Politicians and bureaucrats are always attracted to simple ways to control health-care spending. In the early 1990s, they decided the best way to control spending was to cut down on doctors. This brilliant idea resulted in a doctor shortage that has taken the past decade to fix.

The reach for the quick fix has made fundamental change in health care all but impossible. It has given us the worst of all possible worlds – a system in which everyone behaves as if the competition for resources is a zero-sum game and no one is rewarded for acting in the collective interest. The system virtually guarantees turf wars. As a result, the medical professions resemble medieval guilds – fiercely protectionist, rigidly conservative and jealous of their status and perks.

This explains why all the sweeping top-down master plans to fix our health-care system will never work. As one insider puts it, “At each step, you find the structural impediments to change are extraordinary.”

There are lots of cheaper, more effective ways to do health care. But the system is rigged to squash innovation. Take a simple thing like colonoscopies. This procedure – the single most effective screening test for cancer – is conducted in Canada by gastroenterologists. In other countries, it’s done by nurse-clinicians. Why can’t we do that too? Because the barriers erected by the various professional silos are almost insurmountable. Who would pay? Who would be ultimately accountable for the procedure? And so on.

Or take prescriptions. Do you really need to see a doctor to renew your Lipitor? Why don’t we give prescribing powers to pharmacists? In fact, much of the work that family doctors do – ordering tests, taking your blood pressure, lecturing you to lose weight, even treating your bladder infection – is routine. Nurse practitioners and physicians’ assistants could do it just as well. Don’t try to persuade the doctors, though. (The last time I tried, they told me I might have bladder cancer and could die.) Besides, they need the fee income they get from seeing you.

But doctors are defeated by the system too. One group of doctors came up with a way to improve care for breast-cancer patients. Instead of sending a woman on an endless round of specialist appointments to the radiologist, the plastic surgeon and so on, they arranged for all the specialists involved in her care to meet with her all at the same time in order to lay out a treatment plan. When they told the hospital CEO about this breakthrough, he begged them not to spread the word. He feared the hospital would be flooded with patients it had neither the space nor the operating-room time to treat.

What kind of room is there to do things more effectively and efficiently? Here’s one suggestive statistic. We spend around 12 per cent of our GDP on health care. Singapore spends around 2.4 per cent. By almost any measure, Singapore has better health-care outcomes than we have.

Everybody knows that health-care costs cannot continue to rise at the current rate. Everybody in the system can point out lots of ways to do things better. We have a highly trained work force full of talented, hard-working and dedicated professionals. But until we can figure out ways to get them to work collaboratively together, and to reward innovation – not punish it – genuine reform will be impossible. Doctor-bashing is not the place to start.

< http://www.theglobeandmail.com/news/opinions/margaret-wente/doctor-bashings-not-the-cure-for-health-care-costs/article2434938/ >

Ontario physicians are angered by the provincial government’s high-handed approach to fee negotiations. Perhaps it’s time for both sides to do the obvious: End fee-for-service medicine; put doctors on salary.

Originally, the pioneers of Canadian medicare assumed that doctors would become salaried employees of government. That’s what happened in Britain when its National Health Service was established after World War II.

In Saskatchewan, the storied birthplace of Canadian medicare, an established system of salaried rural doctors already existed when Tommy Douglas’s Co-operative Commonwealth Federation (the forerunner of the New Democrats) took power in 1944.

But Douglas’ CCF didn’t follow the British example. The reason was fierce physician opposition.

Self-employed doctors — and even many salaried physicians — preferred the piecework system known as fee-for-service, one in which practitioners are paid set amounts for each procedure or consultation.

In part, this was because doctors preferred to see themselves as independent entrepreneurs.

But in part, it was because fee-for-service gives doctors great leeway in determining their own incomes. To get more money, a physician need only see or treat more patients.

Eventually, Saskatchewan’s CCF government adopted the fee-for-service variant of medicare. That in turn became the model for the entire country when medicare went national in 1968.

In spite of doctors’ initial misgivings, fee-for-service medicare turned out to be a bonanza. They could still charge piece-work rates. But their payments were guaranteed by government.

