When governments make a decision that is stupid, embarrassing, overly partisan, or risks causing an outcry, they tend to do so late in the day and late in the week, preferably on the eve of a holiday long weekend, when citizens – and journalists – aren’t paying much attention.

So, late Thursday, the government of Stephen Harper dropped this bombshell, as related in a brief announcement posted on the web site of the National Aboriginal Health Organization: “NAHO funding has been cut by Health Canada. It is with sadness that NAHO will wind down by June 30, 2012.”

This travesty of public policy only came to light because of feisty publications like Windspeaker and Nunatsiaq News.

Founded in 2000, NAHO oversaw many research and outreach programs, in crucial fields such as suicide prevention, tobacco cessation, housing and midwifery. It collected an invaluable series of audio and video interviews with elders recounting traditional tales and knowledge. The group also published the Journal of Aboriginal Health and was home to one of the best collections of aboriginal health research in the world.

There are many political and policy differences among aboriginal groups, but NAHO managed to bring them together at one table, with a common purpose, improving the health of the unhealthiest, most disenfranchised people in the country. It wasn’t always smooth sailing, but it was an achievement in itself.

We are destroying this asset for what reason exactly? To save a few bucks?

NAHO received $4,955,865 from Health Canada last year.

In the world of $25-billion (and counting) fighter jet contracts, that’s a pittance.

And what does it say about the federal government’s priorities?

If you want to trim the Health Canada budget – and the plan is to shed $200-million – then trim some bureaucratic fat at the Tunney’s Pasture headquarters – don’t cut grants to groups that actually do useful things.

If we want to fight a war, why not a war on poverty and health disparity in aboriginal communities?

The abysmal health status of First Nations, Inuit and Métis peoples is Canada’s greatest shame.

Taking an ax to an organization that highlights these health issues – and, better still, pursues solutions – is not going to make these problems go away. It is merely going to sweep them under the carpet, where they have been for far too long.

One cannot help but see this as part of the continuing attack this government has waged on information, particularly information that casts the government in a bad light.

Here’s the kind of information we need to know about the health status of Canada’s 1.2 million aboriginal people, no matter how uncomfortable it makes us:

Life expectancy: Aboriginals can expect to live, on average, a decade less than other Canadians;

Disability: Native people have higher rates of disability and live, on average, about 12 more years with a disability;

Infant mortality: Aboriginal children die at three times the rate of non-aboriginal kids, and are more likely to be born with severe birth defects and debilitating conditions such as fetal alcohol syndrome;

Injuries: Members of First Nations and Inuit communities suffer traumatic injuries at four times the rate of the general population;

Suicide: The rate is six times higher;

Chronic disease: Natives have three times the rate of diabetes; suffer more heart disease and at a younger age;

Infectious disease: Tuberculosis rates are 16 times higher in first nations than in the rest of Canada; HIV-AIDS rates are growing fastest in the native population; medieval water-borne illnesses like dysentery and shigellosis are still commonplace in native communities;

The unemployment and poverty rates are five times those in the non-aboriginal community;

Education: Only 4 per cent of natives have a university education, one-quarter the rate in mainstream society. One-third of aboriginal people do not graduate high school, three times the rate for non-aboriginals;

Housing: More than one-third of First Nations people have, in government jargon, a “core housing need,” meaning their homes do not meet the most basic standard of acceptability;

Infrastructure: Overcrowded houses, lack of running water and inadequate sewage are the norm in many native communities;

Environment: The contaminants that stalk some communities are frightening: Mercury, PCBs, toxaphene and pesticide levels are all higher in the bodies of aboriginals than non-aboriginals.

NAHO’s role is the “advancement and promotion of health and well-being of all First Nations, Inuit and Métis individuals, families and communities.

Clearly, NAHO’s work – “the advancement and promotion of health and well-being of all First Nations, Inuit and Métis individuals, families and communities” – is not done; heck, it has barely begun.

There’s a disturbing pattern here. The government has also cut funding to the Aboriginal Healing Foundation. And the First Nations and Inuit Health branch at Health Canada oversees what is without question the worst health system in Canada, making every effort to slough the responsibility off onto the provinces and territories.

Jack Hicks, an Iqaluit-based suicide researcher summed it up this way: “The Conservatives want out of the aboriginal business.” Who can forget the historic apology proffered by Prime Minister Stephen Harper to survivors of the residential schools? But words are not enough, and a Truth and Reconciliation Commission is not enough.

Concrete actions need to be taken to help the 150,000 Inuit, Métis and First Nations children who were forcibly separated from their families, but action must be taken too in their broader communities, where another million or so aboriginal people, who did not go to residential school, also need help.

The healing process may take generations, true reconciliation even longer. But the ultimate goal must be healthy communities.

Closing the gap will not be easy, or quick. But it starts with small steps, the kind that can be found every day in the contributions of groups like NAHO.

Those footsteps of progress should not be silenced.

< http://www.theglobeandmail.com/life/health/new-health/andre-picard/harpers-disregard-for-aboriginal-health/article2396146/ >

One of the country’s biggest labour contracts – the deal between the Ontario Medical Association and the province that is worth more than $8-billion annually – expires on March 31.

The government of Premier Dalton McGuinty has stated clearly that it wants to freeze spending on physicians for at least two years.

So why no outcry over the prospect of 0, 0? Why aren’t doctors threatening picket lines and calling in sick en masse to press their demands like other labour unions?

There are a few reasons.

The OMA is not your typical union. It is, without a doubt, the single most powerful interest group in the province. It has a cozy relationship with the Ministry of Health (and the government more generally), so it doesn’t need to resort public displays of displeasure.

