan’s Principle.

Isn’t it time we put children’s long-term health and wellness on the national agenda?

d03d5a1d-d159-4bb6-b5f5-552b4f8fe4c2Chris Harper is a Contributor with EvidenceNetwork.ca, a medical student at the University of Toronto.

Three Things the Federal Government Can Do to Improve the Registered Disability Savings Plan

January 8, 2016 3:07 pm
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Many of us in the disability community were pleasantly surprised when the Liberal party promised to create a National Disabilities Act that would safeguard disability rights, reduce systemic barriers and establish a foundation of opportunity for those affected by disability.  Canada is an outlier among developed nations for not having one – the U.S. has had theirs for 25 years – so it could not arrive soon enough.  

But the federal Conservative government did make some positive contributions of their own for the disability community during their decade in power – most notably, the Registered Disability Savings Plan (RDSP).  

The RDSP was the brainchild of non-profit organization, PLAN and was championed by the late Finance Minister, Jim Flaherty, who made it a reality in the 2007 budget.  Flaherty had first-hand experience with disability; one of his sons contracted encephalitis as an infant with lasting health consequences.  

The RDSP is Flaherty’s legacy to Canadians with disability and it remains an important and valuable program – at least in theory.  

According to a 2014 study, only about 15 percent of eligible Canadians take part in the program, meaning almost half a million eligible Canadians are losing out. With a wave of teens with autism reaching adulthood in the coming years, helping families affected by disability help themselves has never been more important.     

So what is an RDSP and what needs to be done to make it work better for Canadians?

The RDSP is a savings plan that helps parents and caretakers of those with a disability save for their loved one’s long-term financial future with some financial contributions coming directly from the government – free money, in other words.  

There are two components to the RDSP in addition to personal contributions: a federal grant and a federal bond.  The grant is based on family income and how much a family contributes privately to the RDSP.  It can equal as much as $3,500 in contributions from the government each year.  The bond is based solely on family income (those making less than $43,953) and can be as much as $1,000 in contributions from the government per year.  

Over the lifetime of an RDSP, an individual can receive as much as $70,000 from the federal grant, and if eligible, as much as $20,000 from the federal bond.  

So why are so few using the RDSP?  

In 2014, a cross-party Senate Committee undertook a study to answer this very question.  It’s time our new federal government dusted off the report and put some of the recommendations into action.

Here are three quick ways the federal government can improve the RDSP and help families affected by disability now:

1. Establish an RDSP automatically once an individual is eligible for Revenue Canada’s Disability Tax Credit.  

When I initiated my son’s RDSP, I was required to provide his Disability Tax Credit status, a Social Insurance Number, proof of age and residency in Canada.  It’s a lot of intimidating bureaucratic paperwork that could put off families who may have time, language or educational barriers.  

2.  In the meantime, raise the awareness and understanding of the RDSP program.

I regularly encounter families in the disability community who have never heard of the RDSP program or don’t know how to initiate it.  Others have told me they don’t have the money to start one – unaware they’d be eligible for free government bonds just for opening the account without requiring a penny of savings from them.

The Senate report recommends the federal government should partner directly with advocacy groups to help spread the word. This makes good sense since it’s often the front-line non-profit groups who are directly engaged with disability families and know best how to reach them and could help them with administrative hurdles.  

Another promising model is to have health practitioners work directly with their patients.  Recently, a coalition of healthcare providers, researchers and community agencies based in Ontario and Manitoba have created a Get Your Benefits! Toolkit to help healthcare workers improve the wealth – and thus the health – of their patients by helping them access income and other supports they may be entitled to. 

3. Allow other family members and friends to contribute easily to an existing RDSP

This recommendation isn’t in the Senate report, but it’s one that comes from my own experience and from others I know in the disability community.  If you have a disabled child, ‘extra money’ is not always easy to tuck away.  But birthdays and other special events are an opportunity for loved ones of the child to contribute meaningfully to their future.  

Financial institutions should work with the federal government to find an easier way for those who are not plan holders to contribute to an individual RDSP in small or significant amounts (in theory it is permitted now, but in practice, it is almost impossible in some plans).  It takes a community to raise a child after all.