Today, however, governments don’t want to pay as much. Over the years, they have gradually eroded physicians’ fee-setting autonomy

Ontario’s government, for instance, began by negotiating overall financial settlements with the Ontario Medical Association,leaving physicians to divvy up the pot.

But that proved unsatisfactory since it allowed the most politically powerful factions within the OMA to reap the bulk of the rewards. This in turn left some areas — particularly general practice medicine — woefully underfunded.

Then governments began to involve themselves in the nitty-gritty. Premier Dalton McGuinty’s Liberals initially used carrots, giving doctors extra bonuses on top of fee-for-service in those areas of medicine where the government wanted more done.

Now, the Liberals are using sticks, threatening to unilaterally remove some of the goodies they introduced in the first place.

In short, the government is doing its best — in a rather clumsy way — to treat doctors as employees, calling upon them to do more for less.

It’s the same message Queen’s Park is giving all of its salaried workers, from teachers to prison guards.

So maybe it’s time for both sides to face what is going on. So-called alternative payment schemes (such as paying doctors on the basis of their patient rosters) have already moved the system away from pure fee-for-service. Why not go the whole way?

Incidentally, salaried docs don’t do that badly. In Britain, a general practitioner can earn up to $131,000 for a 40 hour work week. And that’s just base pay. There’s overtime and merit pay on top.

There’s also a handsome, fully inflation-indexed pension plan and up to six weeks paid holiday annually — perks that Ontario’s self-employed doctors don’t enjoy.

Best of all, the entire pay packet goes to the physician. Overhead and office costs are covered by government.

The advantage for government is that it can manage the system it funds. The advantage for doctors is they can focus on medicine.

And patients? The evidence from Britain suggests they do just fine with salaried doctors.

< http://www.thestar.com/news/canada/politics/article/1177014–walkom-why-not-put-all-ontario-doctors-on-salary >

Settling in by the window of a French bistro along the strip of Harbord Street that caters to Toronto’s academic gentry, the psychiatrist David Goldbloom refuses a glass of wine without a second thought. Frankly, he looks appalled at the suggestion, as he will soon be seeing patients at the Centre for Addiction and Mental Health, where the lingering odour of even the most delicate grape could cause untold problems.

And yet, given the daunting task before him as the new chair of the Mental Health Commission of Canada, whose national strategy launches on Tuesday, one imagines the man could use a drink.

For the casual observer, the parade of news stories about mental illness at the extremes can inspire despair. In Halifax, a gay activist is killed by a man on a one-hour leave from a secure forensic psychiatric unit. In Toronto, a schizophrenic man kills his father at home, and then himself in jail. An Ontario appeals court rules that a man who killed his wife may collect on her life insurance, over their son’s objection, because he was insane when he did it.

And the Ontario legislature vows to review police procedure to reduce the number of mentally ill people hurt or killed in confrontation with police.

With headlines like these, it is tempting to see serious mental illness as the incorrigible problem child of Canadian health, social and justice policy, epitomized by Ashley Smith, the mentally ill New Brunswick teenager whose cross-country tour of Canada’s penal system illustrated its myriad failings and ended with her suicide being videotaped by guards.

But as he prepares to launch Canada’s long-awaited national strategy on mental health, complete with a budget-style media lock-up on in Ottawa, Dr. Goldbloom is much more optimistic, and his perspective is wider than the terrible extremes.

“We do have a problem with perceptions of dangerousness among people with mental illnesses,” he said. But it is only that — a perception problem — and things are changing.

“We know that prisons, jails, are the last great asylums of North America for people with mental illness,” he said over a lunch of steak frites and tap water. “The biggest asylum in the United States is the Los Angeles County Jail. There’s about 20,000 inmates and about 2000 of them are severely mentally ill. We know that people with mental illness are really vulnerable to being victimized in a prison system, and that care in a prison system for people with mental illness is nowhere near where it needs to be.”

At the same time, he said a shift in public attitudes to mental health has opened vast new possibilities for progress all across the spectrum of mental health — from problems that are not illnesses, through the various forms of depression, anxiety and behavioural symptoms, to serious and persistent illnesses like schizophrenia and bipolar disorder. Big philanthropy has followed suit, such as the $10-million donation last week by Margaret McCain, widow of food magnate Wallace, for youth programs at Toronto’s Centre for Addiction and Mental Health, where Dr. Goldbloom is senior medical advisor.