In its last deal, the OMA did well, squeezing 12.5 per cent in pay increases out of the government over four years – 3, 2, 2 and 4.5 per cent annually from 2008 to 2012.

The method of payment has also changed for many doctors in recent years, so for many, wages increased beyond the negotiated hikes. Ontario doctors were making, on average, $100,000 more in 2010 than in 2005, according to a recent report by the Institute for Clinical Evaluative Sciences. (The average gross pay for Ontario physicians is $335,000, though that varies a lot by specialty and, of course, many doctors have overhead costs.) Negotiators for the doctors know better than anyone that limiting physician costs is a lot easier said than done.

Very few doctors get a set salary that can be frozen. Rather, they can be paid on a fee-for-service basis, or alternative fee arrangements, which can include a mix of fee-for-service (with the fees established in a master agreement), salary (for teaching students, for example), capitation (a set fee per patient) and bonuses for achieving targets.

About 70 per cent of Ontario doctors now receive some level of alternative funding but, over all, 70 per cent of their earnings come from fee-for-service billings. In the recent report of the Commission on the Reform of Ontario’s Public Services, Don Drummond said this equation should be flipped so that doctors receive 30 per cent of their pay via fee-for-service. Otherwise, it’s virtually impossible to control costs. Outside hospitals, there are few restrictions on billing: The more acts doctors carry out, or the more procedures they perform, the more they are paid.

These payments rarely, if ever, go down, individually or collectively. In Ontario, physician costs were $3.7-billion in 1992; today they are $8-billion and counting.

Overall physician costs – which account for about 20 per cent of the provincial health budget – depend on the number of physicians, not just individual payments. Since the last time governments attempted to cut costs due to recessionary pressures (in the early 90s), the numbers of doctors, and payments to same, have risen steadily.

There are 5,000 more doctors in Ontario today than a decade ago – 26,000 in total. Canadian physicians practicing in the U.S. are returning in record numbers. Enrollment in medical schools is at an all-time high. (Upon graduation, every new physician gets a billing number.) Provincial medical associations also play a constant game of one-upmanship, arguing that they need to increase wages or risk losing doctors to other jurisdictions. Ontario’s doctors are now the best paid in the country, according to the recent Drummond report. The OMA has disputed that, arguing that Ontario doctors are actually the 7th best paid in Canada.

Finally, let’s not forget that what we pay doctors is just a small part of physicians’ financial impact on the system. Doctors control access to hospitals, to prescription drugs and to tests. Yet we place virtually no responsibility on them for controlling these enormous costs. As a result, there is virtually no gatekeeper function.

It’s hard to imagine how it will be possible to keep costs contained in those circumstances.

So what is to be done?

You can take some showy measures like capping salaries – for example, forcing doctors to forfeit 25 per cent of the first $50,000 over the cap, 50 per cent of the next $50,000 and so on. Ontario used this approach until 2005 but it was ineffective. The result was docs “capping out” after six or nine months, and then no longer providing services or going to practice in another jurisdiction for part of the year.

You can try revamping the fee schedule but, at 812 pages, that’s a long-term job, and it still doesn’t address the fundamental problem of paying for piecework disconnected from outcomes.

Aiming for a zero increase is actually the wrong starting point because it merely perpetuates the status quo. Restricting spending a couple of years and then doing catch-up increases when the economy improves – as the patterns always goes – resolves nothing.

If we want to get value for money for physicians’ services, we need to ask more basic questions than: “How much should we increase existing pay?”

Health policy analyst Steven Lewis stated the challenge succinctly in a recent essay published by Longwoods.com: “Are we paying doctors to do things, or accomplish goals?”

Right now we pay them to do things in a rather open-ended fashion. The reality is that our health system is almost entirely devoid of goals, even for what are arguably its most important employees: physicians.

If we want healthy citizens – as opposed to citizens who have ready access to sickness care – we need a profound philosophical shift in what we should expect from medical professionals. We need to reward and incent quality, not quantity.

Two weeks before the expiry of a contract is hardly the best time to tackle this sort of fundamental issue, but we can’t put off these big decisions much longer.

The long-term goal in doctor-government talks should not merely be holding the line on costs, but ensuring that we get better value for money and, ultimately, better care.

< http://www.theglobeandmail.com/life/health/new-health/andre-picard/how-do-we-control-physician-costs/article2374017/singlepage/#articlecontent >

“Loneliness is the most terrible poverty.”

– Mother Teresa

There are few things more heartbreaking than a child with no friends.

But being friendless is the norm for Canadian children with physical and developmental disabilities.

A new study, written by Anne Snowdon, a nurse and professor at the Odette School of Business at the University of Windsor in Ontario, shows that 53 per cent of disabled kids have no friends.

Even those with friends have very limited interactions. Outside of formal settings such as the classroom, less than two hours a week spent with their peers is the norm; only 1 per cent of children with disabilities spend an hour a day with friends.

The problem is most serious for boys – who tend to have far more developmental disabilities and fewer social skills – and it gets worse with age. In childhood, efforts are made, but by the time kids hit age 10 or so, when cliques and social circles form outside of parental control, ostracization and isolation is near complete.

In Canada, we talk a good game about integration, about breaking down barriers to allow the inclusion of people with physical and social disabilities in every aspect of daily life. But reality is more stark and harsh.

Real integration requires a lot more than building ramps, adopting human rights legislation and funding programs. Grudging accommodation, with a dash of tokenism, is not enough.

If we want people to be healthy – physically, mentally, emotionally – and to reach their full potential, they need to be full citizens.