The RDSP really is an excellent program and needed as much today as when it was created.  The federal government just needs to give it wings to make it fly.

O'Grady_Kathleen-high res (1)Kathleen O’Grady is the Managing Editor of EvidenceNetwork.ca, a Research Associate at the Simone de Beauvoir Institute, Concordia University, Montreal, and the mother of two sons, one with autism.

Ottawa Legal The Big Picture: Ottawa Law Firms are Amongst the Best in the World

11:51 am
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It is the trade of lawyers to question everything, yield nothing, and talk by the hour.
— THOMAS JEFFERSON

From international media coverage of gripping court cases to the dramatic portrayals of lawyers on television and film screens, we love to watch the law. As a city that is home to some of Canada’s most respected law firms and talented lawyers, Ottawa undoubtedly plays a role in generating some of this interest. Hundreds of different types of law firms have set up shop in Ottawa, ranging from long established and internationally renowned firms, to local, new and vibrant boutique practices.


Starting at the top, Ottawa is home to the Supreme Court of Canada. It formally became the court of last resort for criminal appeals in 1933 and for all other appeals in 1949. The court was established first with six judges, and increased by one additional member in 1927. In 1949 the bench reached its current composition, of nine Justices.

The Supreme Court of Canada building was built between 1939 and 1946 from plans by noted Montreal engineer and Art Deco designer Ernest Cormier who included two candelabrum-style fluted metal lamp standards at the entrance, marble walls and floors in the grand interior lobby that contrasted with the châteaustyled roof. In 2000, it was named by the Royal Architectural Institute of Canada as one of the top 500 buildings produced in Canada during the last millennium.

The building also contains two court rooms used by both the Federal Court of Canada and the Federal Court of Appeal. The Canadian court system is pyramidal, with a broad base being formed by the provincial or territorial governments. At the next level are the provinces’ and territories’ superior courts, where judges are appointed by the federal government. Judgments from the superior courts may be appealed to a still higher level, the provincial or territorial courts of  appeal. Several federal courts exist in Ottawa (and across Canada) including: the Tax Court of Canada, the Federal Court, the Federal Court of Appeal, and the Court Martial Appeal Court of Canada. Unlike the provincial superior courts, which exercise inherent or general jurisdiction, the federal courts’ jurisdiction is limited by statute. In all, there are over 1,000 federally appointed judges at various levels across Canada, many from the national capital region.

Each year, the Supreme Court hires 27 recent graduates from across Canada to work as law clerks providing aspiring lawyers with a privileged opportunity to work with Canada’s top legal minds in the nation’s capital.

The Ontario provincial courts and Ottawa courthouse are located the heart of Ottawa at 161 Elgin St. It is not unusual to witness a flurry of media activity around these buildings, as reporters cover high-profile Canadian cases. When political figures find themselves in court, they often turn to Ottawa lawyers to defend them.

Many of Ottawa’s most reputable law firms – Osler’s, Gowlings, Nelligan O’Brien Payne, May & Konyer, and Soloway Wright, are located in close proximity to the courthouse on Elgin street, some of them in heritage buildings, others in modern towers. These firms specialize in a range of areas, from criminal law to business law to estate law. With over 100 law firms dispersed throughout the city, if you need a lawyer, you’re all set.

Ottawa is also a prime destination for law students as we have the largest law school in Canada. The University of Ottawa’s common and civil law programs accept close to 400 students every year. The Supreme Court hires 27 graduates from across Canada to work as law clerks providing aspiring lawyers with a privileged opportunity to work with Canada’s top legal minds.

Ottawa’s legal reputation today is a far cry from our roots as a rowdy, bawdy sawmill and lumber town.

Pre-Confederation, Bytown (as Ottawa was called then), was a scarcely populated lumber town that often erupted with violence and debauchery. Brawling was common. Lt. John By, responsible for the supervision of the construction of the Rideau Canal, was forced to reassign several canal workers to work as street patrollers. However, they had little influence or power. In 1842, fresh out of law school, 18-year-old, John Scott placed an advertisement in Ottawa’s then newspaper, the Bytown Gazette. Scott would later become Bytown’s first official mayor. That same year, Bytown’s first courthouse and jail were built by architect Thomas McKay. In 1841, citizens had voted in favour of the construction of the courthouse and jail, in an effort to reduce violence and crime. Though the original courthouse and jail burnt down, the structure was rebuilt in 1871 and still stands today at the corner of Nicholas St. and Daly St.