Once an aspiring actor, he also chairs the Stratford Shakespeare Festival, and comes from a family of prominent doctors. Energetic and funny, he joked that he recently emailed some Jewish friends about the Stratford Festival’s recent Broadway smash hit production of Jesus Christ Superstar, and included a “spoiler alert” in case they did not know the lead character dies in the end.

“I’ve never seen anything quite like it,” Dr. Goldbloom said about the spike in public and government interest in mental health programs, and the newfound ease with which these topics come up in public discourse — even in death notices that explicitly mention suicide, where once it was taboo. By taking lessons from grassroots advocacy for breast cancer and HIV, Dr. Goldbloom said he hopes to harness and promote this trend, but problems keep coming fast and furious, and he has taken over the commission at a decisive moment in its history

Formed in 2007 with $130-million in arms-length funding from Health Canada, and set to close in 2017, the Commission has always had a dual purpose, first articulated by inaugural chair and retired senator Michael Kirby, whose family experience with mental illness inspired his 2006 report Out of the Shadows At Last.

On the one hand, the MHCC combats stigma, a goal it has pursued, for example, by commissioning research on media archives to show journalism students how frequently news stories that mention “schizophrenia” are negative in tone, and how infrequently they are positive.

On the other hand, the MHCC was also mandated to prepare a national strategy on mental health from its uniquely independent position outside the federally-funded provincially-administered health system.

It is that duality in the commission’s purpose — between its optimistic orientation against stigma toward empowerment and recovery, and the worryingly frequent system failures on serious mental illness that call out for a comprehensive strategy — that has caused it the greatest grief and put it on the defensive, never more than last year, after the leak of a draft strategy that was long on platitudes, but short on substance.

One psychiatrist observed that the draft version did not even mention “psychiatry,” nor “schizophrenia” or “bipolar,” but “recovery” was mentioned 67 times and “support” 127 times. Advocates for schizophrenia treatment have similarly warned of the influence of anti-psychiatric academics, even anti-medicine conspiracy theorists, on the commission’s many advisory boards.

The draft was so widely criticized that the Commission’s CEO, Louise Bradley, vowed in a letter to Canadians to “correct” its failures of emphasis, because it “does not sufficiently reflect the essential role neuroscience, treatment and psychiatry have to play.”

This is one of the many problems Dr. Goldbloom, a long-time MHCC board member, was promoted to solve. As a front-line expert on the nastiest of mental disorders, he is ideally qualified to quell suspicions of anti-psychiatry from without, while also confronting expressions of it from within. But he is touchy about what went wrong.

“What got released was a draft. The draft was nowhere near a level of reaching board approval. It was a work in progress,” he said. “It’s a better document now. The language has been refined over the course of the last year to try to better communicate the beliefs of the commission and the beliefs of the people who serve on it.”

He said the next few years will be devoted to the critical “translational aspect” of the strategy, in which a national vision is adapted for local application, from provinces, most of which already have strategies, down to the level of municipalities.

Dr. Goldbloom said the board focused closely on the strategy’s terminology, deciding on the term “severe and persistent mental illness” to capture the worst, while also taking the position that not all mental health problems are illnesses. He said “presenteeism,” for example, or being incapable of working while at work, is of major social and economic concern, though not an illness in itself.

“That is not talking about mental health ‘issues,’” he cautions. “I hate ‘issues.’ Nobody with cancer says ‘I have neoplastic issues,’ ‘I have cell proliferation issues.’ They say they have cancer.”

It is a refreshing bluntness. More than any other health problem, mental illness is vulnerable to fuzzy, clichéd thinking. Psychiatry itself has a mixed history in this regard, Dr. Goldbloom said, of being misled by its own metaphors, and forgetting what is proven and what is fanciful theory. Freudian psychoanalysis is the big example, but the same can be seen in theories, false but once widely held, about the origins of mental illness in faulty parenting.

With the rise in understanding of genetics, Dr. Goldbloom said we have shifted to “a much more profoundly biological paradigm” in how we understand mental disorders, but full insight remains elusive.