Kids with disabilities can’t be segregated and shut out of mainstream society. They need to be like every kid, in school, in swim class, on the bus, in the playground and hanging out at the mall with friends.

That is the underlying theme of the new report, Strengthening Communities for Canadian Children with Disabilities, which Dr. Snowdon presented last week at the annual conference of the Sandbox Project. (Sandbox was founded in 2009 by pediatric surgeon and now MP Kellie Leitch, is designed to spur improvements in the health outcomes of Canadian children in areas such as injury prevention, obesity, mental health, and the environment.) “Children and youth with disabilities and their families need and want to connect and engage with their communities in a meaningful, accessible and accommodating way that enables social interaction and development,” she said.

To conduct the research, Dr. Snowdon and her team conducted in-depth interviews with 166 families in Regina, Fredericton and Toronto, along with some focus groups. All the families had children with physical and developmental disabilities (ranging from Down syndrome to autism). Children with psychiatric disabilities such as bipolar disorder were not included, but one can imagine the issues would be similar.

Above all, the report focuses on the practical. What are the challenges caregivers face and what help is available to them?

Interestingly, the most common complaint was not lack of services but poor communication.

“Finding information on what is available is a big challenge,” said Sally Jordan, a caregiver to her 22-year-old nephew with severe developmental disabilities. In this, the communications age, she relies on word-of-mouth and tips from other parents to find out what services are available.

As far as anyone can tell, there are a plethora of programs for kids with disabilities. But a startling 78 per cent of parents said their children don’t participate regularly in community programs. There are a variety of reasons. Many programs are inaccessible (and that doesn’t mean there are no ramps, it means they are at inconvenient times or in inconvenient places). Transportation is a major problem for children who, because of their disabilities, can’t use public transit. And cost is a big factor, especially as parents of children with life-long disabilities often stop paid work to become caregivers.

In the report, Dr. Snowdon makes three main recommendations:

* Create a single online reference tool that lists all community programs, services and professional care available to people with disabilities.

* Invest in programs where disabled kids are integrated, not segregated, so they can feel part of their community.

* Find ways to expand the social networks of children and teenagers to break the isolation.

Facebook and other social networking tools have been a godsend for disabled kids because they removes barriers – like being judged for the way you look. But being a “virtual” citizen is only a baby step in the right direction, it’s not enough.

Dr. Snowdon said she was surprised to learn from parents and children themselves that isolation was far more painful to live with than physical or development disabilities themselves.

It’s an issue, she said, that really tugs at the heartstrings.

But beyond the emotional response, there are practical consequences. Social interaction is key to quality of life: It’s how we find love, how we find work and how we have fun.

Having a disability does not obviate those needs; if anything, it magnifies them.

Sometimes weneed to stop and reflect on the value of friendship, of a sense of belonging, and the value of community itself to our individual and collective health.

Relationships matter more than fancy programs, but where programs do exist, they should be known and accessible and, above all, foster interaction.

< http://www.theglobeandmail.com/life/health/new-health/andre-picard/dont-shut-disabled-kids-out-of-society/article2319759/ >

Last week, the premiers of all 13 provinces and territories gathered in Victoria. A key item on their agenda was to discuss the future of medicare in light of the federal government’s long-term take-it-or-leave-it health financing deal.

By now the details are well-known: Ottawa will increase the Canada Health Transfer – currently worth $27-billion in cash and $13.6-billion in tax points annually – by 6 per cent per annum until 2016 then tie the increases to economic growth (meaning they will be around 4 per cent a year) for another decade. In the future, Ottawa will dole out the money on a strict per-capita basis, with no adjustments based on the economic status or demographics of the provinces and territories. (There was an equalization formula in earlier deals.)

There will also be no strings attached, meaning the provinces and territories can spend the money as they see fit and that the federal government will no longer try to entice the provinces to tackle common problems like wait times or lack of electronic health records, nor will it use the money to ensure that provincial programs are equitable across the country.

Before the meeting there were dire warnings that drastic cuts to health-care delivery would be necessary in some provinces; others said it could spell the end of medicare as we know it, and so on.

What is certain is that Prime Minister Stephen Harper has fundamentally changed the federal-provincial relationship in the shared jurisdiction of health care, essentially relegating Ottawa to the role of disinterested benefactor of a decentralized system.

“The premiers were unanimous that the federal government’s decision to unilaterally decide funding was unprecedented and unacceptable,” said B.C. Premier Christy Clark.

A crisis requiring firm action indeed.

The premiers huffed about the lack of money Ottawa was offering and they puffed about the feds abdicating their responsibilities. And then they drew in a big breath and mightily declared that … more study was necessary.

Seriously?

By the end of the meeting, having tapped all their collective wisdom, political savvy, economic insight and social policy expertise, the cream of the crop of Canadian politics came up with a hard-hitting response … forming two committees.

Seriously?

Let’s pray there’s some secret plan they’re not telling us about because this is pathetic.

Mr. Harper took the 13 premiers to the woodshed – albeit with a velvet paddle – and their response was a vigorous bout of committee forming?

Mr. Harper is no Chuckles the Clown but he must be laughing himself silly at how easy it was to divide and conquer the provinces and save himself a few tens of billions in transfers in the process.

There was a golden opportunity here for the provinces and territories to say: “We have common interests and, despite Ottawa’s indifference, we’re going to ensure a semblance of a national health-care system remains.”

For example, the premiers could have agreed to a set ofcommon standards for reimbursement of prescription drugs, an area where there are gross disparities between jurisdictions. Creating this kind of national (not federal) program would be immensely popular with Canadians because it would be a de facto expansion of medicare. (Currently there are common standards only for coverage of hospital and physicians services.) The additional cost would be minimal and, with a united front, they could probably shame the federal government into paying for it.