As the legal system developed in Bytown, so did the town itself. In 1855, its name changed to Ottawa, and it officially became known as a city. In1857, it was chosen by Queen Victoria to be the capital. By 1867, Canada had officially become a country, and the British North America Act of 1867 called for the creation of a federal Supreme Court. On April 8, 1875, the bill proposing the creation of this court was officially given royal assent, and law firms such as Henderson McVeity, established in Ottawa in 1887, began opening their doors for business in the nation’s capital.

In 1857, it (Ottawa) was chosen by Queen Victoria to be the capital of the provinces of Canada. By 1867, Canada had officially become a country, and the British North America Act of 1867 called for the creation of a federal Supreme Court.

Today, Henderson McVeity is known as Gowling Lafleur Henderson LLP (Gowlings) and is the second largest law firm in Canada with offices in Beijing, Moscow and London. Its Moscow office was one of the first Western law firms on the scene in post-Soviet Russia and the firm sent a young talented lawyer named Monique Couture to lead the charge in what was then the wild west of new Russia. Her work there is still paying dividends for the firm’s reputation today.

There are several Ottawa firms with an international presence. Cassidy Levy Kent’s main offices are located in Ottawa and Washington, Blake Cassels and Graydon has offices in Ottawa, Vancouver, New York, Chicago and London, and Osler has headquarters in both Ottawa and New York City, just to name a few. Osler has been in the business of law since 1862, when Bath Osler began to practice law in Dundas, Ontario (70 km west of Toronto). By the age of 23, Osler had opened two law offices (Dundas and Hamilton) and started his own venture in what would become one of North America’s  first commuter railways. In 1882, Osler moved his practice to Toronto, the provincial capital and at the time Canada’s second most important city for business, after Montreal. Within a decade, the enterprise grew to become one of the top three law firms in Canada and it would eventually set up shop in Ottawa. Almost from the start, the firm’s clients included many of the country’s largest companies and others that would grow to become leaders in key emerging industries including railways, banking and insurance, manufacturing and natural resources. As the firm prospered, it attracted international companies seeking opportunities in Canada. Osler’s has been ahead of the game in promoting women in a sector that was far too long known for having a glass ceiling for women. In 1968, Osler became the first large corporate law firm in Canada to admit a woman as a partner, Bertha Wilson, who went on to become the first female Justice appointed to the Supreme Court of Canada.

Other firms in Ottawa have had similar success while remaining true to their Ottawa roots. Nelligan O’Brien Payne LLP was founded in the capital in 1963 and the mid-sized general practice firm has kept Ottawa as a home base, with an additional presence in Alexandria, Kingston and Vankleek Hill. The firm and its lawyers have an exceptional and decades long record as active participants in the community, and support a wide variety of volunteer and locally based activities including the Terry Fox Run, the United Way campaign, the Ronald McDonald House Ski Day, and various other fundraising activities throughout the year. They also support numerous community events through sponsorships or donations and host the annual Lawyers Play where the musical and dramatic talents of their lawyers are put on display at the Great Canadian Theatre Company.

Nelligan has received an A+ rating from Ottawa’s Better Business Bureau. Real estate and business law firm Soloway Wright, established in Ottawa in 1945, prides itself on being a community-based firm, with locations in both Ottawa and Kingston. The firm is centered on community involvement, and has been recognized for its philanthropic efforts.

Though some of the city’s historical firms have been growing since Confederation-era Canada, others in Ottawa have only just recently opened but are prospering. LaBarge Weinstein LLP, opened in 1997, specializes in knowledge-based and technology companies, while the 20-year-old firm, Sicotte Guilbault LLP, is another growing vibrant general practice firm. From global to local, from old to new, Ottawa’s range of law firms suggests that the national capital region has become a hub for both experienced lawyers and aspiring ones.

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