“We don’t know what causes schizophrenia, but it’s not bad parenting,” Dr. Goldbloom said, pointing out that if you have an identical twin with schizophrenia, your odds of getting it are 50%.

“The point is it’s not 100%. If it was cystic fibrosis, you would get cystic fibrosis,” he said. So there is more going on than just genes, some of which you might be able to control, such as exposure to stress, for example, or marijuana, which in susceptible young people can trigger psychoses. Similarly, if everyone in your family had a heart attack at 40, you would probably take measures to prevent your own,” Dr. Goldbloom said.

“This is about managing risk. You can’t control genes, you can’t pick your parents. But genes are not absolute destiny,” he said. “The extent to which stigma, illiteracy or shame stops people from checking things out is a tragedy.”

At the extremes, the contrasts between normal and pathological are stunning and clear, but Dr. Goldbloom doubts he will ever be able to pin mental illness to the wall, in the way that viruses explain the common cold, or tobacco smoking explains lung cancer.

“What people don’t appreciate is that we draw arbitrary lines in medicine, between health and disease, all the time. There’s been intense focus on this line drawing in psychiatry, in the context of all of the controversy around DSM-V [psychiatry’s diagnostic manual],” he said. “We are inexorably attracted to certainty. We love dichotomous variables. We love lines that we can draw. Unfortunately, the simple conclusions are often the most alluring and the most incorrect.”

He cited the panic over suicide and drug abuse among NHL enforcers as an example of jumping to glib conclusions, but he acknowledges that the impulse to grasp at even a wisp of understanding is unavoidably human.

“How do the parents of any child who has any kind of disorder not wonder about their own genetic contributions to their kid’s illness?” he said. “Every caring parent scrutinizes themselves, their behaviour, their biology, when they see a child of theirs suffer. I think it’s inevitable. We don’t have evidence they could have done something difference when it comes to schizophrenia or autism, so I think one of the comforts we can provide to families is alleviating that sense of blame, castigation, but also not simply blame, but sometimes shame. Those are not the same. And one of the things that magnifies shame is stigma. Because if your child has liver failure or diabetes, the response of the community around you is support. They’re all over you like a dirty shirt… But [in the case of mental illness], for some families the response is social distance. People back away.”

< http://news.nationalpost.com/2012/05/06/a-character-study-of-mental-illness-and-change/ >

Six organizations studying how government policies on everything from toxic chemicals to the legacy of residential schools impact women’s health will lose their funding as part of widespread cuts to the federal budget.

Health Canada expects to save $2.85 million a year by eliminating the Women’s Health Contribution Program, which supports the work of four research centres and two communications networks across the country, by next March.

The organizations now facing an uncertain future have conducted publicly available research looking at on-reserve aboriginal programming for maternal and infant health, barriers to treatment for pregnant women and mothers addicted to drugs or alcohol, and casting a critical eye on funding for the HPV vaccine.

Anne Rochon Ford, the Toronto-based executive director of theCanadian Women’s Health Network, one of the groups set to lose its federal funding, said the biggest loss will be how the groups went beyond clinical research to focus on how particular government policies and regulations affect the health of women.

“That analysis, I think, is unique to the program and that will be gone,” Rochon Ford said Wednesday.

The National Network on Environments and Women’s Healthbased at York University, for example, has taken a look at how the federal regulation of toxic chemicals affects the female population in a particular way.

“Women are exposed to more chemicals, because we use more personal-care products and . . . women are often making these decisions about what chemicals they are exposing themselves and their families to,” said Jyoti Phartiyal, projects manager at the network.

Steve Outhouse, a spokesman for federal Health Minister Leona Aglukkaq, noted the program began in 1996 when there were fewer resources available for research into women’s health.

Outhouse said Health Canada now plans to focus its research funding through the Canadian Institutes for Health Research (CIHR), which includes an Institute of Gender and Health with an annual budget of about $54 million.

“We’re not diminishing the work that anyone has done, (but) when we’re in a process of deficit reduction we’re always looking at how do we achieve that mandate as efficiently and effectively as possible?” said Outhouse.