The premiers could have shown leadership on a file that has festered for decades and started the process of dragging medicare into the 21st century.

Instead, we got a boatload of platitudes for public consumption and a new reality in health care where the rich provinces got richer and the poor ones got poorer.

With the fundamental principles underlying medicare – equity and fairness in health-care delivery and funding – crumbling, the premiers are fiddling.

We now have a new working group, chaired by Manitoba Premier Greg Selinger, to examine the federal government’s new funding formula (even though the federal government says it is not open for discussion). We also have a new Health Care Innovation Working Group, composed of all provincial and territorial health ministers and co-chaired by PEI Premier Robert Ghiz and Saskatchewan Premier Brad Wall.

This bold exercise in innovative thinking will focus on only three areas: the scope of practice of health professionals (important but hardly a task for premiers); human resources management (read: Hey guys can we stop stealing doctors and nurses from each other by co-ordinating what we offer them in collective agreements?) and encouraging the development of clinical practice guidelines (another triviality best left to professional associations.) That is work for bureaucrats, not premiers. When the first ministers meet, they should be articulating a vision for the future of medicare, not whimpering like snubbed school children.

We don’t need more studies or committees. Every royal commission, provincial inquiry, independent analysis for the past five decades has come to the same basic conclusions about what we need to do reform medicare:

* Control spending by limiting medicare coverage to essential treatments that work;

* Modernize primary care by moving away from solo physician practices to interdisciplinary teams;

* Create some kind of universal prescription drug plan;

* Shift money from institutional care to home care so we can look after people where they live, in the community and at home;

* Instead of spending obscene amounts of money to marginally extend survival of the terminally ill, invest it in palliative care.

The premiers have six months until their next meeting. In the interim they should be making plans, real plans, for improving medicare – with the money they have (which is about $141-billion in public funds and another $59-billion in private dollars.) There is no magic bullet, least of all more money. The improvement needs to be made, little by little, but that can’t begin to happen until there are specific goals and leadership from the top.

We don’t need more working groups. We need work to begin. Now. Seriously.

< http://www.theglobeandmail.com/life/health/new-health/andre-picard/the-premiers-want-more-health-care-study-seriously/article2312182/singlepage/#articlecontent >

It is often said that Prime Minister Stephen Harper is a brilliant tactician. We saw a striking example of that on Monday when, over lunch, his finance minister presented his provincial counterparts with what was essentially a take-it-or-leave offer on federal health and social transfers.

The gradual levelling off in growth ofhealth transfers is probably the best possible deal the provinces and territories – and Ottawa for that matter – could hope for. At least in base political terms.

But shrewd tactics and political palatability are not the same thing as good public policy. At a time when medicare needs leadership and vision, the new accord continues the lamentable tradition of thoughtlessly shovelling money at the status quo.

Jim Flaherty’s offer was this: Continuing the 6-per-cent annual increase in the Canada Health Transfer and 3-per-cent per annum hike in the Canada Social Transfer until the 2016-17 fiscal year; after that, until at least 2024, increases in the CHT will be tied to economic growth, while the CST will continue at 3 per cent.

Until now, Ottawa has basically refused to negotiate the CHT/CST, so the provincial/territorial finance ministers were gob smacked by the move. A predictable outpouring of rhetorical rage followed.

Still, the deal offered by Mr. Harper’s government is reasonable. It is fiscally responsible, tying spending increases to inflation. It is also politically astute, for a host of reasons:

* It avoids the sordid scene we saw in 2004 when provincial premiers ganged up on prime minister Paul Martin and extorted $41-billion in additional health dollars and a spendthrift 6-per-cent escalator clause on transfers.

* It is a 10-year deal, just as the provinces demanded, allowing some certainty in budgeting.

* It respects Mr. Harper’s election promise to maintain 6-per-cent increases beyond 2014 – at least nominally. (Those who wanted 6 per cent per annum were dreaming in Technicolor.)

* It puts the onus on the provinces to justify why health-care spending should exceed inflation, something they have never been able to do.

* It places no restrictions on how the provinces spend the $40-billion a year they receive in federal health transfers (along with another $20-billion in social transfers for education and welfare programs.)

Ultimately, though, the Canada Health Transfer should not merely be a means of transferring federal dollars to the provinces while sustaining minimal political wounds. It should be an instrument for improving health-care delivery, and in that regard, Mr. Flaherty’s offer fails miserably.

In the proposed deal, funding increases will slow from 6 per cent to 3 per cent, but the approach remains the same: mindless shuffle of money between jurisdictions.

What the public should expect from Ottawa is that federal funds be used to exercise leadership and foster innovation (or to “buy change,” to use an expression that has become hackneyed through rhetorical misuse.) The reason Ottawa transfers money to the provinces in the first place (because health is a provincial responsibility constitutionally) is to ensure some semblance of equity coast-to-coast-to-coast. But there are areas, such as catastrophic drug coverage and homecare, where there are gross regional disparities.

This accord will force the provinces to rein in health spending, which is not a bad thing in itself. But one of the consequences will likely be greater disparities in the quality of care and breadth of coverage between the have and have-not provinces.

The great failure here is not refusing to increase transfers by 6 per cent, it is failing to attach strings to the monies.

Federal dollars should be used to level the playing field, to ensure there is a semblance of a national medicare program. That should be a goal even for a government that, philosophically, believes in decentralization, as the current one does.

With this deal, Mr. Harper has shown himself to be politically astute and fiscally prudent, but he has failed to show a commitment to strengthening health care, and medicare more specifically.

That, ultimately, is what should matter to Canadians.

< http://www.theglobeandmail.com/life/health/new-health/andre-picard/shrewd-tactics-not-the-same-as-good-health-policy/article2277226/ >

When Canada’s health ministers meet this week, one issue will dominate discussions, at the table, in the corridors and in the media: The 2014 Health Accord.

The meeting in Halifax on Thursday and Friday will be the first formal opportunity for Ottawa, the provinces and territories to feel each other out on this crucial financial and political issue.

There will be a lot of posturing, but this must be a priority for the health ministers because the way we finance health care in Canada is going to change profoundly in the next few years. The transfers from Ottawa to the provinces and territories are just one piece of the puzzle, but an important one, especially politically.

Renegotiating the Canada Health Transfer – the mechanism Ottawa uses to transfer health-care dollars to the provinces – is a golden opportunity to send a message: The days of blindly shovelling money into health care are over.

We need targets, we need accountability, we need budgets that are respected. And we need to stop pretending we can keep doing the same old thing and get better results.

The CHT money is significant – $27-billion in cash and $13.6-billion in tax points – and increases six per cent a year. Aside from helping round out provincial/territorial budgets, the money carries symbolic weight.

Constitutionally, health is a provincial responsibility. But the CHT gives Ottawa the moral authority (if not the legal right) to impose conditions on provincial health spending, and to create a semblance of a national system. When medicare began as a national program in 1965, the federal government paid half the tab; today, it covers less than one-quarter of public health spending, so the moral authority is waning.

(The Canada Health Act, the cornerstone of medicare, sets out the five conditions the provinces and territories must meet to receive federal cash: universality, comprehensiveness, portability, accessibility and public administration. The law gives Ottawa the power to claw money back if the provinces violate these provisions. Some of them do, routinely, but there is virtually no enforcement.)

During the spring federal election campaign, Prime Minister Stephen Harper effectively snuffed out debate on health funding by vowing to maintain the 6-per-cent escalator. He did not, however, say for how long, and has played his cards close to the vest since, aside from saying, intriguingly, that the feds will expect more accountability in exchange for the money in the future.

Most interest groups, whether they represent hospitals, physicians, nurses, patients or others, have been saying for years that they want Ottawa to place strict conditions on the CHT as a way of ensuring specific programs are undertaken. This was done in the 2004 health accord with wait times and was moderately successful. The other priorities in the 2004 accord were so vague that little progress was made.

The provinces have largely been saying that they want a repeat of 2004, when they got a 10-year deal with 6-per-cent increase per annum, and virtually no conditions on the money.

No one honestly believes that is going to happen, not at a time when most provinces are vowing to keep increases in health spending below 3 per cent a year, and least of all in the current economic conditions.

But what is the alternative?

One possibility is extending the 2004 deal to 2016 which, not coincidentally, will be time for the next federal election. The provinces, rather than accept much smaller increases in the CHT, could gamble that this will become an election issue. Ottawa could buy time for its larger plan to radically revamp federal transfers to the provinces (including the CHT, CST and equalization.)

A second possibility is negotiating separate deals with each of the provinces and territories rather than one national accord. This fits Mr. Harper’s philosophy of decentralization and could prove attractive to many provinces, who believe they could do better than they do now.

Regardless of the direction negotiations take, the current formula, which is as convoluted as it is complex, is changing.

The CHT amounts to about $1,100 per capita. But the cash portion each province receives varies because of the way equalization payments are calculated.

In 2014, that will change so that cash is distributed on a per capita basis, without accounting for tax points. Practically, this will mean significantly more cash for Alberta and Ontario, and less for B.C. and Quebec.

Another hot issue, especially for the Atlantic provinces, is a desire to adjust the CHT to reflect demographics – namely that health-care delivery is more expensive in provinces with older populations, like those in Eastern Canada.

This approach, known as needs-based funding, is already used by several provinces in calculating transfers to their regions.

These seemingly technical matters will be on the table this week in Halifax, so don’t expect any earth-shattering news, especially because the Senate committee studying the 2004 accord has not yet tabled its report. When it does, we will have a much clearer idea of Ottawa’s tack.

In the meantime, the health ministers jockeying should serve as an important reminder that we have focused too much on the amount Ottawa is transferring to the provinces/territories overall and too little on how the $40-billion-a-year pie will be divvied up.

Regional bickering will make it a lot easier for Ottawa to negotiate a deal (or deals). It’s in Mr. Harper’s interest to drag out the talks in the hope that the common front will crumble.

It’s also in the country’s interest that the Prime Minister and the premiers be willing to go out on a limb and fundamentally revamp health financing – starting at the top – because the current formulas aren’t working.

< http://www.theglobeandmail.com/life/health/new-health/andre-picard/days-of-blindly-topping-up-medicare-are-over/article2244214/ >

For supporters of Insite, Vancouver’s supervised injection site, and those who believe in evidence-based public-health measures more generally, Friday’s ruling from the Supreme Court of Canada was a huge legal victory.

But the celebration should be short-lived. Now that the Champagne has been drained, we are left with a whopping hangover of a realization: Canada’s drug strategy remains deeply flawed.

A comprehensive drug strategy has four pillars: prevention, treatment, harm reduction and enforcement.

The court has shored up one of those pillars, harm reduction. The government has embraced one other, enforcement. The other two key elements, prevention and treatment, have been starved of funds, leaving us with a teetering response to one of society’s biggest public-health challenges – drug misuse and addiction.