Outhouse added the annual budget for gender health research includes about $33 million for “open” research, which is one way the groups losing their federal funding can still apply for grants to conduct research on a project-by-project basis.

Rochon Ford noted that in contrast to the scientists conducting clinical research funded by the CIHR, the groups had a mandate to advise the federal government on policy.

Still, Rochon Ford said that role had diminished long before Health Canada announced the funding cut.

“That has eroded considerably with this latest government. It’s been made very clear to us that they don’t want our policy advice,” said Rochon Ford.

Outhouse pointed out that health care is a provincial and territorial responsibility and that the research funded by the CIHR will be available to hospitals to incorporate into their practices.

Health Canada has also come under fire for plans to wind down the National Aboriginal Health Organization (NAHO) by the end of June, but Outhouse explained that was largely due to internal problems with the non-profit group.

Three of the five national aboriginal organizations that made up NAHO recommended in a letter to Aglukkaq last fall that it disband and be replaced with three separate agencies for First Nations, Inuit and Métis, which Health Canada rejected.

“That made the decision fairly straightforward at that time, since the organization doesn’t technically exist without the national aboriginal organizations,” said Outhouse.

Health advocates are also upset with a decision to cut $15 million from the Federal Tobacco Control Strategy, arguing that it will scale back regulatory and enforcement activity at Health Canada and eliminate a grants and contribution program that went to anti-smoking initiatives.

Aglukkaq said Health Canada is turning its anti-smoking efforts toward Canadians with above-average smoking rates, such as aboriginal populations, where smoking rates are as high as 50 per cent.

< http://www.thestar.com/news/canada/politics/article/1167987–federal-budget-2012-health-canada-cuts-funding-to-women-s-health-research-groups >

I don’t know about you, but in my house we don’t each buy our own toothpaste. It’s not a good use of money to have multiple small tubes scattered around the sink — not to mention the wasted time if each family member makes a separate trip to the drugstore. We agree on a brand, buy one big tube, and save our money and time. Ditto with planning meals: one person buys the groceries. We may each be responsible for feeding ourselves, but we all have access to whatever is in the fridge.

I share this just in case the prime minister and premiers do things differently at their houses and might find the approach instructive. Because it’s clear that when it comes to health-care policy, they’re wasting the family budget buying multiples of everything, and everyone is cooking a different dinner. To make matters worse, the person who’s supposed to be the head of the family has left an allowance on the table and gone on vacation. Indefinitely.

Whose job is it to co-ordinate health-care reform in Canada? Canadians expect our federal government to play that role. We want to know that wherever we live, we will have access to an equivalent basket of services. We want to know that our governments are buying in bulk whenever possible, maximizing savings. And we want assurances that some basic standards are being met from coast to coast to coast. Health care may be a provincial responsibility, but we know there’s a need for a family to co-ordinate its efforts.

So when the Harper government plunked a 6-per-cent escalator on the table and walked away from its role in health care, I was disappointed. And it seems I wasn’t the only one.

A recent Environics poll on health care showed a sea change from 10 years ago — 62 per cent of Canadians think that health care is about more than just money, it’s about what our leaders do with it. That’s up more than 20 per cent from 2002.

And the Senate report released last month, “Time for Transformative Change”, urged the federal government to take an active role in transforming the health-care system, and ensure that funding is used as an incentive for change. The report assessed the impact of the 2004 health accord, and showed clearly that a 2014 accord is needed to further improve our system.

Senator Art Eggleton echoed this point, saying that the federal government can’t just put the money on the table and walk away — it needs to be a key partner in leadership on health care.

Meanwhile, the 2012 federal budget cut Health Canada, and said nothing about meaningful change. The only nod to improving the system was a three-year, $6.5-million study on cost-effectiveness in health care.

But that ignores the mountains of evidence we already have about how to improve our health-care system while making it more efficient. It’s becoming baffling to Canadians as to why our federal government wouldn’t co-ordinate a national pharmacare system that could save billions. Everyone knows you get a better deal if you buy in bulk.

Cost-effectiveness can also be found by making the right choices around a more caring and appropriate system for our elderly. We need a spectrum of continuing care, from long-term care, assisted living, home care and palliative care that alleviates pressures on hospitals and puts the patient first. We should be shifting as a nation toward a system that puts less pressure on acute resources, and respects the choices of our seniors.

The Environics poll also shows that those Canadians who have the most frequent interactions with the health-care system are most pessimistic about it. We’re not doing as well as we could be for people with chronic conditions, and improving community care and self-management is another win-win — it’s cost-effective, and better for patients.

But the poll also showed that Canadians are still optimistic about our health-care system. Most of us believe it’s the best in the world. We’re happy with a publicly funded system. A lot of us think that it takes care of our most vulnerable, and that it will be there for us if we’re ill or injured.

It makes you wonder why the federal government wouldn’t want to fight for that system, and lead the transformation needed to keep Canada ahead of the pack on health care. Canadians take pride in their health-care system — so should their government.

Danielle Martin is a family physician in Toronto and Chair of Canadian Doctors for Medicare.

< http://www.thestar.com/opinion/editorialopinion/article/1161499–active-federal-participation-in-health-care-remains-essential >

By almost every indicator, Canada’s aboriginals are facing a public health crisis. They have abnormally high rates of diabetes, infant mortality, teen pregnancy and tuberculosis at a time when they are also the fastest-growing segment of the population. The suicide rate in Nunavut is 12 times higher the national one. And research in the area of aboriginal health is still in its infancy.

That is why closing down the National Aboriginal Health Organization (NAHO) is a serious misstep. Its paltry $5-million-a-year budget is a small saving for Health Canada. If the government has a better idea about how to more effectively, and economically, address the critical health disparities that First Nations, Inuit and Métis people face, it should certainly make these ideas public.

In the meantime, however, NAHO has played a crucial role in advancing research on aboriginal health, collecting and analyzing data, and leading community initiatives, such as programs to help people quit smoking, prevent suicide and avoid teen pregnancy. It has produced 12 issues of the Journal of Aboriginal Health, and had already put out requests for research papers for this fall’s edition, to be devoted to “Inuit health and wellness in its broadest sense.”

Aboriginals face unique challenges that seriously impact their health, including a traumatic history of family separation and residential schooling; inadequate housing; difficulty accessing clean water and food; high rates of alcoholism and unemployment; poverty; and exposure to environmental contaminants.

One would imagine that the federal Health Minister, Leona Aglukkaq, herself an Inuk and Nunavut’s MP, would be perfectly positioned to recognize the severity of these problems. Instead, in a cruel irony, she has been unwilling to protect the only research organization of its kind dedicated to improving health outcomes for Aboriginals. The closure of NAHO will reverse a decade of progress, and leave a gaping hole for those who are most in need.

< http://www.theglobeandmail.com/news/opinions/editorials/health-canada-should-not-have-closed-national-aboriginal-health-organization/article2396383/ >

Dr. Gary Bloch says he worries Ontario’s proposed budget cuts will affect his patients — some of the city’s poorest residents — the most.

After years of skyrocketing health costs, the cash-strapped McGuinty government announced in its budget Tuesday a series of tough austerity measures, including capping the growth of Ontario’s health portfolio at 2.1 per cent over the next three years.

Compared to the average 6.1 per cent growth over the last decade, it’s a dramatic cut that Finance Minister Dwight Duncan said was necessary to rein in the province’s crippling deficit.

But for Bloch, a family physician and University of Toronto professor who founded Health Providers Against Poverty, the government’s austerity-focused agenda does a disservice to public health, especially for the poor.

“I’m very concerned,” Bloch told the Star Tuesday. “I’m worried it’s a cut with a dull knife and it’s largely the people who live in poverty, especially the extreme end of poverty, who are impacted the most.”

Economist Don Drummond made more than 100 recommendations to improve Ontario’s health-care system in his report to the Ministry of Finance earlier this year — a focus on primary care and patient-focused medicine among them. He also said that without cuts, health-care spending would balloon to $62.5 billion by 2017-18.

In line with Drummond’s recommendations, the McGuinty government’s budget has proposed cuts to large provincial health agencies, capped funding for hospital corporations and potential wage freezes for doctors.