Back to the Supreme Court ruling for a moment: In a unanimous 9-0 decision, it upheld the federal government’s right to use criminal law to restrict illicit drug use; at the same time, the court said Insite could stay open, ordering Ottawa to exempt users and staff from prosecution.

Why? Because the scientific evidence demonstrates incontrovertibly that supervised injection sites provide intravenous drug users with clear health benefits, along with advantages for the community. For instance, as a result of Insite, addicts are less likely to share contaminated needles with other drug users. That means there is a lower risk of transmitting diseases such as HIV-AIDS and hepatitis. There are also significantly fewer drug users injecting in alleys and discarding used needles.

“The effect of denying the services of Insite to the population it serves and the correlative increase in the risk of death and disease to injection drug users is grossly disproportionate to any benefit that Canada might derive from presenting a uniform stance on the possession of narcotics,” Chief Justice Beverley McLachlin wrote in a key section of the ruling.

The court’s strong support for harm-reduction measures and its position that law enforcement does not trump public health is a victory of sorts.

But did we really need the top court in the land to tell us that supervised injection sites save lives? The scientific evidence has been clear for years.

The federal government not only chose to ignore the evidence, it mounted a moralistic anti-science campaign against Insite. Former health minister Tony Clement went so far as to say that supervised injection sites offered “no harm reduction” but rather “harm addition.”

The current health minister, Leona Aglukkaq, greeted the Supreme Court’s ruling by saying the government was “disappointed” but would reluctantly comply.

Ottawa is not exactly embracing harm reduction, or evidence for that matter. Further, it seems to have not absorbed one of the most important lessons of the ruling, a reminder that governments are stewards and have a duty to act in ways that enhance the health of individuals and their communities – even when doing so is politically unpalatable.

There is some speculation that the court ruling will pave the way for supervised injection sites to open in other major cities with large populations of injection drug users, such as Montreal, Toronto and Ottawa.

But having the law and science on your side is not near enough. You need money, you need the support of local public-health authorities, you need the backing of the provincial government (meaning a province willing to pick a fight with Ottawa at a time when federal health transfers are being negotiated). And you need to convince a skeptical public that you’re not wasting tax dollars coddling “junkies.”

That’s not going to be easy to do at the best of times, let alone in the current “tough-on-crime,” recessionary atmosphere.

Finally, anyone who wants to open a supervised injection facility still has to apply to Ottawa for an exemption and they are undoubtedly in for a long, expensive legal fight.

In fact, one of the most tragic aspects of the Insite story is how much money was wasted on lawyers and how many opportunities were lost to advance public health while the legal bickering dragged on for years.

Instead of using its energies fighting for the survival of a service with demonstrated benefits (supervised injection), Insite should have been expanding into other areas such as supervised inhalation (sniffing having become a massive problem), and other groups throughout the country should have been expanding their harm-reduction programs such as distribution of safe-crack kits, wet shelters, and finding innovative ways to counter the scourge of methamphetamine addiction.

In pooh-poohing the court ruling, Ms. Aglukkaq said that the federal government prefers to spend on prevention of drug addiction rather than on harm-reduction measures for addicts.

The sad truth is that it has done neither to any appreciable degree.

Instead, the current government treats drug addiction not as a sickness but as a crime. It has chosen to spend dizzying amounts of money building prisons instead of investing in harm reduction, treatment and rehabilitation.

Prisons are not tools of prevention; on the contrary, they are places where addictions and needle-borne infectious diseases flourish.

The other unfortunate aspect of the Insite battle is that it has focused too much attention on harm reduction to the detriment of other important interventions.

Supervised injection targets a small minority, the sickest of the sick. The threat of prosecution is meaningless in this group and, sadly, treatment options are few. So you try to minimize the harm they can do to themselves and others – for compassionate and economic reasons.

But most addicts do not live on the means streets of Vancouver’s Downtown Eastside. They live in mainstream society – struggling at work, in school, at home. Most suffer from another form of mental illness.

The four-pillars approach – prevention, treatment, harm reduction and enforcement – is what they need and what governments should be embracing.

The Supreme Court of Canada has provided a timely reminder that putting all their eggs in the enforcement basket is a legally dubious approach, not to mention poor public-health policy. But it remains up to us – and our leaders – to act.

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Local health-integration networks. Remember that term because, as a fall election approaches in Ontario, LHINs (pronounced Lynns) are shaping up to be a hot-button health issue.

The Conservatives, who are leading in the polls, have promised to scrap them. So, too, has the surging NDP. The ruling Liberals are promising to make LHINs more accountable and effective.

The sudden interest in governance of the health-care system should warm the heart of any policy wonk. But one can’t help but wonder if politicians are really interested in addressing the complexity of co-ordinating and managing care, or if they have merely zeroed in on a small and unlovable element of the government apparatus and made it a convenient scapegoat.

Ontario has a massive health-care system with a budget of $44-billion.

The Minister of Health, Deb Matthews, does not personally dole out that money dollar by dollar. Nor does the Health Ministry centrally distribute the money. As most provinces do, Ontario has broken down its territory into regions; there are 14 of them. Regionalization is supposed to allow the health system to be more responsive and better able to meet local needs.

About half of Ontario’s health budget, $21.5-billion, is funnelled through LHINs. But they have a lot more power in theory than in practice because a) the ministry likes to micromanage; b) there is no clear hierarchy so no one really answers to LHINs and; c) there is a lot of manoeuvring by vested interests that undermines regional authority.

A regional health authority, if it’s going to be effective, should be able to determine how money is spent within a region, shifting money from hospitals to community care, from treatment programs to prevention, and so on. This approach worked extremely well in Alberta, so well that it was dismantled because it stripped too much power and control from politicians and policy-makers in the Health Ministry.