Bloch said those cuts will certainly affect the delivery of health care, but he added that wider social service cuts recommended in the budget — freezing welfare and disability support payments, for example — will likely do enormous damage to his patients’ health in the short-term.

He compared Duncan’s austerity plans to the sweeping social service cuts made back in the mid-1990s. Those cuts, “trending away from social programs,” have proven to negatively impact the health of the population and especially the low-income cohort, he said.

“I worry this is a continuation of that same trend that will absolutely impact those who are most vulnerable first and I think it’s incredibly unfortunate,” Bloch said.

“And I worry this will result in our society being less healthy, which should be the number one goal of the government”

< http://www.thestar.com/news/canada/politics/article/1152827–toronto-doctor-worries-budget-cuts-will-affect-poor-patients-the-most >

Ontario will invest in two pilot birth centres, giving women a new choice in where they deliver their babies, Premier Dalton McGuinty announced Tuesday.

Currently, mothers in the province can have their babies in hospitals or at home with a midwife. Birth centres would provide a third choice for women who don’t want a hospital birth but aren’t comfortable delivering at home.

“We think it’s important to create a new option for our moms,” McGuinty told a news conference at Ryerson University, which runs one of Ontario’s three midwifery degree programs.

• MORE: Ontario to fund two birth centres

He said the decision to invest $6 million in the pilot centres, which will be run by midwives and promote natural childbirth in a community setting, “marks the beginning of an important evolution in how we deliver babies in Ontario.”

The pilots, expected to be up and running within a year, will be evaluated for potential cost savings and quality of care and will lay the foundation for future birth centres throughout the province.

One of the sites is likely to be in Toronto, though locations have not been decided and will be chosen in the next few months based on proposals from midwifery practices across Ontario. All are eager to have a birth centre in their community.

Birth centres currently operate in Quebec, the United States and Britain and last fall Manitoba opened its first one in Winnipeg.

Midwives at the centres will care for mothers from conception through to six weeks post-partum and serve as community hubs for prenatal education, breastfeeding and parenting support.

The 550-member Association of Ontario Midwives, which has been lobbying hard for birth centres for the past year, had hoped for five pilots. But president Katrina Kilroy called the announcement “a great start” that will help ease the address the demand for midwifery service, reduce health care costs and boost the rates of natural childbirth.

Currently, four out of every 10 Ontario women who want a midwife can’t get one, largely because midwives are restricted in the number of hospital births they can attend.

Birth centres are expected to help reduce the high number of caesarean births, which account for more than one in four Ontario deliveries. They would be located close to hospitals in case a mother needs to be transferred for medical care and would not offer medical interventions like epidurals or inductions.

• MORE: A look inside Quebec birth centres

< http://www.thestar.com/living/article/1149137–premier-says-two-birth-centres-will-create-new-option-for-our-moms >

Re: Canadians face ‘tough choices,’ PM says, Jan. 16

I guess we’re fortunate to have a tough, level-headed economist at the helm. Obviously cuts must be made but, as we all know, some things are just too important to be left behind. I’m sure we can trust the Harper government to keep its priorities in order.

Tax cuts for Big Business, support for Big Oil, the purchase of F-35s, the building of new prisons — these are the things Canadians want and need. It’s time to take a scalpel to all those useless programs involving education, health care, government services, social programs and the environment.

And while we’re at it, let’s get rid of that useless freedom of information nonsense. I sure by now we all know we can trust our government to put our taxes into the things that matter and serve those who matter.

Randy Gostlin, Oshawa

The Conservative government inherited a surplus and created a record deficit. They are asking for Canadians to tighten their belts in order to compensate for their spending spree and corporate tax cuts.

Canadians named health care as their number one federal election issue, yet, the Conservatives have chosen to cut Health Care Transfers and abandon their health care responsibilities.

Canadians care about the environment but they are cutting many jobs at Environment Canada, which include climate change and toxic chemical research positions, jobs that produce scientific facts that may not favour the oil sands pipeline expansions.

They cut many jobs at Service Canada processing centres and reduced the number of locations causing Canadians to wait longer for EI payments. They have mentioned possible cuts to CPP.