In Ontario, LHINs were never given much power. More than half of all health spending is on labour, and contracts for nurses, physicians, pharmacists and so on are negotiated centrally. The province never wrested power away from hospitals (which have all kept their own boards of directors) and community-care access centres maintain control over health services in the community.

What does that leave for LHINs to administer? Well, nothing really. Only about 1 per cent of their budgets are discretionary. Other than that, all they do is transfer money without adding any value.

There is a lot to dislike about LHINs. They are essentially a layer of middle management with nothing to manage. Their boards are larded down with political cronies. They spend way too much on bogus consultations. They are often undemocratic.

But to suggest that scrapping them is going to improve the health system, or save a lot of money, is illusory. The 14 LHINs have only about 400 employees in total, compared with more than 4,000 in the Ministry of Health and Long Term Care. The total budget for LHINs is $68-million.

Yes, LHINs, in their current form, are ineffectual.

But is scrapping them the only answer? What if LHINs were given real authority and spending power? If you are worried about excessive bureaucracy, why not eliminate the overlap with hospital boards and CCACs? Why not take an axe to the ministry itself?

The two harshest critics, Conservative Leader Tim Hudak and NDP boss Andrea Horwath, have both said they will take the money spent on LHINs and put it directly into patient care.

Sorry, but that’s hollow rhetoric. Do they honestly believe that a health-care system can magically manage itself? There needs to be an administrative apparatus. The question is: What should it look like?

What we need to hear from Ontario politicians is what they are proposing as an alternative to LHINs. That should be the central health-care debate.

Do we want the system in which administrative power is centralized in the Ministry of Health and Long Term Care in Toronto? Or do we want a highly decentralized system in which regional authorities have real power?

Ontario has to do decide if it wants to continue to have a health system in which decisional and spending power is concentrated in hospitals or whether it wants regional authorities – called LHINs or something else – that determine the right mix of spending among institutional care, community care, prevention programs and so on.

The fundamental problem is that Ontario has tried to do all these things simultaneously. The result is a bloated bureaucracy with no clear lines of responsibility. The reality is that the province’s regionalization efforts have, at best, been half-assed. LHINs are not the problem, they are a symptom of a much larger problem.

Good governance and stewardship are essential – in the public and private sector alike. And in health care, we have taken these fundamental matters for granted. We lurch from problem to problem, in perpetual crisis-management mode, and that is why our system is adrift.

Planning and management should not be dirty words. And those who want to lead the government should articulate their vision of how that system should be run.

“Scrap LHINs” is not a vision; it’s a cop-out.

< http://www.theglobeandmail.com/life/health/new-health/andre-picard/what-kind-of-health-system-does-ontario-want/article2088797/ >

With a body count that has not even reached two dozen, the “superbug outbreak” in Southern Ontario hospitals is all but over.

Doctors and nurses have been sternly reminded to wash their hands. Fingers have been pointed: The “crisis” is due to a) the contracting-out of cleaning services; b) wrong-headed priorities of the dreaded local health-integration networks; or c) provincial cuts to health spending.

Take your pick and then we can all go back to sleep.

That’s how crisis journalism works, especially in the age of Twitter. We focus intensely on an event like a spike in deaths from Clostridium difficile in hospitals in the Niagara Region. We extract some earnest concern and vague promises from political leaders, and move on.

If only pathogens were as easily mollified.

The challenge of C. difficile cannot be explained in 140 characters or less, or by focusing on a handful of hospitals.

The deaths in Niagara Region are, unfortunately, commonplace.

Nosocomial (hospital-acquired) infections kill about 12,000 people a year, the Community and Hospital Infection Control Association of Canada says. Nasty bugs like C. difficile, methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus(VRE) sicken another 250,000 or so.

This is a state of normalcy we ignore.

Some of this mortality and morbidity is avoidable. In fact, what was most glaringly lacking in the daily Niagara hospitals body count was information on who was dying.

Some hospital patients are gravely ill and particularly susceptible to infection. Not so long ago, the terminally ill routinely got bacterial pneumonia, nicknamed the “old man’s friend” because it causes a rather peaceful death.

C. difficile causes violent diarrhea and gruelling intestinal pain. When it is not fatal, it can cause life-long disability. In other words, it is extremely costly.

Equally worrying is when young, healthy people – including health workers – start contracting nosocomial infections, or when they migrate into the community.

Studies have shown that about one in 20 hospital patients will contract an infection.

The average hospital stay is five days, but that jumps to 22 if a patient gets an infection. One U.S. study estimated that nosocomial infections cost $35-billion a year – which translates to about $3.5-billion in Canada.

So what is to be done?

Yes, handwashing is necessary for health-care workers, patients and visitors. But in Canada, we too often skimp on support staff like janitors. It’s not enough, however, to throw bodies with mops into the equation: In health care, everything should be evidence-based, including room cleaning. Some excellent research indicates that hydrogen peroxide kills C. difficile.

Patients with pathogens like C. difficile should also be placed in a private room, and traffic should be minimized. More broadly, shouldn’t private rooms be the norm in modern hospitals? In Canada, a patient can have as many as 46 roommates during a hospital stay, and emergency departments routinely have hallway medicine – ideal conditions for spreading disease.

Just as important as preventing the spread of pathogens is minimizing patient susceptibility. C. difficilepounces when the path is cleared of other bacteria, making patients on antibiotics vulnerable.

There is a lot of evidence that antibiotics are overused, particularly in elderly patients and in hospitals. Figuring out whether to treat a bacterial infection or let it run its course is crucial. And patients have to understand that these miracle drugs can have unintended consequences.

Research also shows that patients taking proton pump inhibitors (which can upset the balance of flora in the gut) for gastrointestinal woes are far more susceptible to C. difficile infection.

There is decent evidence that cheap, over-the-counter probiotics can lessen the symptoms of C. difficile.

But more than anything, to come to grips with the challenge of hospital-acquired infections, a change of attitude is needed.

We need to empower patients and their families with basic information. For example, infection rates should be routinely published, not just when there is a deadly outbreak). And physicians need to discuss the pros and cons of antibiotics and PPIs openly.

Above all, we need a culture of safety in our health system, with an obligation – nay, an obsession – to pursue innovation and improvement. We need to make minimizing hospital-acquired infections a point of pride.

For too long, providers and administrators have washed their hands of this issue, with deadly consequences.

< http://www.theglobeandmail.com/life/health/new-health/andre-picard/southern-ontario-hospitals-superbug-outbreak-abates-but-enemy-still-lurks/article2096447/ >

There won’t be a new health accord.

At least not the kind of health accord that we came to expect under previous Liberal governments.

“Health accords are a Liberal invention. Why would Stephen Harper want to do the same thing?” said Judith Shamian, president of the Canadian Nurses Association.

Instead of a long-term deal with all 13 provinces and territories, we can expect a short extension of the current deal – which would fulfill the Conservative campaign promise of maintaining annual increases at 6 per cent – followed by a fundamental revamping of federal transfers.

Bill Tholl, an Ottawa-based consultant who was the long-time secretary-general of the Canadian Medical Association, said instead of an omnibus deal with all provinces and territories, he expects the new majority government to propose signing a series of bilateral agreements.

That approach has several advantages.

First, it reflects Mr. Harper’s political philosophy that health care delivery is exclusively within the provinces’ jurisdiction. Second, it would allow Ottawa to provide targeted funding for initiatives that would be popular in particular regions – for example, money for a catastrophic drug plan in a province like New Brunswick, or a waiting-times initiative in Ontario. Third, bilateral agreements would do away with the need for a first ministers’ meeting.

For all the talk about coming negotiations on the health accord, the fact remains that Mr. Harper has never committed to a first ministers’ meeting on health. (As PM, he has played host to only two gatherings of premiers, both focused on the economy.)

“We want to work co-operatively with the provinces to make the system work better,” is all Mr. Harper said during the campaign.

There is no legal obligation to have a meeting, nor does there need to be a single agreement. There have been only three health accords – in 2000, 2003 and 2004 – since the Liberals dramatically revamped health and social transfers.

During the last negotiations, the premiers extracted a 10-year deal from former prime minister Paul Martin with an escalator clause of 6 per cent a year and very few restrictions on how the money could be used.

Going into a room where all the premiers can gang up on him is not the current PM’s style. Mr. Harper has also said repeatedly that he expects “accountability and results” in exchange for federal dollars. Having a set of benchmarks could ensure a modicum of national standards, which would counter the concern that bilateral deals would lead to regional disparities.

“If this government can tie funding to performance, we would strongly encourage them to do it,” Dr. Shamian said.

The Canada Health Transfer, which currently provides $27-billion in cash and $13.6-billion in tax points, expires in 2014.

During the recent election campaign, to assuage concerns that cuts were coming, Mr. Harper said his government would continue with 6-per-cent annual increases in the health transfer (as did the other party leaders). But, said Megan Leslie, the New Democratic Party health critic, “he didn’t say how long he would keep the 6-per-cent commitment.”

In projections accompanying the most recent federal budget, the 6-per-cent increase was assumed to continue for two years beyond the accord’s expiration, to 2016. After that, it is very unlikely increases will exceed the rate of inflation.

Ms. Leslie said bilateral agreements are a real possibility because the Conservatives have said repeatedly that health is strictly a provincial matter. “They’re looking at just being a source of money,” Ms. Leslie said. “So I don’t really expect any new initiatives or any leadership on health.”

Deb Matthews, Ontario’s Health Minister, said she would like to see a deal on health funding done quickly, before the end of 2012. The province is on record saying it wants another 10-year agreement with 6-per-cent annual increases. Ms. Matthews refused to say if Ontario would be willing to sign a bilateral agreement with Ottawa. “Ideally, we should have a national agreement, but we should let the premiers do their work, do their negotiating,” she said.

Whatever the outcome of those talks, in the long term even more significant changes are coming. Mr. Tholl said the Conservatives have been clear that they are going to revamp the federal-provincial fiscal arrangement, and the Canada Health Transfer will be affected in the process.

One of the most talked-about proposals originates with Ken Boessenkool, a long-time Harper adviser and now an executive fellow at the School of Public Policy at the University of Calgary. He has suggested that Ottawa do away with the myriad programs it has for transfers and equalization payments and instead turn over the monies collected from the federal GST to the provinces.

“The result would be a stable and steady revenue source for the provinces to use for health care and other programs they are responsible for,” Mr. Boessenkool said. This would satisfy the provinces’ desire for more money and Mr. Harper’s twin desires of getting Ottawa’s hand out of provincial jurisdictions and shrinking the federal government.

This debate, coincidentally (or not), is in its infancy and should be revved up by 2016, the next federal election date, and after several provincial elections have brought in a new generation of premiers eager to do health care differently.

Editor’s Note: The secondary headline of the original newspaper version of this article, which was reproduced in some parts of globeandmail.com, incorrectly attributed comments to the Canadian Medical Association. The comments were made by the former secretary-general of the CMA. This online version has been corrected.

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