Taxpayers want their money to be spent on things all Canadians need, want and use like health care, the environment, CPP and job creation.

Cathy Kalisiak, Waterloo

The federal government has signalled its intention to reduce its role in shaping medicare to writing cheques. This would complete a 35-year journey that began in 1977, when Ottawa first capped its financial contributions to the provinces. At its peak, Ottawa’s share of publicly financed health-care spending reached 41 per cent. Today, its cash contribution is just over 20 per cent.

The provinces run health care and have traditionally welcomed federal cash transfers with few strings attached. So what’s wrong with Ottawa’s self-imposed exile – is it not merely recognition that it has no legitimate role in shaping how the system develops?

Not in our view. Writing cheques and walking away from the duty to improve medicare is not only a retrograde step that endangers health care and the economy, it also reveals a vision of an increasingly shrivelled and parochial federation, where governments look inward and the whole becomes a pastiche of increasingly isolated parts.

Here are seven reasons why a strong federal presence in health care is vital to Canada:

Successful nations are built on unifying infrastructure. Think railways and the Trans-Canada Highway, seamless telecommunications networks, the armed forces, regulatory and judicial processes. Health care is a level up in importance because health is a fundamental precondition for full participation in society.

A high-performing nationwide public system contributes enormously to the economy. Businesses don’t have to design and fund complex health plans for their employees. Workers don’t have to worry that taking a job in another province will compromise their health care. Only leadership from Ottawa can guarantee a common set of programs and standards and ensure that program enhancements are available to all Canadians. The 2004 health-care accord acknowledged that Canada’s public coverage of prescription drugs is not up to international standards. Ottawa must insist on improvement and put its money behind it.

The intelligent use of health information is the key to improving access, quality and efficiency. Analysis and comparison are the midwives of improvement. Canada’ health-intelligence network is unco-ordinated, sluggish, incomplete and fragmented, a clumsy hybrid of paper and electronic records from which anything useful emerges slowly and at great cost. Both leadership and investment from Ottawa on an unprecedented scale are essential to creating high-quality, standardized information that improves clinical practice, policy and accountability.

Provinces can’t transform their systems on their own regardless of how much money they spend.The politics of health care are simply too fraught, and the vested interests too powerful, to effect large-scale change. Even worse, the jurisdictions routinely engage in unconstructive bidding wars for personnel and are whipsawed by vendors, such as pharmaceutical companies, that exploit their isolation and vulnerabilities. Ottawa should play a major role in creating a more collegial and co-operative federation that overcomes obstacles to reform and bargains more effectively in the public interest.

Ottawa could do a great deal to reduce the redundancy and bureaucracy in the system. A great example to emulate is the common process for reviewing the cost-effectiveness of drugs that both eliminated duplicate efforts and the confusion caused by multiple reports. Similarly, the whole area of professional credentials and regulation could be greatly simplified and standardized, with Ottawa promoting and brokering change. Something is wrong when it’s more difficult for some professionals to get licensed in another province than it is for a Polish nurse to get a job in Liverpool.

Canadians deserve to know more about where the system succeeds and where it fails. Because Ottawa is not held as politically accountable for health care as the provinces, it’s the ideal mirror to and conscience of the overall system. It shouldn’t only invest in and co-design the health-information infrastructure but also mine that asset to report on how well the system performs, and promote a culture of openness and transparency where independent researchers and health-care providers can do the same.

Ottawa must proudly stand up for single-payer, not-for-profit health care and ensure that its financial contributions reinforce this commitment across the country. Several provinces have turned a blind eye to blatant violations of the Canada Health Act, and Ottawa has stood by in indifference. The country needs to know where its government stands on the basic character and values of medicare.

If the federal government abdicates, Canadian health care will be increasingly fragmented and costly, and two-tier medicine will grow not because the public wants it but because Ottawa allows and perhaps encourages it. Giving up on medicare is in a sense giving up on the Canadian values that have knit us together. There is more to leadership than writing cheques.

Roy Romanow, a former premier of Saskatchewan, wrote a royal commission report on health-care reform in 2002. Linda Silas is president of the Canadian Federation of Nurses Unions. Steven Lewis is a veteran health-policy analyst.

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